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 Book Review: "The Checklist Manifesto" by Atul Gawande 

Reviewed by Darshak Sanghavi, Special to The Chronicle

Friday, January 15, 2010

The Checklist Manifesto

How to Get Things Right By Atul Gawande

(Metropolitan Books; 209 pages; $24.50)

Modern doctors are arguably the most hyper-educated professionals in the world, requiring eight years of higher education, followed by three to 10 years of residency and subspecialty training.

And yet, according to well-respected studies from the Rand Corp., roughly half the time doctors fail to provide the right preventive and acute medical care for adults and children for everything from ear infections to heart attacks to sexually transmitted diseases. Doctors long ago discovered treatments for the conditions. Why, then, do they so often fail to apply them correctly?

In his compelling book, "The Checklist Manifesto: How to Get Things Right," the surgeon and writer Atul Gawande expands on the ideas popularized in his 2007 New Yorker essay about the remarkable impact of simple checklists on medical care. Fundamentally, he notes, there are two reasons for failure: ignorance (not yet knowing how to do something) and ineptitude (failing to apply what is already known). The former can be forgiven, but the latter rightly arouses anger and judgment.

The most intriguing chapters are those in which Gawande hangs out with skyscraper builders, sous chefs and airline safety officers to understand why other professions have far outpaced medicine in breaking down complex processes to deliver reliable results.

Centuries ago, he writes, builders used to be a lot like today's doctors, where a "Master Builder" was given total autonomy to construct projects like Notre Dame and the U.S. Capitol building. But making skyscrapers became so mind-bogglingly complex that no one builder could handle it. So builders created elaborate production checklists (they "ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way") and, more important, specified key communication tasks between experts like elevator installers and engineers. Today, less than 0.00002 percent of buildings fail though they're more complex than ever.

But in medicine, Gawande notes that "a lone Master Physician with a prescription pad" still works in a system that is "completely uncoordinated." To explain how good checklists are created, Gawande turns to engineers at Boeing since airline pilots, more than any other field, have pioneered the science of checklists.

Following the spectacular crash of Boeing's "flying fortress" test bomber in 1935, Boeing engineers created an index-card-size checklist of critical tasks that was so effective, not a single of the 13,000 planes ever crashed again. Most recently, Capt. Chesley Sullenberger's 2009 "miracle of the Hudson" landing is owed to an emergency checklist.

These checklists, argues Gawande, should be widely used in health care. The successful ones accomplish two things. First, they ensure that narrowly specific "stupid stuff" isn't missed, like allergies or proper antibiotics. Just as important, the checklists also build in communication checks to ensure people work as a team.

In 2008, for example, he and a team of researchers from the World Health Organization deployed a 19-point pre-surgery checklist to be used in hospitals worldwide from Tanzania to Toronto; incredibly, major complications dropped by a third and death rates were cut in half.

Gawande spins out the implications of his project: Couldn't checklists be expanded to address heart attacks, strokes, kidney failure or seizures, whose treatment is surely not more complicated than flying a massive bomber?

For too long, medicine has been insulated from the kinds of quality and process improvement that's become standard in all kinds of industries. In calling attention to the power of checklists, Gawande argues convincingly and eloquently for doctors to learn from others. After all, our lives may depend on it.

Darshak Sanghavi is Slate's health care columnist and a contributing editor for Parents. E-mail him at

This article appeared on page F - 4 of the San Francisco Chronicle