Atul Gawande’s Manifesto: HealthCare Reform on the Ground– Part 1

On the first page of his new book, The Checklist Manifesto: How to Get Things Right, Boston surgeon Atul Gawande tells the story of a man who arrives at an ER with a stab wound on Halloween night. The doctors cut off his clothes and examine him head to toe. There it is: “a neat two-inch red slit in his belly, pouting open like a fish mouth. A thin mustard yellow strip of omental fat tongued out of it—fat from inside his abdomen, not the pale yellow superficial fat that lies beneath the skin.”

The patient is stable, though pie-eyed, and babbling incoherently. It seems that he had become involved in a disagreement that turned nasty at a Halloween party.

The injury doesn’t look too bad. The team leaves the patient waiting on a stretcher while the OR was prepped.

Then, a nurse notices that he has stopped babbling.  On closer inspection, it turned out that his heart rate is skyrocketing, and his blood pressure barely detectible. The trauma team can’t get his blood pressure up. They are losing the patient, and have no idea why.

They “crash” into the operating room, “stretcher flying, nurses racing  . . ..”  There the surgeon grabs “a fat no. 10 blade and slices down through the skin of the man’s abdomen in one clean determined swipe from rib cage to pubis.”

He then parts the fat underneath the skin and pierces his way into the abdominal cavity when “suddenly a ocean of blood burst out of the patient.”  The blood is everywhere.

“The assailant’s knife had gone more than a foot through the man’s skin, through the fat, through the muscle, past the intestine, along the left of his spinal column, and right into his aorta, the main artery from the heart.”  Hence, the blood..

One physician notes that he hadn’t seen a wound like this since Vietnam.

Indeed. They later discovered that “the other guy” at the costume party was dressed like a soldier and carrying  a bayonet.

The patient survived, but the doctors were shaken. They had done almost everything right: “the head-to-toe examination, the careful tracking of the patient’s blood pressure, pulse and breathing, the fluids run in by IV,  the call to the blood bank to have blood ready, the placement of an urinary catheter to make sure his urine was running clear.”

 Everything, except– they had forgotten one detail. No one had thought to ask the emergency medical technician who brought him in: “What did the weapon look like?”

They needed a checklist.

     Preventable Errors

Medical mistakes are more common that we think.  Gawande lays out the stark facts:  

Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually.”  

— Following their surgeries, more than 150,000 patients die each year, more than three times the number who die annually in traffic accidents.  Research consistently shows that at least half of these deaths and major complications are avoidable. In other words doctors knew what to do, but for some reason didn’t do it. “The knowledge exists,” says Gawande. “But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.” Human beings are fallible.

Step back, and imagine what those mistakes mean on a global scale. Annually, medical errors disable at least 7 million people and kill 1 million worldwide — the equivalent of six sold-out 747s crashing every day, killing everyone on board. “Gawande admits that "sick people …are phenomenally more various than airplanes," and treating a patient suffering from five chronic condtitions is more comlplicated than flying a plane, but “medicine's safety record is still shockingly bad.”

 “So what do we do?” Gawnade asks.  “Our usual approach? More technology?  Or train people longer and longer?

In a revealing interview with Democracy Now’s Amy Goodman, Gawande rejects the notion that either more technology or more years of training will solve the problem of human fallibility. “I went through eight years of training to become a surgeon, and yet I still see mistakes every week,” he confides.  

“So we decided to try something new,” he explains, “which was a checklist” –much like the check-lists that pilots and co-pilots use. The checklist is used before surgery begins.  It is designed make sure that everyone in the OR is on the same page, and most importantly, understands that they are part of a team.  We worked with Boeing to learn how they made checklists for cockpits,” says Gaande. “We made a two-minute checklist for operating rooms. And when we implemented it in eight hospitals, ranging from rural Tanzania to Seattle and London, the average reduction in deaths was 46 percent.”

The study began in the spring of 2008, and the results were mind-boggling. Without adding a single piece of equipment or spending an extra dollar, all eight hospitals saw the rate of major post-surgical complications drop by 36 percent  in the six months after the checklist was introduced; deaths fell by 47 percent. “In every site, introduction of the checklist had been accompanied by a substantial reduction in errors.”

