"Checklist Manifesto": Healthcare reform rock star

Talking medicine, checklists and alternative music with New Yorker staff writer and surgeon Atul Gawande

Published February 2, 2010 11:20PM (EST)

Atul Gawande
Atul Gawande

Dr. Atul Gawande has only been a practicing surgeon for six years, and he is still just an assistant professor at Harvard, but his game-changing New Yorker essay about the gobsmacking cost of healthcare in McAllen, Texas, became required reading in the White House. As a New Yorker staff writer, Gawande has long been known for his meditative, honest and lyrical essays about medicine, but his work became that much more important as healthcare exploded into a national conversation (and crisis).

Gawande's third book, "The Checklist Manifesto: How to Get Things Right," explores how doctors and other professionals, overwhelmed with the complexity of their work, have become more likely to fail. Gawande's proposed solution is simple and inexpensive, if not terribly sexy: a checklist. Sound too mundane? Keep in mind that Gawande proved, in conjunction with the World Health Organization, that doctors and surgical teams who use checklists save lives.

I arranged to meet Gawande on a crisp, clear Wednesday afternoon in downtown San Francisco while he was on book tour. The doctor arrived a few minutes early, so instead of looking out for him, I had my head buried in Paul Starr's "The Social Transformation of American Medicine," and my iPod headphones on. It was Gawande who got in the first question.

"What are you listening to?" he asked.

LCD Soundsystem, I told him, as we shook hands. Like me, Gawande is an alternative music fiend. Later he pulled out his own iPod, suggesting Bon Iver and a Scottish Band called Frightened Rabbit, whom he recently saw in a bar in Boston with 30 other people. "Maybe it's the surgeon in me, but many of their songs involve someone who has been either maimed or dismembered," he said. And later, we both agreed that Radiohead still ruled the day, and that as amazing as the Flaming Lips are, "Embryonic" wouldn't fly in the operating room, where Gawande famously plays music while he operates. But before that, we talked about how he influenced "Grey's Anatomy," his simple suggestion for fixing a sprawling problem and, of course, the ongoing debate about healthcare reform. (Note to readers: This interview took place a week before the election in Massachusetts.)

If you had to make a checklist of, say, three killer items that reform must address, what would they be?

First, it has to offer coverage for the population. We have to eliminate families going bankrupt because of healthcare bills. The second thing is not killing the deficit. The third has to do with delivering reform -- being able to begin providing opportunities for change that would begin phasing away from fee-for-service medicine.

Will this bill change what you saw in McAllen?

One of the things I saw was how fragmented and disorganized care was. Doctors are paid for doing things piecemeal rather than knitting care together in some meaningful way. And further, they were pursuing that as a business objective. The doctors were caught between maximizing the needs of their business and the needs of their patients.

I think the incentives in this bill will begin to provide opportunities for people who want to change that culture. The key moment that matters most is when the doctor -- who has control of 90 percent of spending -- sits down with the patient and has to make a decision about the right thing to do, and whether [doctors] are equipped to make the decisions that avoid wasted and unnecessary care.

But the entire success or failure of this reform package will depend on what we do in communities. If there's one community that manages not just to bend the curve but actually lowers costs and raises quality, then it will become the metric for reform. Then we need to determine how to implant them.

Let's talk more about that moment when a doctor is sitting down with his or her patient trying to decide what to do. When doctors are paid to do more, and patients often expect more, how are we going to make it so that doctors are doing the right thing? As we both know, that isn't always ordering more tests, drugs or procedures. Consider the recent outrage over the breast cancer screening guidelines, which recommended fewer mammograms. 

