Not long ago, I walked in on a group of medical residents inserting a central line catheter into a patient in the intensive care unit. They were gowned and gloved, working quietly over the patient’s neck, exposed through a small hole in a sterile blue drape, where a thick needle was entering under the collarbone. I noticed they had neglected to drape the abdomen and legs, but at this point it didn’t seem wise to interrupt the procedure, so I let it go. They had also apparently forgotten to don face shields and caps. I let that go, too. Like them, I wanted to get the procedure over with as quickly as possible before something bad happened.
Gawande, a professor of surgery at Harvard Medical School and a staff writer at The New Yorker, makes the case that checklists can help us manage the extreme complexity of the modern world. In medicine, he writes, the problem is “making sure we apply the knowledge we have consistently and correctly.??? Failure, he argues, results not so much from ignorance (not knowing enough about what works) as from ineptitude (not properly applying what we know works).
Gawande passingly notes that checklists could be used to improve weather prediction. But he doesn’t mention that weather is an inherently chaotic phenomenon: small perturbations in initial conditions can result in big, unpredictable effects. When Gawande writes that an investment manager he knows believes a checklist can help him reliably beat the stock market, the case seems to have been pushed too far.
Yet despite its evangelical tone, “The Checklist Manifesto??? is an essential primer on complexity in medicine. Doctors resist checklists because we want to believe our profession is as much an art as a science. When Gawande surveyed members of the staff at eight hospitals about a checklist developed by his research team that nearly halved the number of surgical deaths, 20 percent said they thought it wasn’t easy to use and did not improve safety. But when asked whether they would want the checklist used if they were having an operation, 93 percent said yes.