Too Much Airplane for One Man to Fly

I first wrote about Gawande's “Checklist” in 2007, the year that I began this blog. At the time, he had just published an article in the New Yorker, describing why and when the pilot’s checklist was invented.

Gawande takes us back to “October 30, 1935, at Wright Air Field in Dayton, Ohio. “  There, “the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build its next-generation long-range bomber.  Everyone thought they knew who would win. Boeing’s “gleaming aluminum-alloy Model 299” was the clear favorite. “It could fly faster than previous bombers and almost twice as far. A small crowd of Army brass and manufacturing executives watched as the Model 299 . . . roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill,” the U.S. Army Air Corp’ chief of flight testing.”

The cause of the crash?  Pilot error. “Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs . . . and constant-speed propellers whose pitch had to be regulated with hydraulic controls . . .While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed as one newspaper put it, ‘too much airplane for one man to fly.’”

Perhaps the pilot should have had more training. “But it was hard to imagine having more experience and expertise than Major Hill,” Gawande observes. “Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checking for takeoff, flight, landing and taxing.”

With that checklist, “pilots would go on to fly the Model 299 a total of 1.8 million miles without one accident,” Gawande writes.  “The army ultimately ordered almost thirteen thousand of the aircraft, which is dubbed the B-17.”

“Medicine has entered its B-17 phase,” Gawande declared in that New Yorker article published the end of 2007.  “Substantial parts of what hospitals do . . . are now too complex for clinicians to carry them out reliably from memory alone.”  Hi-tech medicine “has become too much medicine for one person to fly.”

       The Complexity of Modern Medicine

 In his Manifesto, Gawande expands on that idea: “Medicine has become the art of managing extreme complexity –and a test of whether such complexity can, in fact, be humanly mastered.”

The problem is not that we don’t know enough—though that of course is also an obstacle—but that we know too much. What some have called an “information bomb” threatens the 21st century.

Gawande asks the reader to consider heart attacks. At one time, there was little that doctors could do. Now, they have a smorgasbord of effective therapies to choose from: clot-busting drugs, cardiac catheters, open heart surgical techniques. Meanwhile, “in some cases, we have learned that all we really have to do is to send you to bed with some oxygen, an aspirin, a statin, and blood pressure medication."

Faced with an array of possibilities, making the right choice can be difficult, Gawande notes, even for “expert clinicians. . . whatever the chosen treatment each involves abundant complexities and pitfalls.   Careful studies have shown for example, that if a patient is going to undergo cardiac balloon therapy it should happen within 90 minutes of his arrival at the hospital. After that survival falls off sharply.”

Pulling this off is not so easy. Every patient who arrives in the ER complaining of chest pain must be tested; doctors must make a correct diagnosis and set up a plan; they must discuss the plan with the patient; obtain agreement; confirm that there are no allergies or medical problems that they should worry about; line up a cath lab and team; and transport the patient—all within 90 minutes.  

How likely is it that all of this will happen in the in average hospital in the U.S.? In 2006, Gawande reports, the odds were 50/50.

This is not unusual. “Studies show that at least 30 percent of patients with stroke receive incomplete or inappropriate care from their doctors,” Gawande notes, “as do 60 percent of patients with pneumonia. Getting the steps right is proving brutally hard—even if you know them.”

This is where we stand at the beginning of the 21st century: “We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled and hard-working people in our society.” And yet, avoidable errors are “common and persistent.”  The reason, he argues is that “the volume and complexity of what we know has exceeded our ability to deliver its benefits safely, correctly, or reliably.”

He proposes a partial answer to our dilemma:  "Man is fallible, but maybe men are less so.”

This is why we need surgical checklists that bring every member of the team onboard.  The checklists are read aloud before each operation, to make sure that each member of the team agrees that they are ready to proceed. Everyone in the room is responsible:  “Did we get the blood ready? Did we get antibiotics in? Also, does everybody in the room know each other’s name, so we’re working as a team?”  This last question is something that Gawande and his investigators learned from health care systems in other parts of the world.