If we think of having to do it through Washington rules, we'll fail. Instead, it’s important that a doctor and patient [relationship] is part of a system of care that makes doing the right thing easier. For example, we’ve had tremendous growth in the number of CT scans we order, and it’s partly out of the belief that more can’t be a bad thing, even though they cost a lot and expose people to a lot of radiation. But also, the radiologists get paid for doing more scans, and there’s no incentive to moderate it. At my hospital, we decided to tackle this, because we got incentive from insurers to give it a try. Our solution, instead of having a committee or an insurance administrator decide, was to have an electronic system that required you to talk to the radiologist about your decision [to do a CT scan] when your reason fell outside of the established guidelines. The result is that we are below our 2005 ordering numbers while others have been rising.

That result didn’t happen by rationing. The radiologists were instructed not to deny a scan. Rather, it happened by one doctor talking to another doctor, comparing notes and deciding what the right thing to do was. 

You're talking about what happens between doctors, but what about the American health consumer? If I come to you and say I have a headache, and I tell you my friend down the street went to another hospital and had a head CT the same day, I'm going to expect and may even demand the same from you. How do you fix that?

I think that has to do with how we talk to patients, and to learn to have those conversations. Most of medical care is totally invisible to us, and just being able to see what a community does can have an effect by itself. The gray zone is usually not a patient pushing -- it’s how we deal with our discomfort about what we know and don’t know. It’s about reaching the point where the better investment is to consult with a colleague, or about asking the patient to come back in four weeks to recheck him or her.

But there are other tools. I was fascinated by one that pediatricians now are using to deal with antibiotic resistance and ear infections. Before, a parent might come all that way to see the doctor and expect something. Now [since studies show that most ear infections resolve without antibiotics], they write a safety net prescription for ear pain -- go ahead and fill this in 48 hours if it’s not getting better. As much as it sounds like these dumb little tools, how they help manage that social interaction is a chance for some real innovation.

In your New Yorker article, there is a moment that struck me, as a doctor. You were having dinner with a group of doctors from McAllen, and you told them just how costly the care there was. They didn't seem to have a clue about that. So how is it that we know how good a doctor we actually are -- and how do patients also figure that out? 

I think this is something that has been totally overlooked in reform. The National Center for Health Statistics is going to have to be equipped to produce that data, like we do for agriculture, and for economic needs like unemployment. The Medicare data we have now is only there because an academic center -- Dartmouth -- put it together, but that data is three years old. I haven't seen the real goods, which is pulling data from all insurers regardless of where a person is receiving care and putting it together with clinical information. How many operations are done in my country, and how many ended up with a disability or death because of it? How many people had a heart attack, and how did they fare in the hospital? We have that data on maternal and infant mortality, but that’s about it. The fact that we have no idea about how our health systems are doing now versus, say, two years ago -- that flabbergasts me. 

By the end of the book, I talk about how we’re obsessed with components in medicine: Do I have the best medicine, do I have the best doctor? The reality is that a doctor embedded in one system may get different results than if he or she were embedded in a different one. Some studies have started to show doctors getting different results when they work in more than one hospital. I think it’s much more critical for patients to see how good a system can be. Because care requires a whole chain of events.

So why in the world would you write a book about checklists, of all things?

What we're grappling with in reform or public health is immense complexity. We do 50 million operations a year in the U.S., with 150,000 deaths within 30 days. Five hundred thousand people are disabled, and half of those are avoidable. When we think about how we grapple with complexity, we've been using two solutions: super-specialization and technology. These haven't been good enough. When I looked at how other worlds like aviation and construction grapple with complexity, I found checklists.

But checklists are also an admission of fallibility. It's an admission that individuals aren't the only thing that matter, that chains of people and processes matter. Further, it's an admission that we can't handle the complexity that's coming at us. And I think that's the case across lots of walks of life.

For millennia, we didn't know why we got ill. Now, there are more than 13,000 diagnoses, 6,000 drugs and 4,000 procedures. Back when the main problem was ignorance, people gave doctors leeway. If you succeeded, you were a miracle worker. And if you failed, well, what could you do? But if you fail nowadays, it's because you didn't deliver on existing knowledge. That's infuriating. What do you mean my mom is in the ICU with an infection because someone didn't wash their hands? What do you mean that the bomber got on the plane to Detroit when there were three pieces of information someone couldn't put together? Checklists can help get at that kind of failure.

