Thursday, February 4, 2010

Atul You What

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Atul Gawande
Daily Show

It's not that I'd argue against surgical checklists. Nor do I take issue with the data about lives saved (although I'd like to see them in detail.) It's just that it blows my mind.

Maybe it's me; maybe it's my training. Having started work in the surgical field forty years ago, it astounds me that such a simple checklist can save so many lives at so many institutions. What it tells me is that there are a lot of inferior institutions out there, and inferior surgeons. Dr G's institution included, maybe. Because the sorts of errors the checklist is said to prevent ought not need such a checklist in the first place. People ought to perform better than that. That they don't, that they need such a procedure, says a lot about our health care system. None of it good.

In the thousands upon thousands of operations I did, I ALWAYS spoke to the patient while s/he was fully awake in the pre-op area. (Okay, there may have been rare cases when I didn't, due to some sort of emergency or other. Rare.) In addition to re-telling them the plan, soliciting last-minute questions, trying to reassure them, I'd ALWAYS state the operation and, when relevant, point to -- touching, usually -- the side on which we'd be operating. Breast, hernia, whatever. In the operating room, I'd ALWAYS confirm with the anesthesia person or circulating nurse that an ordered pre-operative medication had been given. If there were special instruments I'd be needed, I'd ALWAYS check to be sure they were there.

Since the 70's, I'd been doing a checklist.

So here's my point: how can it possibly be that -- in academic centers, ferchrissakes -- such behavior hasn't been routine? If checklists have made such a big difference, then the hospitals that are using them and the surgeons operating there shouldn't have been in the business in the first place.

Dr Gawande -- whom I admire, whose books I've read, whose endorsement I sought for my own book (I sent him some snippets, which he said he enjoyed, but he said he had so many endorsement requests that he'd stopped doing them) -- analogizes to pre-flight checklists pilots use. He says things have gotten so complex in the OR that it's not reasonable to go through steps before starting. Fair enough. But the checklist hardly reflects that complexity. Here it is:

It's neither comprehensive, nor, one would think, beyond the expected routines. (Okay, I didn't always introduce myself or the members of the team. Maybe because we worked together all the time: maybe that's part of their problem?)

I'm not saying it's unnecessary. I'm just saying it's shameful that it is.

(I did write about this once before. There's not a lot new in this post, I guess. It's just that every time I see something about it -- the above clip was last night -- it tweaks me again. And it makes me realize how much, in many ways, I miss doing what I did. And how much, in many other ways, I'm glad I'm outta there.)


  1. Ummm Sid, arne't you the one who left his ATM card in the ATM machine??(I KNOW, the "M" in "ATM" stands for Machine)
    Or did you forget that already???
    I LIKE checklists, but then again I was the kid with his mittens handcuffed to his wrists.
    Once forgot to turn off the Forane after a case...embarassing when you find the whole OR staff in Stage 4 anesthesia...


  2. To reverse a saying: an "ought" is not an "is".

    It's sad that it's necessary, but given that it works there's absolutely no reason to resist the lists.

    In fact, I fear that far too many surgeons &c *are* gonna reject adoption exactly because they consider themselves too good to need something so trivial.

    I read about this study some years ago when Ben Goldacre linked to a New Yorker article (I think), and forwarded to a nurse friend of mine. I was appalled at the trouble Gawande had with the ethics board - that he couldn't collect data on efficiency without obtaining consent! I understand the need for ERBs but that was completely ridiculous.

    I hope that simple measures

  3. I enjoyed this post Dr S. Read it in my feed when it went up.

    I wonder why people can't be counted on in something as serious as a surgery to get it right the 1st time ..always do what you are always supposed to do? Seems like a no brainer.

    Then you hear some horror story where the wrong kidney was removed or whatever.

    But all the derails ..they should just be done correctly.


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