Saturday, January 23, 2010

"a stupid little checklist"

From the New Yorker, where you can read the whole article. Very interesting-- hopefully with the recent publication of his book, we'll see more initiatives/investigation/implementation in this area.

Gawande recommends using checklists in hospitals, taking as a model those used by pilots, and test-run and developed by Peter Pronovost at Johns Hopkins, where he found in early attempts that "the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs." Here Gawande explains one of the reasons (in the article from 2007) why it will be some time before it is picked up in earnest.
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.

The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version.

In the NYTimes review of the book, the argument, or rather reservation, against a checklist's complete success is outlined:

Checklists may work for managing individual disorders, but it isn’t at all clear what to do when several disorders coexist in the same patient, as is often the case with the elderly. And checklists lack flexibility. They might be useful for simple procedures like central line insertion, but they are hardly a panacea for the myriad ills of modern medicine. Patients are too varied, their physiologies too diverse and our knowledge still too limited.

I have no experience in medicine, but my understanding is that the point of using the list on "simple procedures" is to reduce later complications, allowing doctors to focus on the "several disorders [coexisting]" without having to deal with new ones popping up each time somebody gets sloppy-- which is reprehensible when dealing not only with people's lives but in a system that, as a whole, values human life so much less than profit. Again, it will be interesting to see where this goes. [Image Richard Prince]

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