Why are people resistant to the idea, and why is it so hard to bring change to the culture of medicine?

A checklist feels like a judgment on who we are in a way that a drug doesn't, and I think there's a deep resistance to that. Also there's a reality -- because a drug costs money, prescribing it means revenue for somebody, while a checklist is free.

Also, we think what it means to be effective is to have it all in your head, to make the right move in the right moment and do it with our gut instinct. It took a long time to change aviation from a culture in which you were just great because you knew what you were doing to one in which, no matter how good you were, you weren't great until you used the checklist. And then you see a kind of joy in the discipline of it.

Besides a checklist, what is it going to take for future doctors to be successful?

Culturally, the shift from individuals to teams, and equipping physicians to lead teams that execute very complex things. Also, how to be a member of a team where you may not be the leader. There’s a couple of lessons given to pilots before they get on a plane. One is that their brain is fallible, and if you don't recognize that, you’re going to die and take some people with you. The second is that pilots get drilled and taken through simulations for complex planes in which you're part of a group. The first time you probably dealt with a major high-stress, chaotic situation was during a code as an intern your first week on call. That’s crazy. I think we ought to import the pilot training into what we do. I’m also fascinated by one experiment at the University of Nevada Reno, where they’ve combined parts of the medical and nursing school -- and co-teaching parts of classes so that both groups have the same language and know each other from the very beginning.

Your fellow New Yorker writer Malcolm Gladwell wrote a book called "Blink," which is essentially about how we make split decisions and judgments. Checklists seem the very opposite of that. Is your book the anti-"Blink"?

[laughs] In the second half of "Blink," Gladwell talks about the Diallo shooting, where the police put 44 bullets in a guy who was just sitting on his porch in New York. So I think he understands the cautionary nature of gut instinct. What he was interested in was how experts achieve the great gut instinct -- to look at a CT scan and see the tumor, or look at an EKG and see the heart attack without having to take the pieces apart. You need that intuitive capability, but you also need preparation upfront, which involves a check on what you're doing. You need to think about, as a group, what could go wrong, and are we prepared for it? Is everything available so when that moment happens and you need that intuitive capability, you're primed as much as you can be.

I understand your first book, "Complications," became the inspiration for "Grey's Anatomy."

It's a sore point. "Grey's Anatomy" was actually called "Complications" when they made the pilot. Every chapter in the book gets used as an episode. They have the blushing patient, the 23-year-old with the flesh-eating bacteria. But they didn't acknowledge it, and I didn't want to battle it. Mostly, I was flattered that they took an interest.

Now, the really flattering thing was a guy named Teddy Blanks, who made an EP called "Complications" based on stories from the book. He also wrote and recorded a song called "The Itch" based on my New Yorker article. That was one of the most gratifying things to me, to feel like people made a connection at that level. I sent him my book and he actually made a whole series of songs -- he's morbidly fascinated by medical things -- and included a cover of the Frank Black song "Headache."

And the checklist made it onto "ER" as well?

I worked with them on that episode, as a vehicle to help people understand what it's about. There's a four-minute scene with Benton fighting with another surgeon who wouldn't use the checklist and wanted to throw him out. And the checklist saves Carter's life. That was much more about the cultural differences in medicine. It was a huge part of our work. It was shown in hospitals here and abroad which were adopting the checklist.

You've been practicing for such a short time, yet you've done so much. When, someday, they put your picture up at Harvard, what do you want them to say about you?

I don't know. My teams once asked me what our mission statement is. All I could come up with is to do cool stuff that lasts. That's all I got. 

By Rahul K. Parikh

Rahul K. Parikh is a physician and writer in the San Francisco Bay Area. He wrote the Vital Signs column on Salon in 2008-2009. His pop culture-medical column, PopRx, runs on alternate Mondays.

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