The Great Checklisting of American Medicine

Dr DuvefeltMedical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.

From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.

Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then.

How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care.

Each one has their own set of checklists, many only slightly different, and none of these lists actually improve diagnostic accuracy; this is somehow taken for granted, or perhaps not addressed because the creators of these checklists, as non-physicians, simply have nothing to say about that aspect of healthcare.

Gawande writes: “There are good checklists and bad….Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brain off rather than turn them on.”

A very simple way to “turn on” or focus providers’ brains is to adhere to a structured format of clinical assessment, but to avoid unnecessary rigidity after that. After all, in my world we have 15-30 minutes at most with every patient for a fee of $50-150. You can only cram so many prescribed agenda items into that kind of time frame before your time is up.

Today’s checklists would have me ask every patient, apart from figuring out what is wrong with them, if they are homeless, home bound, safe from domestic abuse, if they have scatter rugs, firearms in the house (not a legal question in Florida, however), if they are a caregiver and probably several more things I can’t remember. I am sure the architects of these templates meant well, but the end result of long lists like this is that physicians risk not paying attention to the forest because of all the trees. A more appropriate checklist could summarize all these items in one question: “Have you considered the patient’s home environment?”

One item I haven’t found in my new EMR is what we in Sweden always used to include in our medical histories, “Epidemiology”. This simple word prompted the question “Do you know anybody else with the same symptoms as yours?” It is a question I overlooked at least once that I will always remember:

I was fresh out of residency, working in a small town in Maine. A middle aged man came to see me about nausea, loss of appetite and abdominal pain of more than a week’s duration. I didn’t know what was wrong with him, so I ordered some labs and an upper GI series. His CBC was mildly abnormal and while I was waiting for his x-ray to get done, my partner and employer ran into him in the grocery store one Saturday. Doctor Joe approached me the following Monday and told me not to bother with the x-Ray: “Mr. Billings’ dog was just diagnosed with lead poisoning. You might want to check a lead level on him”.

Talking to Mr. Billings, he had been scraping paint off his old farmhouse with his Golden Retriever faithfully waiting at the bottom of the ladder, inhaling the dust from the dried and cracked paint. It never occurred to me to ask about “epidemiology” the way I had been taught, because I had dismissed infectious causes of Mr. Billings’ symptoms almost subconsciously and never considered environmental exposure, which also falls under the “epidemiology” heading.

A similar but more dramatic incidence in “The Checklist Manifesto” involved a surgeon who thought he had all kinds of time to get ready to explore and repair a small stab wound inflicted at a Halloween party.

Suddenly the patient’s blood pressure bottomed out and as the surgeon hurriedly entered the abdominal cavity and found it filled with blood, he remembered he had neglected to ask about the weapon that had caused the stab wound. He later found out it was a bayonet, which turned out to have lacerated the abdominal aorta – he had only assumed it must have been a pocket knife.

Obviously, no check list can be complete enough to include questions about scraping lead paint for every person with abdominal pain and asking about having been stabbed by a bayonet in every laceration – only more general and somewhat open-ended questions will get you all the answers in a reasonable amount of time.

Quoting Gawande again, “The checklist cannot be lengthy. A rule of thumb some use is to keep it between five and nine items, which is the limit of working memory.”

As I contemplate how to continually improve the care I deliver while also addressing the increasing demands for fulfilling and documenting the Government’s requirements, I think I can use my computer and my EMR to streamline the way I meet all the requirements. But I think it’ll be up to me to create my own clinical checklists, because the Government issue doesn’t seem to be my size, which reminds me of another set of Swedish experiences I had – boot camp, blisters and learning to march in formation and follow orders without complaining.

Hopefully, the “official” checklists will evolve over time as people have a chance to assess their impact. Again, quoting Dr. Gawande:

“…no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart….and one needs to study how, make changes, and keep testing until the checklist works consistently.”

Welcome to the real world, any time you wish to see what it’s like, Mr. President, Ms. Congresswoman, Mr. Insurance Executive, Ms. EMR vendor!

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes, where this post originally appeared.


23 replies »

  1. I’ll immediateely take hold of your rss feed as I can’t in finding your email subscription link orr newsletter service.
    Do you’ve any? Please let me realize in order that I coud subscribe.

