Wednesday, February 29, 2012

TED 2012: Is Your Doctor a Member of a Pit Crew?

Atul Gawande is a rock star. From the moment I started to read his book The Checklist Manifesto until the last word, I was spellbound. Gawande writes fluidly, simply, and with great insight about issues in healthcare.  He speaks as engagingly as he writes.

Checklists have worked in other industries, like aviation and major construction, to reduce errors. The Checklist Manifesto is about importing those ideas into medicine.  And Gawande showed how it worked.  As a result of this work in his own hospital, Gawande was commissioned by WHO to devise a surgical checklist that could be implemented around the world.  

Here's the checklist:
The checklist was piloted in eight hospitals around the world, ranging from a rural hospital in Tanzania to world-class teaching hospitals in Toronto and Seattle. There's a knack to making such a good checklist - it had to be general enough to be applicable anywhere, it had to cover the most crucial items, and it couldn't be so long that no one would use it.  The result was a 19-item, 2-minute check list with 3 pause points.  You can see how obvious some of the steps are on the list above.   It's standard that antibiotics are given before an operation to reduce the probability of infection.  Really, now, would people forget such a simple step?  Introducing yourself to everyone on the team?  Give me a break.  Surely that would be obvious, especially in a situation where unambiguous communication might be life-or-death in an emergency that could arise.  Apparently these things are not that obvious: introduction of this checklist reduced complications by 35% and deaths by a whopping 47%.  47% reduction in deaths!! Not by fancy new technology, but by systematizing what everyone already knew was the right thing to do.

In today's TED talk, Gawande talked a bit about check lists, but mostly he talked about the culture and philosophy of medicine.  Medical culture was established back in the days when medical knowledge was sparse, specialists were few, and doctors practiced heroic medicine.  There were few treatments that had been proved effective, and doctors were often heading into uncharted waters and you had to be bold to try a procedure that might help. 

Today, the medical environment is completely different.  There are known treatments for most diagnoses - over 4,000 proven medical and surgical procedures and 6,000 drugs.  No one professional can know everything, and medical practitioners are now deeply segregated into their specialities.  It's all about working as a team, within a known, systematic framework.  But that's not how doctors have been trained.  Our system has trained cowboys.  What we need are pit crews!  We need to focus, not on individual heroics, but on values like team work, discipline and humility. 

Sitting on a hospital board, and thinking a lot about how innovation could take place in healthcare, it seems clear that individual components of the healthcare system can work very well, but the system overall is a mess.  Our hospital delivers fantastic care as a rehab hospital, but it is at the transition points between acute care and our hospital, and between our hospital and the home that the cracks in the system appear.  Ironically, as I've observed in businesses, fixing a broken system yields efficiency, effectiveness, customer satisfaction and cost savings.

Yet, because of cultural issues, Gawande says that adoption of the surgical check list has been slow and has had to struggle against the resistance of the autonomous, lone-hero vision of medicine.  Yet this simple change would save both lives and money.  The cost of adoption - namely training and engagement of staff - should be small compared to buying another sophisticated piece of medical technology.

Gawande's talk was totally inspiring to me, and I leapt to my feet in a standing ovation. I was somewhat surprised that only about 40% of the audience joined me.  I guess this kind of system thinking is not as sexy as some of the other talks we're hearing.

No comments: