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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
books@sfchronicle.com.
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/01/15/DD4S1BGE73.DTL
This article appeared on page
F - 4
of the San Francisco Chronicle