    Feel free to surtf to my blog post … sensitive (Elida)

  2. My example of the “epidemiology” question in the post WOULD have nailed the diagnosis, and it is now on my personal checklist ever since I missed that lead poisoning diagnosis.
    Doctor: “Mr. Duncan, have you been around other people with similar symptoms?”
    Mr.Duncan: “Yeah, I took care of someone who died from Ebola….”

  3. Checklists would not have helped the ER docs to judge Thomas Eric not fit for discharge

    What they needed was a full deck of data, but the EHR impeded their being able to silo search to find the full deck. All EHRs treat all data the same way, whether it be relevant or not: mundane, vanilla, verbiage, jabberwock, mind numbing, unreadable due to tiny font…you get the picture.

    If that ER did not have a EHR running the show, Mr. Duncan would have been admitted.

  4. By the way Bobby, thanks for bringing up that book. I heard about it on NPR a few weeks ago and would like to read it myself.

  5. ” It may also, in the long run, hinder doctors from developing the intuition that enables them to respond to emergencies and other unexpected events, when a patient’s fate can be sealed in a matter of minutes. ”

    A critical statement. This is why doctors do residencies and train under older experienced doctors (and nurses), to help develop these little voices and gut grabbers that make them stop and think. I too am concerned that overreliance on tech and screens between doctors and patients will erode this very important part of a physician’s ability to process important information.

  6. “Isn’t medicine partly artistic?”

    What does that MEAN to you? The phrase “art of medicine” has always made me a bit uncomfortable. But, then, I’m aware of the term “scientism,” too — the epistemological assertion that western reductive algorithmic science is the ONLY way of knowing. See, e.g., the prefatory story in one of my 2009 blog posts:


    “Art” implies making intuitive, heuristic, “creative” cognitive leaps via which to arrive at positive results, be they aesthetic or clinical, right?

    As I wrote in my 1998 essay about my late daughter:

    “Every discipline has its share of the “arrogant and narrow-minded,” but I have mostly found mainstream health care professionals to be a dedicated, unpretentious, and self-deprecating lot quite aware of the limits of their knowledge and the risks of presumption. Once, during a series of health care quality improvement seminars I attended at Intermountain Health Care in Salt Lake City during my Peer Review tenure, a speaker– himself a noted pediatric surgeon– wryly observed that “the best place to hide a hundred dollar bill from a doctor is inside a book.” The Director of the seminar series, Dr. Brent James of IHC (and a Fellow of the Harvard School of Public Health), noted in our opening session that physicians would probably admit– off the record, of course– that perhaps only 10% of their clinical decisions made during daily practice could be traced to the peer-reviewed scientific literature. Dr. James also made the droll observation that, were you to walk into the typical medical administrator’s office, “you’d be much more likely to see copies of the Wall Street Journal rather than the New England Journal strewn about.”

    What can one take away from such remarks? First, the many physicians I have come to know in the past few years are in the main acutely sensitive to the problems of clinical conceit and “paradigm blinders.” Indeed, the Utah pediatrician’s”$100 bill” wisecrack was offered to an audience of doctors and their allied health personnel during QUALITY IMPROVEMENT training. Second, the body of peer-reviewed medical literature does not constitute a clinical cookbook; even “proven” therapies– particularly those employed against cancers– are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child’s play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly– so often in the face of indeterminate, inapplicable, or contradictory research findings.

    Finally, with respect to Dr. James’ Wall Street Journal quip, the capitalist imperatives within which health care clinicians must operate are, in the aggregate, neither of their making nor under their control. Moreover, blanket indictment of the profit motive as necessarily inimical to optimum medical care and research is a rather simplistic notion. Strategies aimed at maximizing investors’ net returns probably spur at least as many medical advances as they inhibit.”

    also apropos, from Nicholas Carr’s new book “The Glass Cage” –

    “THE SMALL ISLAND OF IGLOOLIK, lying off the coast of the Melville Peninsula in the Nunavut territory of the Canadian North, is a bewildering place in the winter. The average temperature hovers around twenty degrees below zero. Thick sheets of sea ice cover the surrounding waters. The sun is absent. Despite the brutal conditions, Inuit hunters have for some four thousand years ventured out from their homes on the island and traversed miles of ice and tundra in search of caribou and other game. The hunters’ ability to navigate vast stretches of barren Arctic terrain, where landmarks are few, snow formations are in constant flux, and trails disappear overnight, has amazed voyagers and scientists ever since 1822, when the English explorer William Edward Parry noted in his journal the “astonishing precision” of his Inuit guide’s geographic knowledge. The Inuit’s extraordinary wayfinding skills are born not of technological prowess— they’ve eschewed maps, compasses, and other instruments—but of a profound understanding of winds, snowdrift patterns, animal behavior, stars, tides, and currents. The Inuit are masters of perception.

