Frequent THCB contributor Maggie Mahar returns today with another of her no-holds barred pieces on the practice of medicine, examining the the controversey over checklists for doctors. Many physicians are opposed to the idea on general principles, arguing that checklists "dumb down" medicine and remove the "art" from their craft. Outside observers disagree, noting that there is room in medicine for an approach that has helped make airline travel safe and improved efficiency in countless industries. If you enjoy this piece, you’ll find a wonderful collection of similar pieces tackling the inner workings of the healthcare system over at HealthBeat, Maggie’s blog at the Century Foundation.
Pilots Use Checklists. Doctors Don’t. Why Not?This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist”is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long”but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).
Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. "She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.”By then“she has a body temperature of 68 degrees—and no pulse.”A helicopter takes her to a near-by hospital. There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “
Slowly, over two weeks, she comes back to life. "Her right leg and left arm [are] partially paralyzed. Her speech [is] thick and slurry. But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.”
“What makes her recovery astounding,” Gawande writes, is "the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of step correctly; placing the heart-pump tubing into her without letting in air bubbles, maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running”all the while "orchestrating each of these steps in the right sequence, with nothing dropped . . .”
This, Gawande says, is what happens in intensive care units, every day of the year, all across the country. “Intensive care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”
American medicine doesn’t do too badly. "The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six percent. [This is something to keep in mind when someone says that we shouldn’t spend so much money on patients in I.C.U. units during their final days of life. Eighty-six out of 100 survive—and usually, it’s impossible to know with any certainty which 14 will die.—M. Mahar] “Going into an I.C.U. is not a sentence of death,”Gawande notes, "But the days will be the most precarious of your life.”
The complexity and intensity of the care is astounding. The average patient in an I.C.U. requires “a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them poses risks,” Gawande observes, citing a study done by engineers who tracked I.C.U. care for 24-hour stretches. “Remarkably,”the engineers found that the nurses and doctors made errors in just one percent of these actions—“but that still amounted to an average of two errors a day with every patient.”
“This is the reality of intensive care,”Gawande adds. “At any point, we are as apt to harm as we are to heal.” Line infections are common…I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between five and twenty-eight percent of the time, depending on how sick one is at the start. . . . The I.C. U., with its spectacular success and frequent failures, therefore poses a distinctive challenge: what do you do when expertise is not enough?”
Gawande then turns to the story of how pilots began making checklists.“On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build its next-generation long-range bomber.”Everyone thought they knew who would win. Boeing’s “gleaming aluminum-alloy Model 299”was the clear favorite. "It could fly faster than previous bombers and almost twice as far. A small crowd of Army brass and manufacturing executives watched as the Model 299 . . . roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill,” the U.S. Army Air Corps’ chief of flight testing.
The cause of the crash? Pilot error. “Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs . . . and constant-speed propellers whose pitch had to be regulated with hydraulic controls . . While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed as one newspaper put it, ‘too much airplane for one man to fly.’”
Perhaps the pilot should have had more training. “But it was hard to imagine having more experience and expertise than Major Hill,”Gawande writes. "Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checking for takeoff, flight, landing and taxing.”
With that checklist, “pilots would go on to fly the Model 299 a total of 1.8 million miles without one accident,” Gawande writes. "The army ultimately ordered almost thirteen thousand of the aircraft, which is dubbed the B-17.”
At this point in his narrative, Gawande returns to intensive care, announcing that “Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.”
Could something as simple as a checklist help hospitals? Six years ago, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try.”He started with just one problem—line infections—and wrote out the steps a health care provider must take to avoid these infections when putting a line in. "Doctors are supposed to 1) wash their hands with soap, 2) clean the patient’s skin with chlorhexidine antiseptic 3) put sterile drapes over the entire patient, 4) wear a sterile mask, hat, gown and gloves and 5) put a sterile dressing over the catheter site once the line is in.” It doesn’t sound hard, does it?
Pronovost then "asked the nurses in his I.C.U. at Johns Hopkins to observe the doctors for a month as they put lines into patients. “It turned out that in more than a third of all cases, doctors skipped at least one step. The hospital administration than gave the nurses permission to stop doctors if they saw them skipping a step.
Over the next year: "The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven percent to zero. So they followed patients for fifteen more months. Only two line infections . . . in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.”
