Gawande’s “Checklist Manifesto”

Every now and then, I read and enjoy a book, but only later fully appreciate it as its lessons and insights slowly become apparent. Judging by the number of times I’ve said, “That reminds me of Gawande’s observations about ___” over the past month, The Checklist Manifesto is one such book.

In this short, deceptively simple volume, Atul (who I count as both friend and inspiration) discusses the history of “the lowly checklist,” the impact of checklists on various industries, how he came to understand the value of checklists to medical care, and what makes a useful checklist. Most of this content could have been written by a thoughtful healthcare journalist. But Atul put his interest in checklists to practical use, spearheading a WHO initiative to test a checklist-based “safe surgery” program in 8 diverse hospitals around the world, an effort that saved hundreds of lives. His description of this program forms the core of the book.

Which is as it should be, since these autobiographical elements highlight what is unique about Atul, and his book. Yes, he is a gifted journalist (of course, aided by a surgeon’s insider knowledge and access – as demonstrated by last year’s game changing article about healthcare in McAllen, Texas). But he is also a healthcare leader, whose clear aim is not only to explain attitudes and policy, but to change them. It would be as if Malcolm Gladwell had tried to create a Tipping Point himself, and written up the experience. The whole thing gets very “meta” very quickly, and in the hands of a lesser person, might even threaten to become a bit dicey. (Is he a medical George Plimpton – trying out checklists in the OR to provide fodder for his writing?) But there’s no such worry here: Atul’s passion for patients and humility are so obvious that one never questions his methods or motives.

I won’t focus this post on the Hopkins-Michigan central line and the WHO surgery stories, which are both well known to readers of this blog. Nor will I concentrate on the book’s recitation of the history of checklists in fields as diverse as building construction, investing, and aviation (while illuminating and often fascinating, some of the examples, particularly the investment analogies, are a bit thin, a point made elsewhere). Finally, I won’t cover what Atul learns about how to create a great checklist from his field trip to Boeing’s “Checklist Factory,” beyond saying that this part of the book is actually a useful primer for those getting into the checklist business.

Instead, I’d like to focus on the subjects that don’t come through in reviews and interviews (such as Atul’s charming appearance on The Daily Show) but, I believe, are much deeper and more valuable.

“For nearly all of history, people’s lives have been governed primarily by ignorance,” Gawande writes. But in healthcare, he points out, we now know so much about so many things (and can treat so many maladies with our arsenal of thousands of medications and procedures), that when we don’t get it right, “the problem we face is ineptitude… making sure we apply the knowledge we have consistently and correctly.”

This, of course, helps explain why the public is so unsettled by our patient safety and quality flaws. Patients no longer give us the benefit of the doubt, attributing our failures to ignorance. Instead, they assume that we do know the right thing to do, but simply screwed it up. “The public was spoiled by the discovery of penicillin,” Atul said at a recent lecture at UCSF, since it gave people the illusion that curing illness was pretty easy.

In observing that medicine has problems that range from simple (getting the dumb stuff right) to the profoundly complex, he notes that,

… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail.  People need room to act and adapt.

Is he arguing against his central premise, the value of checklists in healthcare? Well, no. He continues,

Yet they cannot succeed as isolated individuals, either – that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation – expectation to coordinate, for example, and also to measure progress toward common goals.

This is one of the book’s epiphanies: checklists can not only ensure that people perform multi-step processes correctly, but can also remind us to talk to each other and coordinate our activities at particularly crucial junctures. Atul learned that the value of the preoperative checklist, coupled with the Time Out, was not simply in ensuring that the team gave the preop antibiotics or had units of blood on hand, but in forcing all the team members to introduce themselves to each other. It was as much a culture-changing intervention as a cookbook.

In fact, the most interesting observations in the book are ones in which Atul describes our culture; it is this culture that explains why checklists rub so many caregivers the wrong way.

In medicine, he writes,

we have the means to make some of the most complex and dangerous work we do… more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity… Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

In broadening this point, he plumbs an even deeper truth: “All learned occupations have a definition of professionalism, a code of conduct… [with] at least three common elements,” he observes: selflessness, an expectation of skill, and an expectation of trustworthiness. 

Aviators, however, add a fourth expectation, discipline; discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own. In medicine, we hold up ‘autonomy’ as a professional lodestar, a principle that stands in direct opposition to discipline…. The closest our professional codes come to articulating the goal [of discipline] is an occasional plea for ‘collegiality.’ What is needed, however, isn’t just that people working together be nice to each other. It is discipline.

These insights about medicine, and particularly the physician psyche, are not only profoundly interesting; they are vital to understand if we are to make healthcare better. Checklists can’t solve all our problems, but they – and other safety-oriented activities like standardization, simplification, forcing functions, and double-checks – can help us deliver healthcare that is far safer and more reliable. In applying these solutions, though, we need to understand that they challenge some of our most deeply held beliefs about the nature of medical practice and what it means to be a good doctor.

We have met the enemy, and it is us.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

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5 replies »

  1. Dr. Garza says:
    > I am disappointed in the lack of COURAGE in our ranks
    Something I have been pleading with doctors (especially) about for years on THCB. Do a search on my name together with the word “guild”. I greatly prefer that professional discipline be handled by professionals and professional organizations, but if they won’t do it someone else will howsoever crudely. I recognize that there will be abuses (and there have been abuses) but “abusus non tollit usus” — the abuse of a thing does not take away (i.e. illegimate) its [proper] use.
    I wonder what collective action doctors should undertake in order to make individual action (like complaining about a fellow doctor) possible. Difficulty working this out is no excuse to abdicate the role.

  2. Great post about a great book. I think it is getting few comments here because there is so little to argue with. Even the defenders of lone ranger medicine have a hard time sticking a knife into an argument so well constructed.

  3. This is indeed a truly outstanding book and much more valuable than about 99% of the books on quality improvement. The book gets to the heart of one of the most vexing problems in modern medicine: how do we manage the knowledge we already have? Reading this book makes me wonder if some of the millions of dollars devoted to developing sophisticated risk adjustment models, cost effectiveness studies, and the like might be better spent on relatively simple but powerful tools like checklists. [FYI—for those of you who are too busy to read this book, you can purchase and listen to an unabridged audiobook edition at Audible.com.]

  4. These qualities: skill, trustworthiness, selflessness and discipline should be the cornerstone of the modern physician. After 13 years in clinical medicine however, I am disappointed in the lack of COURAGE in our ranks to address peers who fall well below this baseline standard. We can and must do better.