The Checklist Manifesto_ How to Get Things Right - Atul Gawande [41]
Reznick had never heard about the demise of Master Builders, but he had gravitated intuitively toward the skyscraper solution—a mix of task and communication checks to manage the problem of proliferating complexity—and so had others, it turned out. A Johns Hopkins pancreatic surgeon named Martin Makary showed us an eighteen-item checklist that he’d tested with eleven surgeons for five months at his hospital. Likewise, a group of Southern California hospitals within the Kaiser health care system had studied a thirty-item “surgery preflight checklist” that actually predated the Toronto and Hopkins innovations. All of them followed the same basic design.
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures—perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them.
But the fourth killer—the unexpected—is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together—to be ready as a team to identify and address each patient’s unique, potentially critical dangers.
Perhaps all this seems kind of obvious. But it represents a significant departure from the way operations are usually conducted. Traditionally, surgery has been regarded as an individual performance—the surgeon as virtuoso, like a concert pianist. There’s a reason that much of the world uses the phrase operating theater. The OR is the surgeon’s stage. The surgeon strides under the lights and expects to start, everyone in their places, the patient laid out asleep and ready to go.
We surgeons want to believe that we’ve evolved along with the complexity of surgery, that we work more as teams now. But however embarrassing it may be for us to admit, researchers have observed that team members are commonly not all aware of a given patient’s risks, or the problems they need to be ready for, or why the surgeon is doing the operation. In one survey of three hundred staff members as they exited the operating room following a case, one out of eight reported that they were not even sure about where the incision would be until the operation started.
Brian Sexton, a pioneering Johns Hopkins psychologist, has conducted a number of studies that provide a stark measure of how far we are from really performing as teams in surgery. In one, he surveyed more than a thousand operating room staff members from hospitals in five countries—the United States, Germany, Israel, Italy, and Switzerland—and found that although 64 percent of the surgeons rated their operations as having high levels of teamwork, just 39 percent of anesthesiologists, 28 percent of nurses, and 10 percent of anesthesia residents did. Not coincidentally, Sexton also found that one in four surgeons believed that junior team members should not question the decisions of a senior practitioner.
The most common obstacle to effective teams, it turns out, is not the occasional fire-breathing, scalpel-flinging, terror-inducing surgeon, though some do exist. (One favorite example: Several years ago, when I was in training, a senior surgeon grew incensed with one of my fellow residents for questioning the operative plan and commanded him to leave the table and stand in the corner until he was sorry. When he refused, the surgeon threw him