    Or at least they used to be. Something changed in Inuit culture at the turn of the millennium. In the year 2000, the U.S. government lifted many of the restrictions on the civilian use of the global positioning system. The accuracy of GPS devices improved even as their prices dropped. The Igloolik hunters, who had already swapped their dogsleds for snowmobiles, began to rely on computer-generated maps and directions to get around. Younger Inuit were particularly eager to use the new technology. In the past, a young hunter had to endure a long and arduous apprenticeship with his elders, developing his wayfinding talents over many years. By purchasing a cheap GPS receiver, he could skip the training and offload responsibility for navigation to the device. And he could travel out in some conditions, such as dense fog, that used to make hunting trips impossible. The ease, convenience, and precision of automated navigation made the Inuit’s traditional techniques seem antiquated and cumbersome by comparison.

    But as GPS devices proliferated on Igloolik, reports began to spread of serious accidents during hunts, some resulting in injuries and even deaths. The cause was often traced to an overreliance on satellites. When a receiver breaks or its batteries But as GPS devices proliferated on Igloolik, reports began to spread of serious accidents during hunts, some resulting in injuries and even deaths. The cause was often traced to an overreliance on satellites. When a receiver breaks or its batteries freeze, a hunter who hasn’t developed strong wayfinding skills can easily become lost in the featureless waste and fall victim to exposure. Even when the devices operate properly, they present hazards. The routes so meticulously plotted on satellite maps can give hunters a form of tunnel vision. Trusting the GPS instructions, they’ll speed onto dangerously thin ice, over cliffs, or into other environmental perils that a skilled navigator would have had the sense and foresight to avoid. Some of these problems may eventually be mitigated by improvements in navigational devices or by better instruction in their use. What won’t be mitigated is the loss of what one tribal elder describes as “the wisdom and knowledge of the Inuit.”

    The anthropologist Claudio Aporta, of Carleton University in Ottawa, has been studying Inuit hunters for years. He reports that while satellite navigation offers attractive advantages, its adoption has already brought a deterioration in wayfinding abilities and, more generally, a weakened feel for the land. As a hunter on a GPS-equipped snowmobile devotes his attention to the instructions coming from the computer, he loses sight of his surroundings. He travels “blindfolded,” as Aporta puts it. A singular talent that has defined and distinguished a people for thousands of years may well evaporate over the course of a generation or two.”

    Carr, Nicholas (2014-09-29). The Glass Cage: Automation and Us (Kindle Locations 1877-1905). W. W. Norton & Company. Kindle Edition.

  7. What I never understood was the doctor patient relationship and what medications the patient was taking at the time. Only when my grandmother moved into a full time nursing care did they scrutinize each and every prescription for all possible drug interactions. Nothing could be given without doctor approvals. Before that time, she was getting one thing from one doctor and another from somebody else. If there was a central database of who is taking what, maybe some of those interactions should have been minimized. It’s up to the patient to disclose such but it would have been nice to have a checklist of sorts.

  8. Great discussion here.

    I’ve just finished Nicholas Carr’s intriguing new book “The Glass Cage: Automation and Us.” A bracing, cautionary read. I will be reporting on it on my blog shortly (Blog.KHIT.org)

    “This is a book about automation, about the use of computers and software to do things we used to do ourselves. It’s not about the technology or the economics of automation, nor is it about the future of robots and cyborgs and gadgetry, though all those things enter into the story. It’s about automation’s human consequences. Pilots have been out in front of a wave that is now engulfing us. We’re looking to computers to shoulder more of our work, on the job and off, and to guide us through more of our everyday routines. When we need to get something done today, more often than not we sit down in front of a monitor, or open a laptop, or pull out a smartphone, or strap a net-connected accessory to our forehead or wrist. We run apps. We consult screens. We take advice from digitally simulated voices. We defer to the wisdom of algorithms. Computer automation makes our lives easier, our chores less burdensome. We’re often able to accomplish more in less time— or to do things we simply couldn’t do before. But automation also has deeper, hidden effects. As aviators have learned, not all of them are beneficial. Automation can take a toll on our work, our talents, and our lives. It can narrow our perspectives and limit our choices. It can open us to surveillance and manipulation. As computers become our constant companions, our familiar, obliging helpmates, it seems wise to take a closer look at exactly how they’re changing what we do and who we are…”

    Carr, Nicholas (2014-09-29). The Glass Cage: Automation and Us (Kindle Locations 43-54). W. W. Norton & Company. Kindle Edition.