"Just ticking boxes is not the ultimate goal here," Gawande writes. "Embracing a culture of teamwork and discipline is."

“In that sense, the function of the checklist is as much psychological as practical. It is a first step toward learning to live with our fallibility — a kind of gateway drug to humility,” says Karthryn Schulz, author of  Being Wrong: Adventures in the Margin of Error in a blog on The Huffington Post.

“To make a checklist like this work requires a shift in power,” Gawande tells Goodman. “What it means is allowing a nurse to tell a doctor, ‘I think we didn’t finish all those five steps that we have to go through. And there comes a moment when the doctor will then say, 'I’m the doctor, and I decide what goes on here.' And if the  administration doesn’t back [the nurse ] up and say, “The culture of our hospital has changed," the checklist will fail.  Hospital management should inist "We have a team, and the nurse can actually say, ‘No, wait a minute, this is a moment that we have to halt because we could harm someone . . .'”


Two years after Gawande wrote his original “Checklist” piece for the New Yorker, less than 20 percent of U.S. hospitals use the surgical checklist that we know can reduce complications following surgery by roughly one-third. 

 This simple, inexpensive  tool has run into what Gawande terms  “cultural resistance.”  Meanwhile, other health care systems have embraced the idea. Not long ago, France went live in all 8,000 of their operating rooms, with surgeons using the checklist to reduce harm in care.

Many American physicians believe that they don’t need a checklist. It can seem demeaning to call out the obvious things that everyone knows that they are supposed to do.

Gawande himself  tells Goodman, “I started using the checklist in my operations at Harvard only because I didn’t want to be a hypocrite. We were implementing this in lots of other places. But did I think I needed it? No.”

As it turns out, “we have caught problems at least once a week, sometimes every day.”

In fact, Gawande recalls a time when a checklist saved him, and his patient. Once, during an operation on an adrenal gland, he damaged a major blood vessel.

“The bleeding was terrifying,” Gawande remembers.  In less than a minute, the patient was in cardiac arrest

Luckily, before the surgery, a nurse going down the checklist discovered an oversight by the hospital blood bank in time to ensure that a supply of red blood cells was on hand.

With the right blood ready, the patient had a transfusion, and “the checklist saved my patient’s life.”


        Reforming the System From Within

In part two of this post, I’ll talk about how checklists can  save, not only lives, but billions in health care dollars if they are used, not only before surgery, but in ICUs, in ERs, and when patients being discharged.

Many complain that health care reform legislation does not contain adequate cost controls. But the truth is, as White House Budget director Peter Orszag noted not long ago, not all of the important reforms have to be in the legislation.

I’ll explain why what Gawande calls “good checklists” can’t be legislated. And I’ll discuss his Checklist Manifesto as a powerful example of how health care professionals can begin to reform healthcare from inside the system.

For the time being, Congress has done all it can or will do. I continue to look for amendments. And I believe that Medicare  can set an example.

But  it’s time to launch a reform movement on the ground—a movement, like the civil rights movement, that moves minds, challenging the conventional wisdom about what is and isn’t possible.  

Inside agitators” are needed to spearhead this movement: doctors, nurses, residents, hospital administrators and public health experts–professionals  who are willing to stand up and insist that we move from theories about health care reform to action.

 They can begin asking why their hospitals aren’t using checklists.  (Hospital legal departments might also raise this question.) They can call for infection control programs that integrate what doctors in Norway—and in Billings, Montana—have learned.  They can institute programs that change procedures for discharging patients like the program that the Society of Hospitalists has launched..  (The program rolls out this spring; I’ll be talking more about it in the future.)

Doctors in private practice can be part of the movement. One HealthBeat reader wrote in to say that he was going to Xerox the AP article about infection control in Norway and hand it to ever patient who complained when he wouldn’t prescribe antibiotics. This  is just one example of how individual physicians can begin educating patients.  There is no need to wait for 2014.

When people don’t change, they risk becoming caricatures of themselves. Remember McAllen, Texas, the town Gawande wrote about in the June 1 New Yorker? 

In McAllen, Gawande explained, a “culture of money”  had set health care priorities. While health care providers racked up profits, patients were exposed to procedures that they just didn’t need.  After the article appeared in the New Yorker, physicians from McAllen decided to visit communities where doctors have figured out how to deliver better care for less.  

