Even medical heroes should be patient

Atul Gawande

The author and surgeon reads from his new book, The Checklist Manifesto. 7 p.m., Jan. 8. The Study at Yale Hotel, 1157 Chapel St. $35. 203-245-3959, rjjulia.com.

Failures in medicine are routine. Checklists prevent many failures. Doctors need checklists. These ideas are the thesis of The Checklist Manifesto, the latest book by Atul Gawande. The Harvard surgeon and New Yorker staff writer argues that modern medicine is too complex for caregivers to remember to perform all the steps it requires. Instead, caring for a patient needs to become like flying a jet or constructing a high-rise — activities that rely on checklists.

The root of many avoidable medical mistakes, Gawande contends, is not a lack of knowledge. It's doctors' failure to consistently apply it. Over and over, medications are forgotten, preventable disasters aren't foreseen, abnormal labs go unnoticed. These days doctors need a kind of meta-knowledge: that of how to manage what they know. "I think we have been fooled about what we can expect from medicine," he writes. "Medicine has become the art of managing extreme complexity — and a test of whether such complexity can, in fact, be humanly mastered."

Checklists with simple reminders like "prepare for expected blood loss" and "administer antibiotic" don't replace medical judgment. Instead, they prompt doctors to "get the stupid stuff right," thus freeing up their judgment for subtle or unexpected problems. Just as importantly, checklists transform the culture of the workplace. When a team uses them consistently, Gawande argues, the result is a more disciplined and meticulous approach to care, accompanied by improved communication and teamwork. These would be welcome developments in the notoriously hierarchical halls of medicine, where lower-ranked people feel uninvested in details or too afraid to speak up.

Amid eye-popping accounts of surgical misadventures that demonstrate the importance of forgotten details, Gawande explores the use of the checklist in other professions that face complexity. He examines Wal-Mart's response to Hurricane Katrina. He reveals Van Halen's unorthodox way of using M&M's to ensure a safe stage (they bury a directive to provide non-brown M&Ms in a list of safety directions, so that if any browns appear in the band's candy bowls, they know they have a careless promoter). And he talks to venture capitalists who pick promising companies more successfully when they force themselves to be methodical.

Unlike pilots, who have relied on them for decades, doctors have not rushed to embrace the checklist. This is in large part because a culture of heroism has long underlain what doctors do. From Marcus Welby to Gregory House, doctors are portrayed as all-knowing, all-responsible leaders, and this is part of their self-image. Yet we must abandon the myth that the doctor's personal character and intellect are where the magic takes place. Gawande brilliantly shows that the "Master Builder" model no longer holds in architecture and construction — the cathedrals may have been designed and overseen by one genius, but no modern building possibly can be, and indeed the high-rise engineers he meets are proud of their checklists.

Gawande writes with vigor and clarity, and his book is all the stronger for being short. Still, one wishes he had included a more detailed discussion about multitasking and distraction — two factors contributing to medical error that may also be overcome by checklists. In addition, he oversimplifies when he compares airplane crashes and building collapses to medical mistakes. The first two represent final, catastrophic errors, while medical mistakes lie on a continuum from trivial to deadly.

Yet there are plenty of smaller mistakes in engineering, and it isn't clear that checklists consistently prevent those. Despite these weaknesses, he makes a persuasive case in an engrossing one-afternoon read that will change the way you think about professionalism. Doctors are consummate professionals, eager to be responsible. But Gawande makes us see doctor's role may constitute a kind of irresponsibility. In an era of unprecedented complexity, to be a medical hero is to step humbly away from the hero's role — and look down at a checklist.

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