    “…A medical exam or consultation involves an extraordinarily intricate and intimate form of personal communication. It requires, on the doctor’s part, both an empathic sensitivity to words and body language and a coldly rational analysis of evidence. To decipher a complicated medical problem or complaint, a clinician has to listen carefully to a patient’s story while at the same time guiding and filtering that story through established diagnostic frameworks. The key is to strike the right balance between grasping the specifics of the patient’s situation and inferring general patterns and probabilities derived from reading and experience. Checklists and other decision guides can serve as valuable aids in this process. They bring order to complicated and sometimes chaotic circumstances. But as the surgeon and New Yorker writer Atul Gawande explained in his book The Checklist Manifesto, the “virtues of regimentation” don’t negate the need for “courage, wits, and improvisation.” The best clinicians will always be distinguished by their “expert audacity.” By requiring a doctor to follow templates and prompts too slavishly, computer automation can skew the dynamics of doctor-patient relations. It can streamline patient visits and bring useful information to bear, but it can also, as Lown writes, “narrow the scope of inquiry prematurely” and even, by provoking an automation bias that gives precedence to the screen over the patient, lead to misdiagnoses. Doctors can begin to display “‘screen-driven’ information-gathering behaviors, scrolling and asking questions as they appear on the computer rather than following the patient’s narrative thread.”

    Being led by the screen rather than the patient is particularly perilous for young practitioners, Lown suggests, as it forecloses opportunities to learn the most subtle and human aspects of the art of medicine— the tacit knowledge that can’t be garnered from textbooks or software. It may also, in the long run, hinder doctors from developing the intuition that enables them to respond to emergencies and other unexpected events, when a patient’s fate can be sealed in a matter of minutes. At such moments, doctors can’t be methodical or deliberative; they can’t spend time gathering and analyzing information or working through templates. A computer is of little help. Doctors have to make near-instantaneous decisions about diagnosis and treatment. They have to act. Cognitive scientists who have studied physicians’ thought processes argue that expert clinicians don’t use conscious reasoning, or formal sets of rules, in emergencies. Drawing on their knowledge and experience, they simply “see” what’s wrong— oftentimes making a working diagnosis in a matter of seconds— and proceed to do what needs to be done. “The key cues to a patient’s condition,” explains Jerome Groopman in his book How Doctors Think, “coalesce into a pattern that the physician identifies as a specific disease or condition.” This is talent of a very high order, where, Groopman says, “thinking is inseparable from acting.” 26 Like other forms of mental automaticity, it develops only through continuing practice with direct, immediate feedback. Put a screen between doctor and patient, and you put distance between them. You make it much harder for automaticity and intuition to develop…”
    (Kindle Locations 1555-1581).

  9. “but there is also a more important place for judgement that can evolve into ‘your own’ checklist.”

    This is exactly what I tell radiology residents. Have and develop your own personal checklists. You’ve taken the words out of my mouth!

  10. You are correct. But it’s going to take a long, long time of sterile medicine for people to get this.

  11. When vendors try to sell you an EHR, sales people use a ‘checklist’ that is imposed by their organization. Are you the real buyer? Do you have authority to sign a check? What is your Specialty?

    You buy from a human being that is able to connect with you and ‘diagnose’ your aspirations and afflictions. Give you a solution that matters to you.

    It is not about technology, it is about solving your ‘case’.

    Not to different from what providers do is it?

    If EHR software sales people have a long irrelevant checklist of questions to ask you, what happens? Turns you off, you hang up.

    Dr. Duvefelt, Dr. Jha, you make some excellent observations. There is a need and reason for checklists, but there is also a more important place for judgement that can evolve into ‘your own’ checklist. Using technology such as EHR software to help with mandated checklists and questions can be helpful.

  12. “The problem is that so many non-clinicians feel entitled to set the agenda for ordinary office visits and the daily work of physicians.”

    Who are these “non-clinitions” and what “checks” do they impose? Surely administrative checklists can be done by office staff, some medical checklists by nurses, even the patient fills out a checklist.

