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.
AG: I write in this new book about the moment when you actually achieve flow in an operating room. It's not an individual moment, that's the really interesting thing. You have a half dozen people working together, and there are certain moments when you actually achieve that pit crew-like flow -- when everybody's anticipating one another, and you move effortlessly through problems.
I had always assumed that you could not achieve that except by the luck of the people gathered that day, your chemistry, your mood. And I'd been very interested in whether you could more commonly achieve that state and -- beyond having fun in the operating room -- be more likely to save people's lives.
TM: How do you compare writing and surgery?
AG: I feel that they're completely different. Surgery is about teamwork, it is partly physical, and it calls for making momentary judgments. Whereas, writing is solitary, it is in my head, and it allows for constant revision. I'm an okay writer, but I've gotten better and better at being a good reviser -- constantly reworking in a way that you can't do in the operating room.
TM: I read that your first New Yorker piece in 1998 took nine months and went through 22 rewrites.
AG: I worked on the first draft for two months, and I thought, “This is killer.” And my editor said, “This has got a lot of promise. You can do with a little work on the beginning, the end has got to go, I don't know about the middle, but I'm sure we'll get somewhere.”
It was nine painful months of first adding stuff in and then pulling stuff out, but it got better every time and I learned a lot. I learn a lot with every piece. The role of the editor is something I don't think people understand. They are the coach.
Writing fills a different part of what I need. Surgery gives me a connection in the real world, while writing lets me try to connect the patterns of what I'm doing.
In the trenches, you can quickly end up mired in the daily politics and the paperwork and the back and forth -- all the things that get in the way of making medicine a rewarding and satisfying experience. Writing lets me remember why I was doing this in the first place.
TM: You write about the physical details in a very graphic way, but you're also looking at a wider context.
AG: If I can begin to make it so you can even smell what's going on in the operating room and see the ideas that underlie it, I feel I've been able to write something that's right.
TM: You have experiences and then tell stories to illustrate and communicate ideas. What makes a good story?
AG: Just because something's dramatic and vivid doesn't mean that there's a story. People have heard the dramatic car crash and the patient dying on the table. The hard part is finding the idea that makes the story interesting and different.
My advice to folks is to ask, “What are you interested in?” Most of my stories start as a question I don't know the answer to. One article for the New Yorker started when a patient came to me because her surgical incision was itching. And I realized I don't understand what itching is and where it comes from and why someone would have such a problem. That led me to investigate the science, and I came across a case where a woman had such a terrible itch that she scratched through her own skull.
The article opens with the case, because that's what's vivid and that's what gets you in, but the stories really start with the questions.
Perri Klass, a Boston pediatrician, writes to understand relationships. She looks at the doctor's relationship with the family or at doctors' relationships with each other.
TM: You've said you think in stories.
AG: Yes, I think I do. I'm not a soundbite guy. The way my head works: I want to tell the story and then unpack it. If I could flip my brain around, I would give the unpacking first and then tell the story. But I see a story, and wonder why is this confusing or emotional or complicated. The story lets me recognize the realities and then unpack them.
TM: You said in a 2005 Harvard Med School commencement speech: 'By putting your writing out to an audience, even a small one, you connect yourself to something larger than yourself. An audience is a community; the published word is a declaration of membership in that community and also a concern to contribute something meaningful to it.'
People think of the surgeon as an individual yet you say surgery is a team effort. Writing is individual, and yet you tie it to the community.
AG: You're speaking to somebody.
When you say something in a blog or in your community newsletter, people always come up afterward and say, “I saw what you wrote.” In some sense, it's an act of bravery to say what you think, because you're opening yourself up to the world. But you're also saying, “I care enough about the community that's reading this to actually spend some time putting the words down, and making an observation about what's going on.”
TM: In The Checklist Manifesto, you say that in medicine everything goes right 97 percent of the time.
AG: But when we're talking about 50 million people having operations, 3 percent where it doesn't go right is not a small matter.
TM: I think a lot of people would be surprised to learn that a checklist is a new idea. How is that so?
AG: The World Health Organization handed us this problem: there's been an explosion in surgery in the world because people are living longer. Infectious disease is no longer the number one killer in the world; it's cardiac disease. Road traffic accidents are a top five killer, cancer is in the top 10.
TM: So what has been true of the U.S. and other advanced countries for a while has now spread globally….
AG: There are now a quarter billion operations a year. It exceeds the number of childbirths -- but with death rates 10 to 100 times higher. Over a million deaths a year. It's suddenly become a public health issue.
