Is Using a Checklist the Answer to All Your Problems?

Most of the discussion about health care these days focuses on politics. This interview talks about the need for reform and the value of reform, but it is also about the practice of medicine.

Atul Gawande, bestselling author, Harvard professor and an innovator in best practices for the World Health Organization, still performs 250-plus surgeries a year. A copy of Sylvia Plath's poem “The Surgeon at 2 a.m.” stands on the desk in his office.” Her surgeon's words: “I worm and hack in a purple wilderness.”

“That poem captures the surgeon," Gawande says, “as a merely human, slightly bewildered and benighted person in a world that is ultimately beyond his control.”

Medicine is just one area of our world that is becoming so complex even the most expert professionals struggle to master their tasks. In his new book, The Checklist Manifesto: How to Get Things Right, Gawande offers a disarmingly simple remedy: the checklist. Now being adopted in hospitals, the 90-second practice has shown to cut fatalities in surgery by more than a third.

Terrence McNally: When did you know you wanted to be a doctor?

Atul Gawande: I'm the son of two Indian doctors. If you know Indian families, you're thinking about becoming a doctor before you're born. I tried along the way to rebel against it. I got my master's in philosophy, hoping I could become a philosophy professor, but I couldn't understand the questions, let alone offer anything like original answers.

When I came to work in Washington [as senior health policy adviser in the Clinton White House], it was with an interest in where politics meets ideas. I learned a lot about how change happens and about the importance of ideas in driving our efforts to make things better. I also learned I didn't want to be staff for other people.

I ended up coming back to medicine, planning to work in public health. I never expected to like surgery, but once in the operating room, the mix of blood and guts, and the sense that I could master a set of very tangible skills that no one could take away, was very attractive to me.

I was also attracted to the character of the people. Surgeons have a great deal of confidence in themselves, and yet they also make mistakes and have to figure out how to take responsibility. They feel that action is better than inaction, even when they know that they don't know everything and their skills are imperfect. I felt like that was the kind of person I myself wanted to become.

TM: One who balances fallibility and action?

AG: In Washington, I watched politicians grapple with uncertainty, trying to pull a very contentious world toward solutions. We've been working for a century trying to make sure that everybody has access to health care. How do we control costs in ways that also improve quality of care? Whether it's surgeons or politicians, the best seem to be able to grapple with uncertainties, and push forward, while recognizing at times they're going to fail and live with that fallibility.

TM: Contrasting those two career options, I'm struck by the immediacy of surgery -- the action is now, the feedback is in the moment.

AG: I've been working, writing, thinking, pushing on health reform for a decade; I was through the debacle of the Clinton administration. I don't think I could give up surgery because every time I finish my day in the operating room, I feel that like I've accomplished something.

TM: I'm reminded of the work of Mihalyi Csíkszentmihályi, who wrote the book Flow. He cites three preconditions: clear goals, good feedback, and a stretch between challenge and skill. People think of rock climbers, ballet dancers, that sort of thing, but surgeons also score very high on flow.