Atul Gawande was the recent guest speaker for the Cleveland Clinic Foundation’s “Ideas for Tomorrow” lecture series. My personal reservations and outright shock that anyone would think the CCF a “model for healthcare” aside, the Clinic does manage to get some interesting and big name speakers to come talk for free in Cleveland. As a student on a budget, I really do appreciate how the CCF is spending its own money to pay for these speakers and put them up in one of two on-campus hotels all in the name of refunneling their profits to remain a “non-profit” entity who won’t pay property taxes.
All things aside, Gawande, while an articulate and interesting speaker, had a hard time actually putting together a coherent theme for this talk aside from the umbrella topic of “healthcare” and all the ornaments attached to it. In many ways, it was a bit disappointing as he basically talked of themes previously rehashed in all three of his books with minimal transition and then spent the last half of the lecture on a book tour to promote his latest, “The Checklist Manifesto“. Gawande touched on the various problems ever constantly regurgitated by popular media and political pundits including how to build a better and more efficient healthcare system, how to go about providing better healthcare, how to pay for healthcare, and how to fix the lack of relationship between quality of care vs cost of care. Gawande offered nothing new insight or opinion wise on any of these topics, unfortunately. He ended the talk with on a personal note, detailing his roots to Ohio (his family is from Athens, OH) and his family’s own recent struggles with disease. Gawande stated that he hoped he and the healthcare industry could do justice to the millions of current patients like his father and to provide for better healthcare to his children in the future.
Gawande’s latest book details how the concept of checklists can be used in seemingly complicated and dynamic systems (medicine, aviation, nuclear reactors, etc) to increase safety. Gawande and the WHO are working together to implement OR safety checklists into everyday operation in all hospitals. From their pilot studies and from independent smaller studies, research results indicate that having these checklists have decreased patient mortality and morbidity significantly and are applicable to both third world hospitals and academic research powerhouses of the Western world.
The most interesting part of Gawande’s talk for me were the three slides he used to detail how the OR safety checklist came about. It’s an adapted system from the aviation industry and the key points to it are 1) identify problems within a workflow, 2) identify “pause points” where checklists can be implemented to prevent/avert crisis, 3) trial a checklist, 4) revise the checklist, 5) repeat. Checklists are more than just “how to” steps, they can also be used in a way that makes clear each persons role on a team. As anyone who’s worked in groups can attest, teams that work the most efficiently aren’t necessarily those with the smartest individual members but are instead those groups where each individuals roles are clearly delineated and members do their jobs.
To illustrate the utility of checklists, Gawande told the story of US Airways flight 1549 that Captain Sully Sullenberger safely landed in the Hudson Bay without casualty after both the jets engine went out due to Canadian Geese. Sullenberger and his co-captain had never flown together prior to that flight, however per FAA regulations during the pre-flight checklist, all the gathered flight personnel went through and listed what their roles would be should engine failure occur. The co-captain would be responsible for running through the necessary steps in order to get the engine back online (via a checklist), flight stewardesses would be responsible for maintaining calm in the cabin & reiterating safety instructions, and Sullenberger would be free to do the most important thing – fly the damned plane. When the engines went out, each member of the team went on to do their respective jobs, allowing Sullenberger to not worry about all the other little and big things so he could concentrate on landing this “brick” on the water. Gawande stated that this story reiterates the importance of checklists, running through each team members roles during crisis situations, and how this tool can be used in a very dynamic and complicated system.
Gawande likened the use of OR and other medical checklists as cost decreasing tools that should be used to avoid or reduce “critical events” in patients – anaphylaxis, shock, wrong medications, hospitalization, etc. He admitted that the biggest obstacle with checklists is getting medical professionals to buy into the idea that an extra 3 minutes up front will ultimately mean a significant decrease in problems down the line. As a medical student who’s seen this “time out” procedure in action at the CCF, private and county hospitals in Cleveland and elsewhere, I can attest that it’s not just the attending surgeons who complain and balk at it, it’s everyone from the scrub techs to the anesthesiologists to the residents to the person in charge of doing the “time out.” Medicine’s greatest hurdle to the checklist is the same as it’s been for the introduction and adoption of any new process – it runs counter to “how things have always been done”.
My preceptor in family medicine told a story of how as a resident in the early 1990′s on a surgery rotation, he was reamed out and yelled at for marking the patient’s site of surgery with a Sharpie. Today, marking the site of surgery is required by JCAHO for patient safety. This preceptor is also someone who’s already implemented and used the concept of “checklists” in his primary care practice with great success. He has checklists for various chronic diseases that he runs through during a “health maintenance” visit to make sure patients are optimized medication, lab result, and social situation wise for their given disease. He also has these patients come back at regular 1-3 month intervals where is runs through this checklist again to make sure they haven’t fallen off and are up to date still with the latest in evidence based medicine. Some people may balk at the idea of seeing their GP every few months when “there’s nothing wrong” and call it a waste of money & resources. However, having recurrent visits with the same patients for their chronic illness is also a great way for GP’s to provide motivational interviewing and counseling on a regular basis to help patients make the necessary steps that are the hardest to do but could potentially save their lives (losing weight, quitting smoking, starting exercising, dealing with various addictions, etc). Seeing patients regularly and tracking their labs and vitals with each visit is also an important way for any GP to be able to spot trouble before it becomes a crisis. I’ve seen him diagnosis early stage renal impairment while still in a reversible stage due to his systematic monitoring of the patient’s hypertension and Cr levels. He’s also diagnosed a recurrence of prostate cancer in one of elderly his patients after seeing a doubling of PSA (despite being within normal limits) after many years of steady state low values.
For this preceptor, he’s found his own way to utilize the idea of the checklist in a very dynamic and ever-changing healthcare environment for, what I believe, is the betterment of his patients. I think in the long run, as the inertia is overcome, more and more of the medical field will take to the idea of the “medical checklist”. I especially hope this is the case with my generation of doctors who will be trained under these “new ideas” and guidelines.
Check, Check, Checklists
