The Checklist Manifesto_ How to Get Things Right - Atul Gawande [36]
“You must understand,” he said. “I manage everything. I am the pediatrician, obstetrician, surgeon, everything.” He had textbooks and a manual of basic surgical techniques. He had an untrained assistant who had learned how to give basic anesthesia. His hospital’s equipment was rudimentary. The standards were poor. Things sometimes went wrong. But he was convinced doing something was better than doing nothing at all.
A Russian bioengineer spoke. He’d spent much of his career overseeing the supply and service of medical equipment to hospitals in different parts of the world, and he described dangerous problems in both high-and low-income settings: inadequately maintained surgical devices that have set fire to patients or electrocuted them; new technologies used incorrectly because teams had not received proper training; critical, lifesaving equipment that was locked away in a cabinet or missing when people needed it.
The chief of surgery for the largest hospital in Mongolia described shortages of pain control medications, and others from Asia, Africa, and the Middle East recounted the same. A New Zealand researcher spoke of terrifying death rates in poor countries from unsafe anesthesia, noting that although some places in Africa had fewer than one in five thousand patients die from general anesthesia, others had rates more than ten times worse, with one study in Togo showing one in 150 died. An anesthesiologist from India chimed in, tracing problems with anesthesia to the low respect most surgeons accord anesthetists. In her country, she said, they shout anesthetists down and disregard the safety issues that her colleagues raise. Medical students see this and decide not to go into anesthesiology. As a result, the most risky part of surgery—anesthesia—is done by untrained people far more often than the surgery itself. A nurse from Ireland joined the clamor. Nurses work under even worse conditions, she said. They are often ignored as members of the team, condescended to, or fired for raising concerns. She’d seen it in her home country, and from her colleagues abroad she knew it to be the experience of nurses internationally.
On the one hand, everyone firmly agreed: surgery is enormously valuable to people’s lives everywhere and should be made more broadly available. Even under the grimmest conditions, it is frequently lifesaving. And in much of the world, the serious complication rates seem acceptably low—in the 5 to 15 percent range for hospital operations.
On the other hand, the idea that such rates are “acceptable” was hard to swallow. Each percentage point, after all, represented millions left disabled or dead. Studies in the United States alone had found that at least half of surgical complications were preventable. But the causes and contributors were of every possible variety. We needed to do something. What, though, wasn’t clear.
Some suggested more training programs. The idea withered almost upon utterance. If these failures were problems in every country—indeed, very likely, in every hospital—no training program could be deployed widely enough to make a difference. There was neither the money nor the capacity.
We discussed incentive approaches, such as the pay-for-performance schemes recently initiated on a trial basis in the United States. In these programs, clinicians receive financial rewards for being more consistent about giving, say, heart attack patients the proper care or incur penalties for not doing so. The strategy has shown results, but the gains have been modest—the country’s largest pay-for-performance trial, for example, registered just 2 to 4 percent improvement. Furthermore, the measurements required for incentive payments are not easy to obtain. They rely on clinicians’ self-reported results, which are not always accurate. The results are also strongly affected by how sick patients are to begin with. One might be tempted, for example, to pay surgeons with higher