The Checklist Manifesto: How to Get Things Right

May 4, 2010 9:22 am

Medicine, like so many other features of modern life, has become exceedingly complex. This has far-reaching implications, not only for how we understand the world but also how we most effectively meet challenges such as those encountered in a field like medicine. Any attempt to respond to complexity will be necessarily multifaceted. One potentially effective tool is deceptively simple: a checklist. This is Dr. Atul Gawande’s thesis in The Checklist Manifesto: How to Get Things Right. The very idea left me wondering if the book would be worth reading. After all, how can checklists help a hospital overwhelmed with desperately sick patients? How can a checklist help a surgeon when performing a delicate surgery?

The answers to such questions are somewhat surprising, although perhaps they shouldn’t be. For medicine is beset with preventable complications, many of which have profound consequences for both medical systems and for the patients whose care is often compromised. Consider the Leamington, Ontario woman who is currently suing for having a mastectomy done on the wrong breast, or a more common example, patient deaths due to hospital-acquired infections. Moreover, the history of medicine is filled with examples of relatively simple interventions having far-reaching effects on people’s health. Gawande tells the remarkable story of a program carried out in Karachi, Pakistan, designed to reduce the incidence of preventable illnesses such as malaria, pneumonia and impetigo. Soap was distributed to all families as well as a guide as to when people should use it and how. Soap, as it turned out, was regularly used in Karachi but not always when it needed to be. Many people, for example, did not wash their hands with soap before handling and preparing food. It was not so much the distribution of soap that changed all that, but rather the instructions that accompanied it. As Gawande suggests, the instructions constituted a checklist of sorts. The results of the program were impressive. The incidence of malaria, pneumonia and impetigo all decreased dramatically.

Gawande’s celebration of checklists is rooted in a subtle understanding of those social and demographic trends with profound consequences for medicine. This is what gives the book its intellectual heft. Indeed, there is nothing trivial in his assertion that checklists prevent complications and in so doing, save money and lives. As life spans grow longer in developing countries, for example, the types of illnesses and causes of poor health also change. Cancers are more common, as well as other diseases associated with aging. So too do the number of surgeries performed in hospitals. Yet the medical systems in such countries are typically profoundly underfunded and under-resourced. Gawande writes of doctors in countries as far-flung as Ghana who might be responsible for performing every aspect of a surgery, from administering the anaesthesia to monitoring the patient’s vital signs, to fixing the ailing body part. In such scenarios, the likelihood of serious, potentially fatal mistakes increases exponentially.

Yet it would be wrong to assume that checklists could only be useful in developing countries with underfunded medical systems. To make his point, Gawande draws a useful analogy between medicine and the decline of the “master builder” in the building industry. The construction of a modern building is so complex and so replete with the potential of disastrous, life-threatening errors, that no one person could effectively manage such a project — hence the proliferation of specialists who must assume responsibility for narrowly defined aspects of the construction process. Likewise, medicine is often so human health and illness so infinitely complex, that doctors cannot in many instances possibly assume sole responsibility for a patient’s care. To do so could be a recipe for error or missed opportunities for improved care. Thus, among the most important effects of complexity in medicine is a necessary dispersion of power and responsibility. Those involved in the delivery of health care increasingly assume specialized roles. Specialization obviously works to improve the quality of care, but it also creates new opportunities for error and a need for more effective forms of communication. Properly designed checklists go a long way to addressing these twin challenges of modern medicine. As Gawande suggests, they constitute a ‘mental safety net’ and facilitate necessary and productive forms of communication among the various members of a medical team.

Gawande’s two previous books, Complications and Better are both masterpieces of medical writing. In a style that is at once dispassionate, accessible and humane, we learn of individuals struggling to cope with cystic fibrosis, cancer, obesity and many among the myriad of other illnesses to which people are subject. The Checklist doesn’t resonate in quite the same way. There are fewer stories of individuals succumbing to or triumphing over illness. Nor does it have the range of his two previous books but the book is another fine example of Gawande’s clearheadedness and his commitment to both explaining and improving medicine. For these reasons, The Checklist Manifesto doesn’t fail to inspire.