Grand Junction, Colorado was on their itinerary. Gawande likes to tell the story: when they arrived “one of the folks in Grand Junction, Colorado called me up to say, ‘You wouldn’t believe it, but these doctors arrived in a private jet.’”

17 thoughts on “Atul Gawande’s Manifesto: HealthCare Reform on the Ground– Part 1

  1. Great piece. I’m really glad that you keep coming back to issues around evidence-based medicine, of which I consider checklists to be one, though as you point out there is also a cultural dimension of teamwork here.
    I wish more progressives would read this blog, and stop getting the bulk of their health care information from places like Daily Kos and FireDogLake.

  2. We’re reading, jd…..
    Never heard of those two sites before tonight. Much rather get my news from Stewart & Colbert 🙂
    Seriously now, I don’t see how anybody can oppose check lists, or evidence based guide lines being made available to physicians and patients.
    It’s the enforcement of evidence based guide lines by payers that is problematic for some folks.

  3. “I wish more progressives would read this blog, and stop getting the bulk of their health care information from places like Daily Kos and FireDogLake.”
    I wish more conservatives would read this blog, and stop getting the bulk of their hearth care information from people like palin, limbaugh/beck, teabaggers and lobbyists.

  4. The “private jet” was probably the cheaper choice, depending on the size and composition of the traveling party, and the airline schedules that were available.
    But ‘You wouldn’t believe it, but these doctors arrived in a private jet.’ sure makes a great sound bite.

  5. I’ve read Gawande’s article about checklists several times and it never fails to bring tears to my eyes.
    The fact that the doctors and nurses at an underfunded, inner-city hospital in Detroit can ensure an infection-free ICU and outperform 90% of hospitals in the country should be a lesson for everyone concerned about care in this country and its cost.
    The public hospitals in Michigan can’t afford VIP suites and duplicative “centers of excellence” that drive up costs. Instead, like the hospitals in Norway, they have to focus on outcomes…and patients are better for it.

  6. When Dr. Peter Pronovost introduced his checklist with such dramatic and positive results, the Office of Human Research Protections (OHRP) declared the use of the checklist illegal and unethical. To do this legally, it has to be treated in the same manner as the introduction of a new drug: Under federal supervision, and with consent of the patient.
    This had to be done, declared the OHRP, in order to protect Dr. Pronovost, and the doctors that were using older regimen that produced unacceptable death rates.
    I listened to Dr. Gawande yesterday, and was unable to call in my question to the NPR interview that dealt with his new book. But what happened to the OHRP edict against Dr. Pronovost? And what does this imply for further improvements in medical practice?

  7. Hi Maggie:
    You make some excellent points on the need to enact some type of procedure. process, or checklist to minimize mistakes in hospitals. Public Citizens Congress Watch arrived at a similar conclusion as Atul Gawande in h its report on MalPractice Lawsuits. Some of the recommendations were:
    – Hospitals Should Use Computer Physician Order Entry Systems
    – Hospitals Should Follow JCAHO Guidelines to Prevent Wrong Site Surgery
    – Hospitals and Medical Practices Should Limit Physicians’ Workweeks to Reduce Fatigue-Induced Error
    According to the Citizen’s 2007 report from 1991 to 2005, “Easily preventable errors include: Surgical or other foreign body retained, wrong body part, wrong patient, wrong treatment, wrong medicine, failure to protect against infection, and wrong blood type. These identifications are taken from the NPDB.”
    It would appear a percentage of this could be preventable with something as simple as a check list.

  8. I heard a story about a hospital CEO once saying “I like complications, I can bill for them.”
    I fear not much will change until that changes to “I don’t like complications, they cost me money.”

