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.