The Wayfinders: Why Ancient Wisdom Matters in the Modern World

March 16, 2010 12:00 am

Wade Davis’s remarkable book,The Wayfinders: Why Ancient Wisdom Matters in the Modern World, is meant, in part, to debunk the antiquated theories of European anthropologists that turned their science into an agent of control over different peoples. Although such theories may seem like relics of Europe’s imperial past, Davis fears their ongoing resonance. Should we not simply allow the accelerated loss of languages that is occurring today? Is this not incontrovertible proof that more dominant cultures are in fact superior to those threatened with extinction? The answer to both questions is an emphatic no, according to Davis. On the contrary, there is much wisdom in ancient cultures.And although Davis celebrates the West’s capacity for science and technological advancement, he also insists that the culture is rooted in a world view that ultimately remains unsustainable. Climate change and all of its fearsome implications are the latest and most dire proof of this unsustainability. The lessons we must learn if humanity is to survive and thrive – that the world’s resources are not infinitely renewable, that the atmospheric conditions that make life possible are held in a delicate balance – were often better understood by ancient cultures.Davis’s book begins with a nod to the past and ends with a sombre but ultimately hopeful nod to the future.

His analysis and prose exude a deep respect for the ancient cultures to which he refers. Some critics will contend that the respect too often runs perilously close to romanticizing the cultures he is describing. There is indeed a romantic undertone to Davis’s writing. He is enthralled by the connections he uncovers between ancient cultures and the wind, the sun and sky and the sea. One senses that Davis feels more at home sailing the Pacific on a giant catamaran than he would, for example, in a big city. Yet this is what enriches both his analysis and prose. The romance, one feels, is what allows him to travel to the heart of ancient cultures and in so doing, uncover many of their brilliant achievements.Their brilliance exposes the lie that such cultures were inherently inferior to that of our own.

Davis’s immersion in Polynesian culture is a case in point. In the 16th century, Spanish sailors could not fathom how the Polynesian cultures they encountered managed to populate multiple islands in the Pacific Ocean, separated by thousands of miles. Their disbelief was rooted in a misunderstanding of equatorial wind patterns, which were predominantly easterly. Easterly winds would have made any attempt to travel to distant islands effectively impossible. The Spaniards, moreover, possessed all the modern tools of navigation, the peoples the Spanish encountered did not. If the Spaniards couldn’t navigate from point A to point B even with the aid of sextants, it was by definition impossible for the Polynesians to have done so.

As Davis demonstrates, however, equatorial winds were not always easterly. On an annual basis, the winds reversed direction and became westerly, thereby making travel possible. This was hardly an astounding insight, even at the time of Spain’s initial encounter with the Polynesians. What was astounding was the Polynesian capacity for navigation. All of the elements – the sea, the stars, clouds, the wind, birds and marine life – contributed to a remarkably subtle and complex navigational system. The shape and colour of clouds combined with their place in the sky were illuminating details for the navigator. Brown clouds foreshadowed strong winds; higher clouds suggested the likelihood of rain. Frigate bird flight patterns helped to determine proximity to land. Constellations were maps stored in the mind. Individual stars were used as reference points. Different weather patterns were discerned based on water waves. As Davis remarks, most remarkable of all, was their ability to simultaneously integrate all of these elements into a system of knowledge that made voyages of discovery possible. A writer of lesser skill may indeed appear to be peddling nostalgia in celebrating an ancient system of navigation that did not require modern technology. In Davis’s hands, by contrast, the celebration seems entirely worthy. For the Polynesian capacity for navigation remains a remarkable cultural achievement.

For Davis, the lessons of the Polynesians (and the Waorani and Canada’s First Nations) are clear. There are alternative ways of understanding and approaching the world to that of our own. To privilege one approach at the expense of all others is a form of cultural arrogance we can do without. Thus one challenge for secular democratic societies is to meaningfully draw on a pool of knowledge that is more global in scope. This, however, is no easy task. For culture and forms of knowledge are not easily separated. And absent from the many cultures Davis explores are those ideas that form the basis of a liberal, secular society. How, for example, can the forms of knowledge Davis celebrates be incorporated into societies in which the market remains the most important mechanism of change and science remains the lens through which we attempt to understand and change our world? Like many great books, The Wayfinders stimulates many questions for which there are no easy answers.

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