Atul Gawande's The Checklist Manifesto. My take.

http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000

I read Atul Gawande's The Checklist Manifesto, over the holidays.  It is an excellent book, telling a cohesive set of stories to convince people checklists are a good idea.  I didn't need to be convinced about the value of using checklists.  My friend and colleague Bryan Liang wrote about using airline/pilot techniques to improve medical quality/safety in the late 1990s.  I bought into it years ago, and I am a firm believer in them.

One thing to start with: the book reminds one just how frequently physicians and others harm patients in clinics/hospitals.  Few of us realize the iatrogenic damage we do.  It is staggering.  

The question is: with so many groups invested in checklists, why has medicine not embraced them?  Why are they not widespread/routine/commonplace/habitual?  The book provides some hints.  Complexity is one.  For all the complexity involved in flying an airplane, it still does not approach the complexity of medicine.  That is shown, for example, in the book's reference to how, when airlines merge, pilots argue about which airline's set of checklists to use.  One gets the feeling that the pilots are arguing about keeping checklists they are most familiar with, and not that the other pilots' are particularly inferior.  Such would not be the case with a hospital merger, I imagine.  Still, there are some basic things physicians could generally agree on, and start with.  The 19 point surgical checklists described in the book is a good example. Indeed, some checklists are already being developed.  In pathology, for example, the College of American Pathologists produces synoptic cancer protocols (essentially checklists) for pathologists to use or follow when diagnosing cancer.  They exist for a variety of sites, including lung.  

Ironically, while pilots have given up the "captain of the ship" mentality, surgeons and other physicians cling to it.  This may be because physicians' training essentially stops after residency (continuing education notwithstanding) and physicians feel threatened.  Being found wanting in one's specialty or subspecialty, even a little bit, is a very real danger to physicians.  This is mainly due I think to the medical malpractice system, and authority of state licensing agencies.  For example, many physicians would probably benefit greatly from some sort of mental health intervention (I know some); however, few if any will do it until forced to do so after some calamity.  It's completely dysfunctional, but I agree with them--its the only rational thing to do.  No one can afford to have some psychiatric intervention on record.  And few believe anything is kept confidential in that realm; and I expect few could ever be convinced otherwise.  Nothing substantial is being done to address this; however.  I have argued for years that physicians should be required to attend mandatory 30 minute sessions each week, whether we need it or not.  That would take the stigma away.  It hasn't happened, at least not yet.  Perhaps if the medical malpractice paradigm goes away, and we have instead some sort of worker's comp-like situation, without lawsuits directed specifically at physicians, physicians will become more like pilots in regard to accepting checklists.

It is also the case that, unlike the airlines, building companies, restaurants, etc. that are discussed in the book--all private companies and entities--medicine is for all intents and purposes a public, federally funded, nationalized utility.  Those private companies work for profit, and either succeed or go under.  Bosses have authority; employees, including pilots, either buy in or leave.  But in medicine, trying to get people (physicians, administrators, nurses, etc.) to buy in to checklists enthusiastically (or hold them accountable for not doing so) is probably not likely to occur.  And what remains of private medicine is gasping for breath to survive; its attention is not solidly focused on quality/safety checklists.  Physicians and administrators have never gotten along well; but today, with everybody fighting for pieces of the pie as the pie shrinks, the hostility is almost overt, palpable.  There are good reasons for this.  Administrators are today focused on essentially nothing except profit/cost.  Because nobody cares about quality, checklists will be viewed as a time waste, and resented.  Those performing the checklists, nurses, etc., will mindlessly check off the boxes, not caring whether they are accurate, resenting having to do so; and no administrator (and few physicians) are going to care or hold anybody accountable.  Completely form over substance.  While one can imagine airline executives and pilots being on the same page regarding safety and checklists, such agreement in medicine is highly unlikely, and to the extent it exists it probably does so only in a handful of elite institutions on the east coast.  Like the authors.'  In that respect I think he is wildly optimistic.  

I would like to see these various states of affairs change, but I am afraid Obamacare only locks in the current mentality.  

As I read over this I realize how harsh and depressing it comes out.  But there it is.  Man, I would like to be able to make some real changes.