We've used two main tools to handle the complexity of doing something as complicated as surgery: first, train, train and train. We've specialized and super-specialized and created more and more compartmentalized people. Second, we've added more and more technology. Despite all of that, the United States has over 150,000 deaths after surgery each year; half appear to be avoidable with knowledge that exists.
Not just in medicine, but in most professions, we have not employed a tool that aviation folks have long embraced, which is the checklist for professionals. We feel that the whole point of becoming an expert is to have enough experience that you know what to do. Pulling out a checklist is seen as a sign of weakness, like you're dumbing things down.
But the aviation world embraced a different set of values. Using a checklist says we are humble enough to recognize that even an expert's brain will fail at times, and they need an aid to make sure things don't fall between the cracks.
Their checklists are designed to make sure teams have things together. So it also embraces another value: it's not just the individual who matters. When you bring a checklist into the operating room, this isn't the surgeon's show, it's about the team.
Surgeons expect nurses to have checklists. They've embraced it for half a century, making sure that contact lenses and dentures are out before the patient comes into the operating room. But when it comes to going through the decisions that I have to make as a surgeon, why would I check? I know what I'm doing.
TM: Could you share a couple of stories of situations where a checklist wasn't present?
AG: A patient who'd had an emergency spleen removal came to me, bleeding terribly. He had come into the emergency room in shock, been rushed to the operating room, and they followed through every step correctly – removing the spleen, getting things under control, saving his life.
Except one. When you've taken out a spleen, there are three vaccines you have to give because the spleen is no longer present to handle three kinds of bacteria. They forgot to give the vaccines. Two years later a pneumococcal infection spread throughout his body because he didn't have a spleen. They saved him from the infection, but he lost all his fingers and toes.
TM: You tell another story about a person who came in on Halloween with a stab wound. The hospital staff treated it as a knife wound, but the person almost died on the table from enormous internal bleeding, because, this being Halloween night, the weapon had been a bayonet.
Forgetting the vaccine after removing the spleen shocks me. Is it because it was an emergency?
AG: No, you can give the vaccine any time in the first couple of weeks after the operation. But you have people working together who think, “Oh, the resident's taken care of that.” The resident might think the attending surgeon's going to take care of it in the office. The attending surgeon thinks the primary care physician is going to take care of it. Or people just forget.
We learned from Boeing who designed their checklist to be useful even in the situation with a crashing plane, tremendous stress, only two minutes to act. There are 4,000 different kinds of medical and surgical procedures. We designed our checklist to face the reality that there is no recipe for every operation and every single thing you have to do. A lot of it is selecting the key items you don't want to miss and then making teamwork work.
So we made an operating room checklist timed for people to execute in under two minutes in normal practice. The checks include some dumb things: make sure an antibiotic is given; make sure blood is available before you make your incision. But some other things are really interesting: make sure everyone on the team has been introduced by name and role; make sure that the surgeon, the anesthesiologist and the nurse have each had a chance to say what their plans are, and what their concerns are.
It doesn't spell out everything you're supposed to do at the end of the operation. It just says, make sure everybody on the team has thought together out loud about the things that have to be part of the plan for the recovery of the patient.
At that moment at the end of the splenectomy, you're busy high-fiving, “We saved this guy.” You've got to take a moment to pause and ask is there anything we could be forgetting that needs to be put in the orders when they leave the room.
We implemented that little 19-item checklist in eight hospitals around the world. We deliberately went to some of the top places: University of Washington Seattle, Toronto, London, Auckland; and to poor places: rural Tanzania, New Delhi, Jordan, Philippines. In every hospital we had a reduction in complications. The average reduction in complications and deaths was over one third.
TM: There isn't a specific one for splenectomies?
AG: We may reach that point. The aviation world started out with a simple set of checks for any kind of airplane, and then eventually developed checks for each kind of airplane and each kind of situation. We probably will evolve in that direction, but there's a set of principles that they've embraced, as have people building really immensely high skyscrapers: You can't reduce it all to a recipe.
The most important thing is to have a series of checks in place that don't take power away from people, but make it more likely they can use their brains effectively as a group. It emphasizes that as a team, you're going to have situations where you have to make decisions on the spot. But do you know who you are and what your roles are? Are you clear about your goals before you start?
It sounds really dumb. We probably do something like a checklist or next steps every time we have a meeting with six people in a room trying to come to a decision. Yet we walk out of that setting into our expert world and stop doing it.