  9. Thanks for continuing to highlight this issue. It seems like it should be so easy to go forward on these safety processes, but the medical cultural issues can be quite difficult.
    My experience is from the operating suite. For a number of years I was the director of anesthesiology for a very busy OR. For several years, I had the privilege of working with Directors of Surgery and OR Nursing who were quite committed to improving patient safety. Yet we found it extraordinarily difficult to enact process changes. Why should this be so? In our instituion a major barrier seemed to be an intense focus on always moving quickly so as to please the “rainmaker” surgeons who brought in high margin “procedures”. Any new process (like a time-out or checklist) will add some small time to a procedure, at least at first. Invariably one of our “rainmakers” would object to the change or feel it was insulting to him/her and go directly to the hospital president threatening to bring “his/her” patients to a different hospital which would be more accomodating and, for all practical purposes, the new process was dead. One of our surgeons was open about the fact that he would sometimes do this over minor changes just to show the hospital administation who was “boss”.
    OR nursing staff can also become complicit in this culture. There is a kind of reflected glory in being a favorite assistant of a powerful rainmaker physician. These nurses and other OR staff members can be empowered by sharing the aura around “their” surgeon. Some become more concerned with pleasing this individual that with the directives of their nominal employer. Then the forms and checklists are “completed” ahead of time so as not to cause any offense. Current hospital electronic records systems also seem set up to produce rote “documentation” by default without the need for any real evaluation to have taken place.
    I do think the analogies to aviation are apropriate, at least for surgery. One of the best definitions of what a quality focused OR would look like is the one I have heard given by aviation and hospital safety consultant John Nance: (forgive the rough paraphrase)”You will know you have a quality focused team when a heart surgeon can be kept waiting for 15 minutes because a low level technician was concerned that something was not yet available for the procedure and EVERYBODY THANKS THE TECHNICIAN!”
    Finally, although the the road may be a tough one, I firmly believe we must get to true quality focused organizations. Over the years, I have come to believe that all the “players” have to be on the same “team” for this to happen. I suspect that this will eventually require wider adoption of an integrated “clinic” model with salaried physicians.

  10. Great post as always! One thing that strikes me is that if there were a brand new drug or piece of equipment that promised equally impressive results, all physicians would be clamoring to get it. We love our technology. Low-tech things like lists and personal counseling get short-shrift because they can’t be charged for and they’re not “sexy.”
    Although it will be a painful process, the only way to cut down on some of these infections and other process issues will be the coming changes in reimbursement. If hospitals no longer profit off of hospital-acquired infections and readmissions, I am confident that they will hire the necessary staff and invest in the necessary procedures to prevent such events.

  11. Part of the problem . . .
    I like my doctor as he is a sports medicine doctor and at 61 I am still running 11 minute miles and 10ks. He is about 15 years younger than I, x-military as I am, and just as athletic.
    I say this as what I am going to say next is not derogratory; but, it is not complimentary either. Doctors are members of a guild. They act in unison the same as lawyers to protect the guild’s best interests outside of the patients. The link I posted earlier has to do with malpractice suits and the reasons for them.
    That a simple check list would cause a doctor to balk at it is ridiculous considering what is at stake; a lawsuit which will be railed upon by the guild and the insurance companies, a patient’s quality of life, and a patient’s life. Who is more important here?

  12. Great job!!
    Thanks for this informative blog. And thanks for continuing to highlight this issue. Its quite difficult to change medical culture. Keep sharing your experience with us.

  13. Maggie, here is a link to an excellent interview with Gwande on Minnesota Public Radio’s midmorning talk show. They also delve into the value lists for aviation and the military. Thanks, as always, for your good and important work. Pat Cook

  14. I had a nice e-exchange with Gawande last week
    Here it is – He was VERY appreciative
    Congratulations. Your new book* on checklists to reduce medical errors is very important. I’ve been enjoying your media appearances that I have watched.
    Allow me to posit that in addition to the book’s very practical value in reducing medical errors, especially in hospitals, perhaps the most important outcome of your book is its power to bring some long overdue humility to physicians. Especially dare I say among surgeons?
    My advice to patients- Never go to a doctor who doesn’t occasionally say “I don’t know”. Atul- The era of “MDeities” is at long last over . Your book will help us become human again.
    Be Well,
    Dr. Rick Lippin

