Checklists, Medicine & B-17 Bombers: Ha, Got You There

If you really, really care about your life, you’d better read this piece.

No kidding. This is scary stuff.

Although we’d registered Dr.Atul Gawande’s name on the periphery of our consciousness a while back, his new piece in the December 10, 2007 issue of the New Yorker was the first time we took a dekko at his writing.

And we are impressed. Make that mighty impressed by his new essay on how extraordinarily complex and dangerous (for patients) the practice of intensive care medicine a.k.a critical care medicine has become these days.

As our life spans and prosperity increase, it’s more than likely that most of us will end up in an intensive care unit at some time or the other.

While some of us will survive the ICU experience, many will not. Of those who do not, perhaps their lives could have been saved if only doctors followed checklists before embarking upon extremely complex procedures. Well, since the future is still not upon us, maybe there’s some hope for those whose lives will hang in the balance during their ICU stay.

Gawande’s thesis is simple – when doctors use checklists in intensive care, infection rates are dramatically reduced and lives are saved. 

To hold our interest, Gawande, an Assistant Professor of Surgery at Harvard Medical School, draws a compelling analogy of the increasing complexity of intensive care medicine with the complexity of piloting a Boeing B-17 bomber in the early days of the aircraft’s launch.

Dr.Atul Gawande
(Pic: Brigham & Women’s Hospital)

As Atul Gawande writes in the latest issue of the New Yorker:

Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.

Yet it’s far from obvious that something as simple as a checklist could be of much help in medical care. Sick people are phenomenally more various than airplanes. A study of forty-one thousand trauma patients—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations for teams to attend to. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for each is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters much.

After describing research studies conducted at Johns Hopkins in 2001 and later by Dr.Peter Pronovost on the use of checklists to tackle line infections and improve care for patients on mechanical ventrilation, Gawande has no doubts as to the conclusion of the study:

Checklists established a higher standard of baseline performance.

And how do checklists help in improving medical care for very sick patients?

Checklists help by improving memory recall – particularly with mundane matters that may get overlooked in the hectic frenzy of events in the ICU – and in explicitly outlining the minimum expected steps in complex procedures. Then, there’s the cost savings that could easily run into hundreds of millions of dollars if not more.

But Gawande cautions us that checklists are not a grand panacea for all our ailments:

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.

So, given its obvious benefits are checklists being widely adopted in America?

Sadly, the answer is No and the chances of checklists becoming standard operating procedure anytime soon is very low.

Why – because of resistance from some doctors to the notion itself, skepticism from other doctors that checklists will work and failure of the medical system to pay as much attention to delivery of health care as is being paid to understanding disease biology and finding effective therapies.

Although checklists have been proven to save lives and cut costs, Dr.Peter Pronovost, the pioneering Johns Hopkins researcher, is skeptical that checklists will ever become as ubiquitous as stethoscopes.

Thanks to Gawande, the simple English word checklist has now taken on a new meaning for us as it should for you too, dear reader.

It’s a pipe-dream sure but if a lot of us read Gawande’s fine piece and then spread the word of the importance of checklists in intensive care medicine surely some good will come out of it.

One Response to "Checklists, Medicine & B-17 Bombers: Ha, Got You There"

  1. ★TRΞY☆   October 30, 2008 at 6:35 pm

    Interestingly I advised a stressed out doctor friend of mine to use checklists. It helped relieve his stress a lot. The doctors are too busy to recognize the importance of a simple spreadsheet, I guess. Responds:

    If we remember our George Eliot right, Silas Marner lost faith only in God and Man…but we’ve lost faith in God, Man and Doctor.

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