Once again, higher quality care and less expensive care go hand in hand. Keep this in mind when someone tries to scare you by saying that under national health care reform, the government will try to lower health care spending. If the government uses medical evidence to reduce costs—which is what the Democratic candidates plan to do—we will all be safer.
Pronovost made other checklists for other procedures and ultimately “took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen.” But he found few people interested in adopting the lists. “So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovsot waking the hallways to make sure the checklists are being used properly.” Gawande explains.
But then he caught a break. In 2003 the Michigan Health and Hospital Association asked Pronovost to try out three of his checklist in all of Michigan’s I.C.U.s. Once again, the results were astounding. Before the project began “infection rates for I.C.U. patients in Michigan hospitals were higher than the national average, and in some hospitals dramatically so . . . Within the first three months of the experiment . . . Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety percent of I.C.U.s nationwide. Overall, infection rates in Michigan had fallen by sixty-six percent.” After eighteen months, the hospitals saved an estimated $175 million in costs and more than 1500 lives. “The successes have been sustained for almost four years,” Gawande notes, “all because of a stupid little checklist.”
In December of 2006, the results were published in The New England Journal of Medicine. How many U.S. hospitals have adopted checklists since?
None. No doubt, many doctors insist that they don’t need a checklist. They know what they are doing. They went to Yale. The idea of being “checked”rankles. But while “the still limited response to Pronovost’s work may be easy to explain . . .it is hard to justify,”Gawande writes. “If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues , detail men offering free lunches to get doctors to make it part of their practice . . .That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobilas; they cost a third more, and reduced infections only slightly—and hospitals have spent million of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a trial.”
Why? Gawande may be too polite to say this, but the answer seems to me clear. There is no profit to be made on a checklist. What do you sell? Any experienced intensive care specialist knows what should be on the list. All anyone needs is a few pieces of paper and a pencil. Pronovost has invented a process for delivering health care—not a new hi-tech procedure, not a new product. And like Jonas Salk, who invented the polio vaccine, he is willing to give his idea away for free.
If there were something to sell, Johnson & Johnson or Genentech would have turned Pronovost and his idea into a new medical breakthrough long ago. The story would be reported in U.S.A. Today, trumpeted on the Evening News, splashed on billboards across the nation. Hospitals would be spending millions on ads bragging that they had this new breakthrough product: “At Mount Hope, Where We Care About Your Safety…”
In our for-profit healthcare system, people become truly excited about an idea when someone sees way to make a fortune. So Merck’s new vaccine, Gardasil, that protects against 70 percent of the viruses that cause cervical cancer has gotten extended play in the press, on TV, and on Wall Street. Meanwhile, the Pap Smear—a test that detects virtually all cases of cervical cancer and has, in fact, made this type of cancer a “rare disease” in the U.S., gets little notice. No national campaign to make sure every woman gets annual Pap Smears. It’s not a high-profit procedure.
In the U.S. the idea that the point of healthcare is better health seems to have been lost in the rush to make money. As Harvard’s Dr. Arnold Relman wrote in the most recent issue of JAMA, ours is “the only health system in the world” where “investors and business considerations play such an important role. In no other country are the organizations that provide medical care so driven by income and profit-generating considerations.”
Recently, Gawande asked Pronovost how much it would cost to do for the whole country what he did for Michigan, and how long it would take. The answer: about two million dollars and two years—“if the country wanted it.”
“So far,” Gawande writes, “it seems that we don’t. The U.S. could have been the first to adopt medical checklists nationwide.” Instead Spain, of all places, is beating us to the punch. While New Jersey mulls the idea over, Spain has already signed up for Pronovost’s program.
Finally, Gawande circles back to the beginning of his story, and confides that he recently spoke to Markus Thalmann, “the cardiac surgeon on the team that saved the little Austrian girl who had drowned.” In the context of Gawande’s larger story, what he learned is almost unbearably ironic: “a checklist had been crucial to her survival.” The team at the Austrian hospital faces three to five patients like the little girl every year, often the victims of an avalanche. For years, they could never save them—until Thalmann and a couple of colleagues made and distributed a checklist. The rescue of the three-year-old girl was their first success with the checklist in place. Since then, it has saved other lives.
But it seems that this is the sort of thing that can happen only in a small town in Austria. Or in Spain. Not in the U.S. In the U.S., no one is going to tell us how to practice medicine.