December 12, 2017

Book Review– The Checklist Manifesto: How to Get Things Right – by Atul Gawande

–LMRasmussen, DVM, MS, DACV

Dr. Gawande has written several insightful books and many articles that speak to me professionally. His latest, The Checklist Manifesto, put to words something I have been dancing around for years. My brain can’t hold it all, and the brains around me can’t hold theirs either. Let’s put it down on paper and put it into a practiced routine. Leave our brains alone for the other essential things! His own words do better justice to convince you to read this book and put its tenets into action, so I give you these excerpts from chapter one of The Checklist Manifesto by Atul Gawande.

“In the 1970s, the philosophers Samual Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed, is ‘necessary fallibility’–some things we want to do are simply beyond our capacity. We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is–and will remain– outside our understanding and control.

There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snow storms, save people from heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre point out, we have just two reasons that we may nonetheless fail.

The first is ignorance– we may err because science has given us only a partial understanding of the world and how it works. There are sky scrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude–because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about….

I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It is not money or government or the threat of malpractice lawsuits or insurance company hassles–although they play their role. It is the complexity that science has dropped upon us and the enormous stains we are encountering in making good on its promise….

Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. What do you mean half of heart attack patients don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors? It is not for nothing that the philosophers gave these failures so unmerciful a name– ineptitude….

For those who do the work, however– for those who care for the patients, practice the law, respond when need calls– the judgment feels like it ignores how extremely difficult the job is. Every day there is more and more to manage and get right and learn…

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields– from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably. Knowledge has both saved us and burdened us.

That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy– though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.

It is the checklist.”

Below is an example of a pertinent, adapted checklist. See what you think; work it; make it useful to your situation; and see if it frees the brain and improves patient care!

Download the checklist here.