And it's not just true for medicine. In the last three years for which we have data, there's been a 36 percent increase in lawsuits against lawyers for legal mistakes. Most common mistakes are clerical and calendar screw-ups, and errors in applying the law. The legal world is aware of the increase in specialization and division of responsibilities and the communication gaps that underlie this.
We saw it with our inability to keep the Christmas terror bomber off the plane. This is not just about dictating what everybody has to do, but about making people out at the edges more effective.
TM: How has your checklist been received? It's most necessary where complexity is deepest, yet that's where our sense of expertise is highest.
AG: There's tremendous resistance to it in medicine and in many other fields. We surveyed people three months after they'd used the checklist, and there was a real shift. In the beginning people were very skeptical, but at the end 80 percent said it wasn't that hard to use, it improved teamwork, and we caught errors.
But there were still 20 percent who didn't like it, who said this is a waste of my time, it takes too long, it doesn't make anything better, we were doing fine without it. Then we asked them one more question: If you were having an operation, would you want the team to use the checklist? Ninety-three percent said they did.
TM: I love that.
AG: That's a reflection of the fact that we have great confidence in ourselves and no confidence in other people.
We have made a transition in our world. We used to deal with problems of ignorance--we didn't have the science to understand how to grapple with illness or our natural world. Now we've developed a volume of knowledge that exceeds our individual capabilities as experts. So we've begun to confront a problem philosophers have labeled ineptitude, meaning: knowledge exists, but people aren't applying it correctly.
The public is losing trust in experts of all kinds. They were willing to forgive experts and leaders in a world of ignorance. If you saved my life a century ago, you were a miracle worker. You were grappling with mystery, and doing the best you could against it. We forgave leaders when they failed. Not any more. Not when your failures are because of ineptitude.
“What do you mean, my mother picked up an infection in the hospital, and is now in the intensive care unit because someone didn't wash their hands?!”
“What do you mean, three different people had information that could have kept the bomber off that plane and they didn't put it together?!”
This is one of the underlying reasons for the anger of a Tea Party looking at Ivy League experts who say, “I know how to run the businesses of our world,” and “I know what you need for your medical care.”
There's a set of values underlying this: humility about our abilities in the face of the complex vision of what we're trying to pull off. If we don't recognize that, if we don't convey that, not only will we fail to save lives, we will lose trust -- and that's fundamentally important.
The second part connects with health care reform. Rather than fear a world of rationing, we must instead recognize that the best places in the country are also achieving lowest cost. These are places that are working to make the whole system of care function in ways that ensure that harm is reduced, quality is higher and resources aren't wasted along the way.
TM: Can implementation of a checklist contribute?
AG: There's a deeper idea here. Health reform debates have been focused on insurance arguments, but the cost and quality issues really originate when the clinician is sitting with the patient making decisions about what to do.
We have two big problems: the incentives run in the wrong direction, and we aren't using the tools that can make it better.
Here's an example: A children's hospital tried out a series of checks to improve care for kids with asthma. This involved things that you normally aren't paid for: phone calls to families to be certain that kids have their inhalers and are using them, making sure homes are inspected for mold and dust mites, things like that. It cut their rate of admissions for that group of patients by more than 80 percent. Absolutely phenomenal. Saved money and improved health.
But guess what their number one source of revenue is? Admissions for kids with asthma. If they expanded this project to their whole population, they were looking at bankrupting themselves. Reform has to be about not just insurance issues, but we must make sure front-end decision-making moves us in the right direction.
We don't know the master plan for making this happen. We know there are problems with the fee-for-service system, that only pays the hospital when the patient is admitted, only pays the doctor when they're sitting with the patient. We're paying individuals for quantity instead of organizations to achieve goals.
There are incentives in the health reform plan to put such checks in place, but it means medical communities reinventing themselves at the front line. There are experiments in giving communities an incentive to pay a bundled price for asthma, for example. Whether kids are being seen in the hospital or the doctor's office, the care of their population for the month or the year would be a bundled fixed price.
We need measures to see what raises quality and lowers cost. These are the conversations we need to be having right now. This is our next step for making a better health system.
TM: I hadn't realized that embedded in the reform bill are a lot of pilot programs, experiments.
AG: Republicans made great fun of this: “To reduce costs, we're going to do pilot programs…it's wimpy, it's weak. Costs are going to explode, we shouldn't even embark on the experiment."
