How checklists are transforming intensive care
You’re probably familiar with Atul Gawande’s writing on medicine for the New Yorker magazine, but if you’re not, his most recent piece will serve as a great introduction to his work. In the December 10, 2007 issue, Gawande, who is a surgeon at Brigham & Women’s Hospital in Boston, writes about how the use of detailed checklists are enabling ICUs to provide complex care and save lives in the face of what used to be extremely long odds. In addition to providing a fascinating nuts-and-bolts analysis of an interesting element of clinical quality improvement, Gawande gets at how what is now achieveable in the hospital is pushing against traditional ideas about what makes for good doctors:
Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.
