Dr. Atul Gawande
Want a hero?
Or a checklist?

October 11, 2010 -- What do you want from your doctor, heroism or checklists? Say you're going in for surgery. Do you want your surgeon to exhibit "expert audacity"? Here's how Atul Gawande describes it in The New Yorker, 12/10/2007, in The Checklist:

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... Checklists and standard operating procedures feel like exactly the opposite, and that's what rankles many people.

Or would you prefer that your surgeon follow a checklist as did the pilot Sullenberger who brought down his failing passenger jet in the Hudson River without losing a single passenger? He said he was no hero but was well-trained and following the procedures.

We Americans love to say of our advanced medical care that we had the best doctor... That our doctor is a genius... That a good outcome is thanks to that skill, that extraordinary person... But this is not a model that scales well nor is it conducive to widespread good outcomes. Only a few people get to be worked on by that genius. And if evidence-based medicine is truly at work, then the "genius" is simply following the best evidence, which every well-trained practitioner should do. (Here is Gawande in 1/29/2009 NEJM, A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.)

Dr. Gawande says that medicine should be more like aviation -- no pilot would fly without first running through his pre-flight checklist, and then using yet another checklist for each situation and task that arises. Checklists are so valuable that he has even made a checklist of steps for making checklists. Of Sullenberger he says:

...it wasn't flight ability, but instead adherence to discipline, and teamwork... Because there were checklists, and because everybody used them... The heroic part of that flight was not the flight ability of Capt. Sullenberger, it was the willingness of the entire team including the flight attendants, who... acted through their protocols.
For my doctor I don't want a hero. It's time to end the culture of expert audacity. I want a well-trained expert, equipped with the best evidence... and the best checklists!

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