  15. Louis, Athena, Tor . . (I’ll respond to everyone else tomorrow)
    Good to hear from you.
    Thanks very much for your comment.It gives me a better idea as to why only 20% of US hospitals are using checklists.
    AS I think about writing part 2 of the post, that’s my biggest question . .
    We know that the checilsit works. Why is it that 80% of hospitals don’t do it?
    Thanks for the comment.
    I feel the same way about the hospital in Detroit.
    From the interviews I’ve done, there are many public hospitals like this one that are battling to do what is best for patients–but given the hospitals’ limited resources . .. the stories are heart-breaking.
    Very good people doing the best that they can in very difficult circumstances.
    I’m hoping that doctors, nurses, residents and administrators at these hospitals will help lead a health care movement that sets out to reform health care from within.
    I realize that people at public hospitals hopsitals have very little time and not as much power as they should have.
    But I’m hoping that reformers at public hopitals will find a way to hook up with much more powerful academic medical centers and other private hospitals.
    I’m going to keep on wriing about this.
    I am pretty hopeful that, with time, more and more health care professionals will begin to realize that only they have the pwoer to work for what is best for patients.
    That was a bone-headed ruling that came out of the Bush administration, It was reversed. See

  16. are the commenters satisfied that checklists are proven to be better ie would a single study with implausible results and mixing wildly different healthcare systems qualify as sufficient evidence to support such a sweeping change in comparative effectiveness world?

  17. jd, Margait, BK MD, Tim, run 75441, Ed, Sharon MD, run 75441, Anna CNA, Pat, Dr. Rick, anonymous
    jd–Thanks for the kind words.
    Yes, I think the need for evidence-based medicine lies at the heart of health care reform. Teamwork is another very impt. dimenion . .
    On Firedog and Daily Kos, , I have to say that I find some very good information on FireDogLake (Scarecrow, for example, and as heatlhcare legislation was written and ameneded, they actually Read the Bills and analyzed them. . .
    But I don’t always agree with their point of view. For instance, I would Not Kill the Bill.
    I find Daily Kos pretty uneven and rarely read it.
    I agree that “enforcement” of evidence based guidelines by payers is the sticky point.
    I think the best way to handle it is to lower co-pays and, if needed, left fees for treatments which evidence suggests provide the greatest benefit for patients who fit a particular profile.
    I’d also raise co-pays and lower fees for less effective treatments.
    This is what payers did to steer people toward generic drugs and it worked quite well.
    Simply refusing to pay leeds to accusation so rationing, and a huge uproar.
    Of course Medicare and others must refuse to cover if we have evidence that the treatment will harm patients, but otherwise, I’d just use financial carrots and sticks to steer patients and doctors.
    BK, MD–
    I too wish more conservatives would read the blog.
    I think the point he was making is that they seemed totally clueless as to how people would perceive their arrival in a private jet.If they’re trying to persaude the world that they’re not living in a money-driven medical culture, this isn’t the way to do it.
    Yes, something as simple as a checklist could prevent many of these errors. And fatigue is also a major problem.
    I plan to write about resdients and 16-hour shifts sometime soon.
    Ed– I agree.
    The fact that Medicare plans to stop paying for an excessive number of preventable readmissions is a start.
    Sharon– You write:
    ‘Great post as always! One thing that strikes me is that if there were a brand new drug or piece of equipment that promised equally impressive results, all physicians would be clamoring to get it. We love our technology. Low-tech things like lists and personal counseling get short-shrift because they can’t be charged for and they’re not “sexy.”
    Also, I too think that the only way to get the attenton of many hospital CEOs is with financial penalties. These days, so many of these CEOs are businessmen–not health care professionals. All they really understand is money.
    Certainly, many docctors do have a “guild” mentality.
    But many truly are professionals–putting hte patient’s interersts first.
    I have to say that, in my experience interviewing both doctors and lawyers, fewer lawyers put their clients first–though some definitely do.
    And yes, one would think that doctors would realize that checklists could protect against lawsuits.
    Anna CNA–
    Thank you!
    Pat–Thanks for the link
    Rick– Glad you get in touch with Gawande. He really does read his e-mail.
    We’re not talking about a single study.
    At all of he hospitals where checklists are used (now 20% of US hospitals)
    people have been keeping track of error rates.
    They always reduce the number of medical mistakes.