The Beauty of Checklists

Ben Bryner -- Atul Gawande has a great piece on The New Yorker's website about the power of checklists to transform health care, particularly critical care. I’ve basically declared myself a “Gawande groupie,” so I enjoyed this article where, in traditional Gawande fashion, he starts off with a case of a patient he saw, and then looks at the origin of the pre-flight checklist in aviation and its impact on safety. Then he identifies one particular physician who brought the concept to medicine, generating checklists for every little step of some procedures commonly performed in the ICU. After describing the astounding effect these ICU checklists have, he outlines the extent to which the checklist has been adopted elsewhere (not much), and concludes with another short but gripping case.

Gawande also talks about the widespread resistance to the idea of a checklist, since some people are afraid that using a checklist will take the art out of medicine and leave cold, dispassionate automation in its place. On the surface, this makes some sense. Patients certainly don’t want to be treated as simply fodder for an algorithm, as just another row of data in a spreadsheet.

And sometimes it seems like there’s already too much of a checklist-approach to medicine: every lecture in medicine seems to follow a dry checklist of its own. Anyone who’s been to a medical school lecture or grand rounds recently will recognize it:

1. Introduction while latecomers trickle in

2. Statistics on the extent of the problem, this being a plea to the audience not to tune out the lecture quite yet

3. Diagrams of the molecular pathophysiology of disease (usually featuring arrows flying in from the side of the screen)

4. Lists of treatment options and side effects

5. A New Yorker cartoon, this being a last-ditch attempt to make the lecture memorable

Check, check, check, and check.

It’s easy to see why people would not want medicine to turn into something this boring and formulaic. But checklists really do the opposite; they take a large part of the intellectual work out of the patient’s management, leaving more time for real thinking. This allows physicians to spend more time considering the twists of an individual case. By getting to know the patient better (which is itself an obvious benefit), physicians can really apply the art of medicine by adjusting the checklist and interpreting the evidence to fit that particular patient.

What about the fact that not all patients will fit into the algorithm? This is true; of course no real patient will fit the checklist perfectly, just like patient gowns don’t fit any patients perfectly. But a checklist has the potential to let a physician spend less time trying to remember all the basic preparations for a procedure like inserting a central line, and more time talking to the patient, considering the patient’s own special circumstances, monitoring the patient’s status, and anticipating problems before they occur.

And besides that, who says a checklist has to always detract from the artistic quality of an endeavor? Consider Gawande’s article itself; it follows pretty much the same overall pattern as all of his articles, but his writing and analysis are still fresh and engaging.

Before medical school, I’d never have imagined being interested in checklists, let alone interested enough to read an article on it outside of class. But the third year of medical school certainly gave me a new appreciation for and fascination with things like this; something simple that can make it easier to apply the art of medicine and get better results is exciting now.