Physicians as Technicians, Armed with Checklists No Less

The Checklist Manifesto: How to Get Things Right by Dr. Atul Gawande

Over the past decade, we've learned a lot from Dr. Atul Gawande, MD, MPH. From his previous works, Complications and Better, we learned (a) to count things (e.g. Apgar Score) and (b) to write something (e.g. The Velluvial Matrix). Now, from his latest masterpiece, Checklist Manifesto, we learn (c) to check things.

To check things by simply checking boxes on checklists, that is.

Or so it seems.

. . .

Physicians are technicians.

Surgeons, especially.

In ancient Greece, evidently, the term techne was used to describe crafts like medicine and music. A modern trauma surgeon, for instance, needs techne (craft-like knowledge built from experience) in order to save patients' lives amidst the particulars that define each case as a unique interaction in time and space. For quite some time, philosophers have referred to this respect for particulars, however transient and non-transferrable, as phronesis.

Cross-pollinating techne and phronesis gives rise to the interdisciplinary spirit that Dr. Gawande fosters and captures in his critically important efforts to reduce/eliminate surgical errors by embracing human fallibility; that is, by infusing a bit of epistemic humility into the art and science of surgery.

Technicians in many other fields, such as aviation and construction, have learned (by hard knocks) from trial-and-error failures that minimalist check lists, when properly constructed, prove useful as decision-making tools under uncertainty, in the face of complexity. Remarkably intricate tasks, such as building a skyskraper in a windy city or landing a plane under inclement weather conditions, do not have to rely on sheer bravado, extraordinary skill, and superior intuition to succeed: checklists can help us do things right repetitively by challenging us to openly recognize opacity (the limits of our knowledge; the limits of our abilities).

In essence, that's the crux of Dr. Gawande's hypotheses as they relate to improving surgery performance in this country and globally. In medicine, a discipline that must constantly confront humbling difficulties, empirical evidence shows that avoidable errors decline quickly (and costs are reduced subsequently) when surgical teams implement simple check lists to avoid known problematic steps in their procedures. In short, a checklist emerges and then evolves when technicians take negative results from experience (e.g. forgetting to check for drug allergies), and then turn these data points into strategic reminders (e.g. key "pause points" or questions) during critical steps in the process, in order to facilitate adoption of habits that prevent (or at least mitigate) human shortcomings from causing catastrophe. Philosophically, checklists address the problem of ineptitude: knowing what things to do, but failing to do those things correctly, to do them properly.

But checklists clearly have domains of applicability.

And I think Gawande understands that dynamic, as communicated in the following:

[T]he real lesson is that under conditions of true complexity--where the knowledge required exceeds that of any individual and unpredictability reigns--efforts to dictate every step from the center will fail. People need room to act and adapt. 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 was the understanding people in the skyscraper-building industry had grasped. More remarkably, they had learned to codify that understanding into simple checklists. They had made the reliable management of complexity a routine.

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nontheless being left the power to manage the nuances and unpredictabilities the best they know how. (79)

In this way, Gawande makes it clear that checklists must (1) avoid too many steps (this becomes burdensome), (2) focus on bottlenecks and critical transitions in procedures (this helps identify the most important activity nodes), and (3) force team members to stop, talk, and double-check that they are all on the same page before proceeding further. For example, in the pre-operative team meeting, a ritualistic checklist process could help (a) build team cohesion (similar to a football "huddle" pre-snap), (b) catch preparation errors (such as failing to mark which limb to operate on), and (c) prime each team member cognitively and emotionally for optimum performance during surgery (as we see powerfully in athletic settings).

Gawande also reminds us that everyone is intimately familiar with checklists already; they permeate our kitchens regularly: they're called recipes! Likewise, unfortunately, everyone knows that they can follow the recipe "to the tee" and still not succeed, frustratingly. That's why cooking, like surgery, is a craft primarily: it's an imperfect game of engineering, of bricolage, that requires constant adapting and re-inventing. Because, remember, you can always create your own recipe from scratch and do things your own way at the end of the day. But what you'll find, though, is an important concept that we should not disregard hastily: homoplasy--convergent evolution--which tends to cluster recipe steps into similar patterns as people test things out, fail, consider new mechanisms, try again, and finally stumble upon a protocol or an algorithm that generates enjoyably edible (successful) results reliably.

And just like chefs must do with their recipes in the kitchen, in the operating room, surgeons must always be ready for moments when their checklists clash with the unexpected:

Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don't. These misses are simple failures--perfect for a classic checklist. And as a result, all the researchers' checklists included precisely specified steps to catch them.

