There is a specter with a scalpel in one hand and a checklist in the other haunting surgical suites around the world. His name is Atul Gawande, and he’s a surgeon at Brigham and Women’s Hospital in Boston. In his latest book, The Checklist Manifesto: How to Get Things Right, he tackles the problem of how to reduce surgical errors. Among the most interesting findings: Cooperation and teamwork make for safer surgical outcomes and all surgical team members need the power to question and express concerns about the surgery. Democracy and surgery: Who knew?
Surgical mistakes are a serious problem. According to Gawande, Americans undergo an average of seven operations in their lifetime. Every year there are more than 150,000 deaths following surgery, and research has consistently shown at least half of these deaths and major complications are avoidable.
The Checklist Manifesto examines power, cooperation, and a changing work culture. It’s worth noting that, in every operating room, the divisions of class, race, and gender determine roles and responsibilities. The majority of surgeons and anesthesiologists are white, male, and upper middle class; nurses are overwhelmingly female, and those who clean and supply operating rooms are working-class people of color.
In no other area of medical practice are competition, hierarchy, and inequality as entrenched with potentially as lethal consequences. It starts with the training of surgeons. Surgeons’ lives are stolen from them. Training to be a surgeon can take up to fifteen years, and surgical residents regularly spend one hundred hours a week in the hospital. They are driven to physical and emotional exhaustion, and are often verbally abused and humiliated by attending physicians. This process of dehumanization is considered a rite of passage. The theft of a life and relationships outside the hospital earns surgeons entrance into an elite and financially lucrative corps and generates a sense of entitlement to unquestioned power and authority. The surgical suite becomes the fiefdom of the surgeon, and his personality, predilections, and pathologies set the tone. But no surgery can happen without a high degree of cooperation between all specialties, though that cooperation may be coerced and directed by the surgeon.
Operating rooms are run like assembly lines, and patients are the “product.” The pressure to perform more surgeries per day is great because they generate profits for hospitals, and surgeons are paid on a fee-for-service basis. More incisions, more money. This “speed-up” and greed is a setup for medical errors. Contributing to the problem is the vast number of unnecessary surgeries performed every year—for example, hysterectomies. It’s estimated that more than two-thirds of the 600,000 hysterectomies performed every year are unnecessary. Moreover, hundreds of thousands of women undergo unnecessary cesarean sections for the convenience of doctors’ schedules and financial incentives—cesarean sections are reimbursed at higher rates than vaginal deliveries.
In the first chapter, titled “The Problem of Extreme Complexity,” Gawande tells a thrilling medical tale about a girl who drowns and dies. A team of highly trained medical personnel at the hospital work on her for hours and days to bring her back to life. Gawande takes the reader through the surgeries, the high-tech medical equipment used, the brain swelling, the painstaking suctioning out of the water and debris from the girls lungs. It is a marvel of modern medicine that not only does the patient survive, but after five years, she had no residual effects from drowning.
It is this type of medical complexity that Gawande argues may be the source of medical errors. Complexity may be one factor, but the causes are more, in a word, complex than that. In the United States, the high rates of medical and medication errors are caused by a health care system that denies millions primary care, extreme competition at the core of the system, the private, for-profit insurance industry, the profound lack of planning and allocation of medical resources, an ongoing shortage of nurses, and the reckless pursuit of profit.
The American health care system is an investor-owned free market. It has multiple payers, with thousands of competing insurance companies, plans with different sets of regulations, and payment schemes that vary from state to state. The knock-on effects create byzantine bureaucracies and excessive complexity.
Competition has created a medical arms race that pits all of the health care industry’s players against one another: hospital versus hospital, doctor versus hospital, doctor versus doctor, hospital versus insurers, drug companies versus insurers, and so on. In this hostile environment, health care resources cannot be adequately planned to prioritize patient safety or to meet patient needs. Competition in medicine is a disaster, and yet we hear over and over from President Obama and the American Medical Association that more competition is needed to improve health outcomes. Gawande’s data prove the opposite. In the chapter “The Test,” he concludes from his study, “There was a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications.” In other words, cooperation not competition improves patient safety.
In order to develop a surgical checklist, Gawande investigates how checklists are used in other industries: aviation, investing, restaurants, and construction. In the chapter “The End of the Master Builder,” he interviews structural engineer Joe Salvia who asserts, “A building is like a body.” The human anatomy, Gawande adds, “has a skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring.” A high level of cooperation and planning between all the trades is crucial to erect any building, the author explains. And there is the ubiquitous checklist that is used to ensure building safety. Just as important, though, are strict building codes that have been developed over decades, often born out of tragedies like fires and building collapses.
From the world of aviation, Gawande gleans advice from pilots about the critical importance of flight checklists. In taut, terrifying, page-turning prose he tells the story of how a flock of geese flew into the engines of a US Airways jet shutting them down. This story has a happy ending. Captain Chesley Sullenberger safely glided the plane into the Hudson River. Not one life was lost. Yet more proof for Gawande that checklists work. The checklist is crucial, but as Sullenberger himself said, it was thirty years of flying experience that helped him stay focused and land the plane. The Federal Aviation Administration (FAA) also plays a significant role in aviation safety.
Gawande and his team of researchers developed a surgical checklist, and, working under the auspices of the World Health Organization (WHO), launched the checklist in eight countries, both rich and poor. At the hospital in Tanzania, there were thousands of patients but only five surgeons and four anesthesia staff. In the overcrowded Delhi hospital, there were seven fully trained anesthetists. In contrast, at the facility in Auckland, there were ninety-two. But when the data were collected, all hospitals were able to reduce the rate of surgical errors and complications. The surgery checklist, despite some detractors and nonbelievers, is a success and is now implemented in hospitals around the United States and abroad.
A checklist works by both organizing and interrupting the work flow. It forces a timeout to review the task at hand, be it surgery, composing a salad, or pouring a concrete floor. That is a good thing. But checklists don’t operate in a vacuum, and they don’t always work.
Atul Gawande is all about transforming complexity into simplicity to save patient lives and avoid life-threatening complications. He’s obsessed with getting things right, so it’s curious he was a staunch supporter of the Patient Protection and Affordable Care Act that Congress passed. The legislation not only reinforces all the complexity and competition in the current system—it adds even more unfathomable layers.
Here’s a checklist of health care principles for Dr. Gawande to adopt (some of them are based on the principles of the British Medical Association) that sets the bar even higher for patient safety and the reduction of medical errors:
- Recognize health care as a human right—everybody in, nobody out;
- Develop a single-payer, government-run, national health program;
- Use public money for comprehensive, quality health care, not profits for shareholders;
- Provide care for patients through cooperation not competition;
- Create safe staff-to-patient ratios;
- Create a system led by medical professionals working in partnership with patients and the public;
- Seek value for money but put the care of patients before financial targets;
- Eliminate racial and ethnic disparities in health care;
- Commit to training sufficient numbers of medical professionals by making medical education free.