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The Checklist Manifesto, Atul Gawande

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Two years ago Atul Gawande performed a surgical procedure to remove a patient’s adrenal tumor. He calls the patient Mr. Hagerman. Gawande is a general and endocrine surgeon at Brigham and Women’s Hospital in Boston. In his career he has performed “somewhere around forty” adrenal tumors “without complication.” Inasmuch as anything like endocrine surgery could be called a safe bet, Mr. Hagerman’s procedure was, in Gawande’s hands, a relatively safe bet.

Gawande performed the surgery laparoscopically, which meant he did it with the assistance of a video monitor and instruments. As he was dissecting the tumor free of the vena cava, he “did something I’d never done before: I made a tear in the vena cava.” “This is a castastrophe,” he adds. “I might as well have made a hole directly in Mr. Hagerman’s heart.”

Mr. Hagerman lost virtually all of his blood within sixty seconds and went into cardiac arrest. Gawande cut open his chest and began compressing Mr. Hagerman’s heart by hand to keep blood flowing to his brain. “I thought that it was over, that I had killed him,” he says.

What saved Mr. Hagerman was that four units of blood were waiting in the blood bank. The reason someone had thought to set them aside, even though no one had expected any unusual complications for this procedure? A checklist.

This is the most personal example from Atul Gawande’s The Checklist Manifesto, but it is just one of many showing the benefits of the humble, unassuming checklist. Gawande argues that the problem we face today is not a lack of expertise in areas such as medicine, finance or government; if anything, we are the most advanced, trained, educated and specialized society ever. The problem, he contends, is that the volume and complexity of our knowledge overwhelms our ability to process and deliver it on a consistent basis. And the solution, he suggests, is a checklist.

If this seems disarmingly simple, that’s partly the point, and it is both the strength and weakness of the book. Gawande makes a strong case, if not quite a manifesto, for the virtues of the checklist to hone and focus expertise on the essential tasks at hand. He uses numerous examples from the aviation industry, notably the miraculous safe landing of US Airways Flight 1549 on the Hudson last January. He also picks the brain of structural engineers to understand how a skyscraper can be built without falling down. Gawande is the type of person who just wants to know how everything works.

He is also one of those effortlessly brilliant people who seem to have twice as many hours per day as the rest of us. Besides being a surgeon, Gawande is a staff writer for The New Yorker, The Checklist Manifesto being his third book. He’s also an associate professor at Harvard Medical School. The World Health Organization asked him to lead a program called Safe Surgery Saves Lives, an endeavor that requires him to attend conferences at WHO headquarters in Geneva as well as travel to various continents. Oh yes, he’s also married with three kids. (I’d bet my bottom dollar he was an Eagle Scout too.)

Perhaps because I (Ben) have read his prior books (Complications being one of those rare books I try to make a point of rereading every few years), I read The Checklist Manifesto less for what Gawande was saying than how he was saying it. Yes, I am convinced checklists can be of great benefit across many fields of expertise. But I could have been convinced of that in an essay (which, in fact, it was before it became this book). And there is no better case for Gawande’s argument right now than the failed bomb attempt in Detroit on Christmas Day. The failure there was not a matter of having enough information; it was a failure of not applying the information we had — “connecting the dots,” as President Obama put it — that something like a checklist might have remedied.

What kept me reading The Checklist Manifesto — the reason why I’d read Gawande on any subject, though he seems perfectly suited for medicine — is the mind behind the words. His thinking is keen, sharp and relentlessly curious. (Think Malcolm Gladwell via the operating room.) It can also be exacting. The most illuminating essays from Complications are the personal ones like “When Doctors Make Mistakes,” the doctor in particular being Gawande himself. In relaying his errors of judgment and practice performing his first emergency tracheostomy, Gawande turns himself into a surgical patient, dissecting with brutal honesty his faults and shortcomings. After almost losing his patient to a combination of ignorance, pride, confusion and panic, Gawande writes that he “felt a sense of shame like a burning ulcer. This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong.”

In the case of Mr. Hagerman, we see the evolution of Gawande as a surgeon, and as a thinker. The essays in Complications were loosely centered on the theme of human imperfection in tasks that demand perfection — matters of life and death. Only because Gawande began using a checklist prior to his operations did he and his team consider the possibility, however unlikely, that the location of Mr. Hagerman’s tumor might lead to major blood loss. The extra units of blood were a last minute addition — “just in case.” But because Gawande was willing to consider the unforeseen, the possibility of his own failure, he trusted in a process that served as a safety net. It required an acknowledgement of humility, and that, to my mind, is the most compelling thing about it, and him.

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One thought on “The Checklist Manifesto, Atul Gawande

  1. Do you think Gladwell (Blink) wants to fistfight Gawande?

    This sounds great. I’ve never read this guy, so I’m looking forward to it.

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