But the fourth killer--the unexpected--is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person's body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together--to be ready as a team to identify and address each patient's unique, potentially critical dangers. (101-102)

Interestingly, Gawande's "fourth killer" resembles Nassim Taleb's "Fourth Quadrant"--both thought-leaders try to map out the limits of our a priori understanding of_unknown unknowns_that, by definition, manifest unconventionally, unpredictably. Checklists won't tame wild randomness in Taleb's extremistan, but they can help us be our best in the land of mediocristan. In the face of these realities, we are left with the challenge of how best to position ourselves to act appropriately to deal with novelty (a patient's blood flow blocking in a rare section of coronary artery, for instance). In Talebian prose, the goal is to be 'long on options and short on obligations'--that is, to get the "easy stuff" out of the way in order to create as much freedom and space as possible to operate creatively to save the day. In response, Gawande notes that the aviation industry studies human errors and generates numerous checklists, each short and focused, to address all known potential emergencies, freeing up pilots and aviation technicians to use their professional skills when navigation-sans-checklists is required. Thus, checklists "are quick and simple tools aimed to buttress the skills of expert professionals"--they should not be bureaucratic devices that force people to 'jump through hoops' mindlessly (128).

So, after all his study of checklists in other industries, what does a medical checklist really look like in surgery. Well, Gawande, through extensive thinkering for a World Health Organization (WHO) project, developed something that looks like this (140-41):

Before Anesthesia
1) Confirm that the patient (or the patient's proxy) has personally verified his or her identity and also given consent for the procedure;
2) Make sure that the surgical site is marked;
3) Make sure that the pulse oximeter is on the patient and working;
4) Check the patient's medication allergies;
5) Review the risk of airway problems;
6) Ensure that appropriate equipment and assistance for them are available;
7) Verify that necessary intravenous lines, blood, and fluids are ready.

After Anesthesia but Before Incision
1) Make sure all team members introduce themselves by name and role;
2) Confirm that everyone has the correct patient and procedure in mind;
3) Confirm that antibiotics were either given on time or were unnecessary;
4) Check that any radiology images needed for the operation are displayed;
5) Discuss the critical aspects of the case: total time, expected blood loss, etc.

At the End of the Operation
1) Review the recorded name of the completed procedure for accuracy;
2) Review the labeling of any tissue specimens going to the pathologist;
3) Review whether all needles, sponges, and instruments have been accounted for;
4) Note whether any equipment problems need to be addressed before the next case.

But does it work? At first, Gawande was not sure. Now he is. After testing this checklist protocol in hospitals across the globe, from Tanzania to Delhi to New Zealand to London to Manila to Jordan to Seattle, Gawande and his comrades have published remarkable results from their trials, providing promising possibilities for further checklist applications going forward.

And, as expected, as any seasoned empiricist would do, Gawande recognizes and reminds us that checklists must continually be tested and updated, indefinitely: "To be sure, checklists must not become ossified mandates that hinder rather than help. Even the simplest requires frequent revisitation and ongoing refinement. ... In the end, a checklist is only an aid. If it doesn't aid, it's not right. But if it does, we must be ready to embrace the possibility" (183-84).

Yet, despite the possibilities, here is the hurdle he faces currently: convincing fellow surgeons to adopt this new modus operandi hasn't been incredibly easy, despite Gawande's credibility. As always, embracing human fallibility doesn't necessarily come naturally, particularly in highly-trained professions like surgery, where a history of autonomy dominates the scenery.

Personally, as I reflect on the role of checklists in medical procedures, I respect the analogies between medicine and the aviation industry--both require extreme safety precautions--but I also keep connecting performance in medicine back to athletics. Surgeons could learn from athletes. Athletes have integrated the notion of checklists into their routines for centuries, pushing human performance to higher and higher levels across the decades. For example, as an experienced tournament golfer, I have self-experimented with various pre-shot routines for years: the waggles, the looks, the shakes, the weight shifts ... whatever it takes. It's all so natural for me. And I am used to failing. But that doesn't stop me. When shots go awry, I simply recuperate and then iterate: that is, I thinker with the recipe, with the checks in my preparatory steps (e.g. See the video below for some Hogan-esque pre-shot routine thinkering).

It's all just techne, anyway.

And phronesis: "One shot at a time," you'll hear golfers say.

Perhaps, if we're lucky, Dr. Gawande will interview some world-class athletes for a follow-up essay in The New Yorker and will realize that sports teach valuable lessons about decision-making under uncertainty.

They teach you how to integrate checklists naturally, subconsciously.

They teach you how to be diligent through habit-formation.

Through routine.

To good health,

Brent