The Checklist Manifesto by Dr. Atul Gawande is a rare book in today’s never-ending flood of innovation non-fiction. Gawande offers not just a look at how simple, non-technical innovations can have outsized positive effects, but also a fascinating examination of the psyche of the medical profession, a critique of our very human resistance to cross-domain learning, and acknowledgement of the emotions that drive resistance to the cultural change that is ultimately the biggest challenge in implementing any innovation.
I was surprised at the large number of negative reviews floating around for this excellent book. Until I realized that those reviews ultimately came from the same place of hubris as the resistance to implementing checklists itself – quite simply, those who reviewed the book negatively believe that they are so infallible that a checklist is beneath them, despite Gawande’s evidence to the contrary. In that way, the reviews track the book itself, and reveal the critical challenge for implementing any new solution to an old problem: that trying something new requires the willingness to risk that it won’t work, the persistence to keep trying, and the humility to recognize that improvement requires that we accept how much we still have to learn.
Gawande’s tale begins with several examples in medicine where treatment protocols are well-known and well supported by research, but where data shows that 30% (stroke) to 50% (heart attack) to even 60% (pneumonia) of patients receive incomplete or inappropriate care. This is the pain point – if the correct treatments are well known, why is it that failure rates are so astonishingly high?
We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hard-working people in our society. And, with it, that have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent… across many fields, from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.
Gawande discusses challenges in quantifying medicine, challenges in the sheer number of steps necessary to care for patients in intensive care environments, and the effects of accumulating errors. It all adds up to the normalization of preventable complications, many of which begin a chain of symptom, treatment, side-effect, and complication that frequently has a greater impact on patient survival and recovery outcomes than the original injury/illness. The care of the 50% of intensive care patients who experience a complication is then undertaken by a growing chain of specialists and super-specialists, with team-members (starting in the OR) who likely have never worked together before. Complex medical care has come to resemble the NFL All-Star game, when it should look like the Super Bowl.
“That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane… down an runway, or building a thousand-foot-tall skyscraper. But in medicine, we see it all the time. I’ve seen it in my own operating room.
Gawande and his team, over a period of many years, challenged the assumption of “normal complications,” looked to other professions for a solution, experimented with different approaches, built test plans, adjusted many times, and carefully assessed results at each step. Along the way, they encountered a neverending array of challenges, both expected and unexpected, and ultimately found that addressing emotions and egos was the key that allowed them to implement their solution.
The checklists were tested in eight hospitals around the world, from different countries, different economic levels, and in different cultures. Gawande and his team found that the use of simple checklists reduced preventable errors significantly. So much so that his own team was surprised and had to double-check the data. Major complications for surgical patients across eight test hospitals fell by 36%. Deaths were reduced by 47% – cut almost in half. The improvements were significant for every hospital, regardless of economic situation or culture. In seven of eight hospitals, the complication rate was reduced by greater than 10%. If the FDA were presented with a pill that reduced post-surgical complications by 36% and deaths by 47% it would be rightly hailed as the greatest medical advance of recent times, and would be fast-tracked to approval.
Still, the checklist meets with resistance. One initial objection was that the study didn’t reach a conclusion about how the checklists reduced complications and deaths. But even among those who were skeptical, when asked whether they wanted the checklist used if they themselves had surgery, the vast majority said yes. While Gawande admits that there is more research to be done, this is one case where letting practice lead research will certainly save lives.
Does Gawande’s work suggest that brilliant specialists can or should be replaced by simple checklists? That was certainly a fear that he had to confront during the testing and implementation. But Gawande would say ‘no.’ In complex professions, the checklist serves to bring a team together, to synchronize actions and timing, and to remove the basics from the cognitive load of the specialists, freeing them to apply their greatest talent to the most difficult problems. “The hard question – still unanswered – is whether medical culture can seize the opportunity.”
Please enjoy The Checklist Manifesto. (affiliate link)