Must Read Summaries - The Checklist Manifesto - Atul Gawande

The Problem

Extreme complexity and specialization

Modern medical care is a good example of how professional fields of expertise have developed in recent years with the coming of the information revolution. Todays medical practitioners are extremely educated and superbly experienced in their areas of expertise, but that increase in specialization is bringing about some unintended consequences. Everyone is getting so busy in their respective areas of expertise some basic and preventable patients deaths are occurring.

Medical care in the twenty-first century is highly impressive. Saves are made daily of patients who just a few years ago would have faced certain death. For all those achievements, however, a surprising number of patients still die due to some very basic human errors:

• Medical machinery which has not been properly serviced and therefore which is not working when it is needed in an emergency setting.
• Teams that cant get moving fast enough in order to perform a needed procedure.
• Someone somewhere along the line forgets to wash their hands and an infection takes hold with fatal consequences.

The World Health Organization has estimated there are now more than thirteen thousand different diseases, syndromes and types of injury. For nearly all of them, science has provided things that can be done to help either by curing the disease or by reducing the harm and misery involved. The challenge is for each condition, the treatment steps are different and they are almost always complex. The average clinician has about six thousand drugs and around four thousand medical and surgical procedures to choose from. This is a lot for someone to get right, even someone who has been trained for many years.

On any given day in the United States, around ninety thousand people will be admitted to intensive care. That means over a year, some five million Americans will receive intensive care and almost everyone will get to see the inside of an intensive care unit over the course of their lifetime. According to one study, the average patient in intensive care will require 178 individual actions per day administering a drug at the right time, turning the patients regularly to avoid bed sores, having someone bathe them and change their sheets without disturbing tubes or lines which may been inserted, etc. Every one of these actions involves risks and doctors and nurses do a remarkable job in minimizing mistakes but even an error of just one percent will mean two mistakes per day per patient are being made.

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending onhow sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.

Atul Gawande

The medical professions answerto all this increasing complexity thus far has been:

Areas of specialization have been broken down further into more narrowly focused areas of superspecialization. Clinicians train until they can do one thing better than anyone else. For example, where there were once anesthesiologists who handled pain control and patient stability during operations, today there are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists and many more.

In the early twentieth century you could get a license to practice medicine if you had a high school diploma and a one-year medical degree. By the end of the twentieth century, to become a doctor you needed a college degree, a four-year medical degree and then an additional three to seven years of residency training in an individual field of practice like pediatrics, surgery, neurology and so forth. Today, even that level of preparation is inadequate. Most doctors also do fellowships which involve one to three years of additional training. Doctors typically dont start practicing independently until they are in their mid-thirties of older.

The result of the recent decades of ever-refined specialization has been a spectacular improvement in surgical capability and success. Where deaths were once a double-digit risk of even small operations, and prolonged recovery and disability was the norm, day surgery has become commonplace. Yet given how much surgery is now done Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made. Medicine, with all its dazzling success but also frequent failures, therefore poses a significant challenge: What do you do when expertise is not enough? What do you do when even the super-specialists fail?

Atul Gawande

Whats happening in the medical care field is also happening in one industry after another right across the entire economy. In the construction industry, for example, the traditional approach to building anything was to go out and hire a master builder who would design, engineer and then oversee construction from beginning to end. Master builders were responsible for the construction of major buildings like the Empire State Building and the United States Capitol building. By the middle of the twentieth century, however, construction went down the same road of specialization medical care has followed. First architectural and engineering design split from construction and then piece by piece each area of construction know-how got split off into its own area of specialization. The building industry today has at least sixteen trades including architects, structural engineers, electrical engineers, mechanical engineers, ventilation engineers and so on. The entire industry has been forced to evolve in order to function effectively.

Increasing complexity has also been a problem in the aviation industry. In 1935, the U.S. Army Air Corps held a competition for airplane manufacturers who wanted to build the militarys next-generation bomber. Boeing Corporation entered its Model 299 which looked like a figurative slam dunk it carried five times as many bombs as the army had requested and had almost twice the range of previous bombers. On October 30, 1935, a crowd of army brass and manufacturing executives gathered to watch the 299s maiden test flight.

The plane roared down the runway, lifted off smoothly and climbed normally to three hundred feet at which point it stalled, turned on one wing and crashed to the ground in a fiery explosion killing two of its five crew members including the pilot, Major Ployer P. Hill. The army had planned to order sixty-five of the aircraft but in light of the crash, the army ordered Douglass airplane instead which almost sent Boeing into bankruptcy.