Wednesday, January 13, 2010
Atul Gawande's Checklist
Dr. Atul Gawande is one of the best physician writers of this decade. A Cancer Surgeon at Harvard Medical School, he also writes for The New Yorker and has written two best selling books, Complications and Better. Now he is on the speaking tour for his new book, The Checklist Manifesto: How to Get Things Right, and I heard him speak last night. This guy is a great speaker and he makes his case clearly and with anecdotal stories that bring it home to the listener.
Gawande knows that medicine has become so complex that there are thousands of tiny steps and decisions that come together to create a good patient outcome. There are also a thousand ways things can go wrong.
I think of the knee surgery I just had. If one nurse or physical therapist didn't wash their hands before they touched me, I could have gotten an infection that would destroy the surgery. If I didn't get my intraop antibiotic before the incision, that is another way to get infected. If the anticoagulant wasn't ordered, I could have a deep venous thrombosis (a common and known complication). If my dressing was too tight, I could have had a skin ulcer that would delay recovery. All caregivers want to do the right thing...but as Gawande says; "We miss stuff because of the complexity of care".
Gawande and a team of researchers copied the airline industry and brought simple checklists into the operating room to navigate complex procedures. The surgical checklist creates a pre-op "time out" for the surgical team and a way for everyone to communicate verbally the details of the case so they are on the same page. Are antibiotics given? Check! How much blood is expected to be lost? Check! Are there any equipment issues? Check!
It sounds simple but there is significant push back from some surgeons for using a simple checklist. They say it makes no difference. It causes unnecessary delays. It is worthless and just another administrative hassle. Yet institutions that use the checklist show a significant drop in complications and better outcomes for patients.
Gawande made the point that health care reform is a way of organizing and paying for health care. But the real advances we make in patient care going forward will depend upon bringing caregivers together to deliver care in organized ways with the emphasis on patient outcome...not just on what we doctors are doing at that moment.
The surgeon constructed my new knee perfectly...but the entire operation could have been a failure if everything that should have happened post-op, didn't happen. Medicine is a team sport and team sports have game plans and everyone knows their role. Atul Gawande is spreading the message.
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