Some people believe that the only way to make health care work is to ration it. Another group says we'll never have the stomach for rationing, therefore we shouldn't cover the population under any circumstance because we'll never be able to afford it. But there are communities that provide higher quality at lower cost. They include places like Kaiser Permanente, where the physicians are on salary and really focus on being organized. Places like Cleveland Clinic are achieving extremely high levels of quality with lower intensity of care. They're less likely to be over-treating or under-treating patients. But we don't know how to take that model and put it in a brand new place.
TM: I've always assumed that single-payer or Medicare-for-all has the distinct advantage of lower administrative overhead. Whether because you don't need to make a profit, you don't need to advertise or market as much, you don't need as much paperwork. I believe the numbers are something like 4 percent overhead for Medicare and 20 percent for private health insurance – and I think I'm being pretty conservative in both cases. That's 16 more cents of every dollar that's going to health care. Is there a compelling argument against that?
AG: No, but there's a large portion of the public that feels that having government or a single entity controlling health care is taking away their freedom. We are in a fierce argument over a set of values.
TM: But most of them will someday be on Medicare, or they or their parents already are.
AG: And it's not that we love the insurance companies. We don't feel that they're any better bureaucracies than the ones we deal with in government.
I think it's actually going to be a very interesting next five to 10 years. Reform will make the insurers much more transparent and make it much harder for them to compete the way they used to. When choosing insurers, you'll be able to see which ones have more money going to profit and overhead.
Medicare has usually been out of the box faster driving change that improves care and lowers cost, but no one has managed yet to solve this problem in any lasting or substantive way. In the next couple of years there should be at least one community that commits to higher quality and lowering costs, not just bending the curve of inflation.
TM: You mean a geographic community?
AG: I mean a town, a city, a county that says we will be about the solution. We will take the best of the tools offered by private insurers and the reform plan and begin trying to do it. And we will learn very quickly who's a help, who's not a help.
When it comes to coverage, reform will be historic. As a cancer surgeon, I've seen many patients through the years fighting for how to take care of their cancer -- because they didn't have coverage. That will be gone. What won't be gone is the threats of increasing costs. We talk about reform as if it's a first step on doing something about cost. It's not, it's a tool kit, and the choice for us is whether we begin trying those tools or not.
We will have fierce discussions three or four years from now as we learn what's working. If it turns out that for care of kids with asthma, teams that have salaried positions do better than the ones who have fee-for-service, we will have a national argument three or four years from now about whether we make all physicians begin making that transition.
Often in the past we've had pilot programs that showed us good things, and lobbyists killed them, but if we don't try, we're saying that we can't fix health care. Then we're doomed as an economy.
I don't think that's the way we are as a country. Despite the fierceness of the anger and arguments that have been swirling around, reform has kept moving forward. We're at the brink of a transformative change: an effort to actually solve a major problem.
TM: You're not saying we're on the brink of solving it, but just that we're on the brink of taking it seriously.
AG: For years we haven't had the guts to take on big problems. We haven't had the guts to take on environmental issues, we haven't had the guts to take on energy issues. If we kill this, it's saying we can't do it across the board. We can't even start.
TM: You worked in the Clinton White House when they were putting forward their healthcare reform plan. What do you think of Obama's methods? – not just with health care, but with financial regulation, climate and energy legislation. He outlines broad principles and then throws it to Congress, which ultimately means the Senate. I believe the Senate – and he knows this having been a senator – is the body most beholden to campaign funders.
Max Baucus, who gets only 13 percent of his funds from the State of Montana, 87 percent comes from people who have business with the finance committee; Kent Conrad, very similar situation; Joe Lieberman, from a state where insurance might be the largest industry….These guys end up having enormous power. Is that any way to arrive at the best solution?
AG: I'm not a campaign finance reform expert, but it's become clear to me that the power of the filibuster exacerbates the influence of money, giving the 41st senator unbelievable power. Scott Brown was elected in Massachusetts by saying he would be that 41st senator and could kill health reform.
There's something wrong when the representatives of less than 15 percent of the population have power to stop what the majority in the country want to achieve. California, similarly, struggles over the two-thirds vote in budget battles. Lobbyists then become very powerful, because you don't have to win the community, you just have to win one person.
TM: Finally, I know you listen to your iPod in surgery. What are you listening to these days, and what are you reading?
AG: Latest download probably Vampire Weekend's new album, which I really like. The band I think everybody should know about is Frightened Rabbit out of Scotland. Unbelievable. Their last album is called The Midnight Organ Fight. I love them and they get no attention. I'm reading Ludmilla Petrushevskaya's collection of macabre fables, There Once Lived a Woman Who Tried to Kill her Neighbor's Baby.