Surgery, Checklists and the BBC Reith Lectures

I love BBC radio and one of the highlights of their great programming is the BBC Reith Lectures series. Around November-December each year, the BBC commissions an eminent expert to give four lectures on her or his subject. This year the lecturer is Atul Gawande. Gawande is a surgeon, a staff writer at the New Yorker magazine, a researcher, and author of a number of prize-winning books including his most recent, Being Mortal: Illness, Medicine and What Matters in the End. I listened with fascination to his first lecture – he’s a quietly captivating speaker – and despite his very different field of interest I quickly thought “this guy speaks my language”. Gawande’s first lecture addressed the issue of how we learn, or more often do not learn, from experience. Indeed, he dared to use the ‘M’ word in his lecture title and this surprised me – I didn’t expect a surgeon to admit to making any mistakes. The more I listened, the more interested I became in his perspective on the fallibility of medical practitioners and his frequent references to complexity as an important part of the explanation for their mistakes. In his second lecture, Gawande describes systems failures in the health services and identified these as a further contributing factor in medicine’s inability to deal with the complexity that both enables and constrains its practitioners. I was hooked. I placed a library reservation for Gawande’s recent book ‘Being Mortal’ and for his earlier prize-winning ‘Complications: A Surgeon’s Notes on an Imperfect Science’. Being too impatient to wait for those to arrive, I also bought his intriguingly titled ‘The Checklist Manifesto: How to Get Things Right’ and found myself reading it in one sitting. The Checklist Manifesto is full of the well-written anecdotes for which Gawande is rightly praised. In it, he brings his world of the operating theatre vividly to life. He also draws in experiences of other professionals – from the aviation industry and the world of huge construction projects – and deftly draws parallels between them and his own realm. Despite this, the Checklist Manifesto is a curious book. For starters, how is it possible to write a whole book simply advocating the use of checklists? Writing a checklist is not exactly rocket science or brain surgery, is it? Except, we quickly learn that rocket science (or its kid brother, the aviation industry) does rely on checklists. And worryingly we find out that brain surgery (and simpler surgical procedures) that you might expect to be awash with checklists to protect patients and ensure nothing gets forgotten, doesn’t seem to have any. Yikes – how is that possible? In answering this and other questions, Gawande shows how the creation and adoption of a simple surgical checklist for the World Health Organisation had to confront issues of ego and teamwork, power and culture, organisational hierarchies, and the unintended consequences that are so often the unfortunate outcomes of well-meaning systems. Gawande’s heart is definitely in the right place – there is more than enough evidence to show that checklists really save lives and reduce infection even in the high-tech operating theatres of the United States. However this is a book aimed not only at clinicians but other professionals too. I was left with a concern that because his own field of medicine does not seem to codify its experience into tools such as checklists, Gawande assumes that very few other areas of human endeavour do so either – except for the aviation and construction industries that are such a source of inspiration to him. My experience suggests that this is an unreasonable assumption and one that risks undermining the broader applicability of his message. So who is Gawande hoping will sign up to his manifesto? Should development practitioners be queuing up to add their names? Well maybe – but aren’t we already pretty good at codifying what we do? And have most of us not embraced procedures such as after action review to learn from successes and unintended outcomes? Well even if we have, there is always room for improvement. The process of preparing a checklist may well be a really good way of recording the results of an after action review in a way that improves our ability to do things better in the future.

Reflecting on development practice got me thinking about my own profession – consulting. I can see that there are some consulting procedures I use that would benefit from simple written (not just mental) checklists to ensure that key points are covered whilst freeing up time and ‘headspace’ to concentrate on the tricky stuff.

One final reflection. Earlier this year I had reason to be in an operating theatre. My left retina detached when I was working in Armenia and I returned to Scotland to have emergency surgery carried out by the surgeon who had fixed my other eye a year before. The surgical team carried out the vitrectomy and laser photocoagulation procedure in less than an hour and I’m happy to say that there were no complications. If I have cause to be wheeled into my local hospital operating theatre again knowing what I have now learned about how easy it is for simple things to be overlooked even by experienced clinicians, I am glad to know that Scotland is one of the first countries to ensure that all of its surgical teams have adopted Gawande’s checklist.

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