    “but in the precious fifteen minutes we as primary care providers have face-to-face with our patients,”

    This is the real failure of our system, supporting specialists and not PCPs. A strong primary care doctor relationship will trump any checklist.

  13. The Institute of Medicine tells us that. People think Mr. Duncan’s case was one of those errors. More government imposed minutia represent one vision of how to reduce such errors. I don’t think that strategy will work.
    Just hoping won’t help. But I agree with you, it would be nice if things got better.

  14. Hello Hans,

    It makes me sad that there are so many medical errors committed everyday. I do hope that things will get better in the future.

    John Doe

  15. Isn’t medicine partly artistic? This at the very least means that all practitioners would not always treat the same way nor obtain the same results…if e.g. everyone treated identical clones of patients. Wouldn’t checklists be anti-innovative and anti-creative in this thought experiment? Is there some value for the patient and for the society in having it partly artistic? Perhaps the tip of the spear in research, the cutting edge, advances faster if medicine is partly artistic? Perhaps the patients are more comforted if medicine is partly artistic? Perhaps its practitioners feel more satisfaction if they use their creativity?

  16. Thanks for the comments. I think checklists made by clinicians for clinicians can be effective tools also outside the operating room, like Dr. Jha’s X-ray example. The problem is that so many non-clinicians feel entitled to set the agenda for ordinary office visits and the daily work of physicians. I can see governmental and public health agendas needing to be addressed by healthcare organizations in some fashion, but in the precious fifteen minutes we as primary care providers have face-to-face with our patients, the agendas need to be clinical. Our checklists need to be relevant to the clinical decisions doctors and patients have to make together at warp speed. The checklists imposed on us by non-clinicians will, I am afraid and convinced, lead to physician distraction and patient harm.

  17. The problem is that while we need checklists to keep us away from errors of neglect/carelessness, we have become awash in checklists to the point that it obscures the patient. I think this is for three big reasons: 1. computers are very good at checking boxes and have made massive checklists easy to fill; 2. Checklists have become the means of care measurement; and 3. Non-clinicians are making most of the checklists. The medical record has become the place where checklists are stored, proof of the quality of care that was given. The problem is, of course, these checklists are not real care documentation and are not useful clinically. Yes, we need to follow checklists, but reading what checklists others followed is less than useless (it harms patients because it distracts us from the people from whom the checklists were generated).

    I wish I knew a way around this. The crap that is spewed at me from other doctors and hospitals is (as I said before) less than useless, and is basically layer after layer of checklist. I am almost afraid to ask other providers for their records because then I’ll have to find the hint of useful information in the sea of checklists.

  18. Consultation and discussion with colleagues and nurses has always been the best checklist. It is amazing how many brilliant ideas arise from simply having a conversation about a case.

    But, nowadays, health care professionals do not have time for conversations as they are busy clicking away on CPOE or checklists, silo searching data, or answering inane clinical decision support questions.

    If there was conversation in the Dallas ER sitting around the table writng a note, I bet someone would have said, “hey, what do you think about this case from Africa?” And then, voila, the answer to the riddle!

  19. ” checklists for our checklists”

    Ha! John, nice use of the recursive fallacy!

    Even after having read tens of thousands of chest x-rays I have a checklist for chest x-ray. It has the catastrophic diagnoses that I can’t miss, ever.

    I still use it, nearly routinely, for films from the ICU. It was created by me, for me. It did not arise from a central authority, if it did it would have been for everyone, and likely useless for me.

    Having good checklists is essential for all physicians. The trouble is thrusting thousands of checklists on a physician and suffocating them with mindless info glut.

    Gawande’s suggestion was good. The trouble was the meme plague it caused, with some believing that all our woes in healthcare can be solved by a checklist.

    Linear thinking. QED.

  20. I think it is safe to say that it never occurred to the people who came up with the idea of using checklists outside of the operating room that they might become so ubitquitous that we would need checklists for our checklists ..

    It’s one thing to apply a clever innovation. It is one thing to apply it twice.

    But when you apply that innovation a hundred times, it is no longer innovation. The solution itself becomes a checklist item.

    And your solution loses the “magic” that made it effective in the first place.

    Your solution becomes part of the problem as it is misunderstood, misapplied and ineptly implemented by unimaginative people who think they have found the answer to all the world’s problems ….