Surgeon Atul Gawande still remembers the operation years ago that went catastrophically wrong. He was removing a tumor from the adrenal gland of a patient he refers to as Mr. Hagerman.
Gawande had performed this procedure dozens of times before. But this case was particularly tricky. Mr. Hagerman's tumor was behind his liver, nestled tightly against an important blood vessel known as the vena cava. Gawande was almost done when all of a sudden, he nicked the blood vessel.
"I ended up creating a hole in the vena cava, which meant that he then pretty quickly lost his entire blood volume into his abdomen. Complete blackout on the screen...and utter chaos," he recalls.
Gawande took the man's heart in his hand and began compressing it to keep blood flowing to his brain.
"I mean, he lost basically ten times his body volume in blood. But we were able to give him enough blood to keep his circulation going. He had a cardiac arrest twice. We were finally able to repair the hole in the vena cava, get the tumor out, and have him recover," he said.
It was a happy ending, and, at first blush, a textbook case of medical heroics. A doctor makes a mistake, but he fixes it, taking a heart into his bare hands and squeezing life back into his patient's body.
But skill and brainpower were not the reason Mr. Hagerman survived. Gawande says what actually saved his patient's life was a plan the surgical team had made before they began the surgery. This plan wasn't grand or complicated. In fact, it was a humble checklist.
"And what happened was...when we ran the checklist, when we got to the part where we said, 'What's the goal of the operation and tell me anything unexpected about this,' I mentioned to the anesthesiologist that this tumor was pretty tightly against the vena cava. The anesthesiologist then prepared to get more blood into the room, just in case."
Today on Hidden Brain, we'll go inside the operating room with Gawande — and hear about a 1930s plane crash that inspired his obsession with checklists — as we explore the subtle biases that cause very smart and very skilled people to become their own worst enemies.
"A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population," New England Journal of Medicine, 2009.
"Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative," Annals of Surgery, 2017.
"An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU," New England Journal of Medicine, 2006.
Hidden Brain is hosted by Shankar Vedantam and produced by Maggie Penman, Jennifer Schmidt, Rhaina Cohen, Parth Shah, and Renee Klahr. Our supervising producer is Tara Boyle. You can also follow us on Twitter @hiddenbrain, and listen for Hidden Brain stories each week on your local public radio station.
SHANKAR VEDANTAM, HOST:
This is HIDDEN BRAIN. I'm Shankar Vedantam. All of us have days when despite our best efforts, everything just goes wrong - sometimes terribly wrong.
ATUL GAWANDE: It was a devastating problem.
VEDANTAM: Atul Gawande is a surgeon at Brigham and Women's Hospital in Boston. He's also a writer. You might have read his work in The New Yorker or in Slate. A few years ago, Atul was at work operating on a patient he refers to as Mr. Hagerman (ph).
GAWANDE: I was taking out a tumor of the adrenal gland laparoscopically.
VEDANTAM: He'd performed this procedure dozens of times before. But this time was particularly tricky. Mr Hagerman's tumor was behind his liver nestled tightly against an important blood vessel.
GAWANDE: The main blood vessel returning the blood of the body to the heart.
VEDANTAM: It's known as the vena cava. Atul began the surgery and everything was going smoothly. He was almost done detaching the tumor when all of a sudden, he nicked the blood vessel.
GAWANDE: I ended up creating a hole in the vena cava, which meant that he then pretty quickly lost his entire blood volume into his abdomen - a complete blackout on the screen and utter chaos.
VEDANTAM: Atul took the man's heart in his hand and began compressing it to keep blood flowing to his brain.
GAWANDE: I mean, he lost basically ten times his body volume in blood, but we were able to give him enough blood to keep his circulation going. He had a cardiac arrest twice. We were finally able to repair the hole in the vena cava, get the tumor out and have him recover.
VEDANTAM: A happy ending and at first blush, a textbook case of medical heroics. A doctor makes a mistake but he fixes it, taking a heart into his bare hands and squeezing life back into his patient's body. This is the stuff of countless movies and TV shows.
GAWANDE: Our whole idea of the hero is the person who can kind of know it all, save the day on their own just by force of their brain and their skill.
VEDANTAM: But skill and brainpower were not the reason Mr. Hagerman survived. Atul says what actually saved his patient's life was a plan the surgical team had made before they began the surgery. The plan wasn't grand or complicated. In fact, it was a humble checklist.
GAWANDE: And what happened was when we ran the checklist, when we got to the part where we said, you know, what's the goal of the operation? And tell me anything unexpected about this. And I mentioned to the anesthesiologist that this tumor was pretty tightly against the vena cava. The anesthesiologist then made a plan to get more blood into the room just in case.
VEDANTAM: Just in case.
GAWANDE: When disaster came, he was prepared. And that was the only reason that this man got through it.
VEDANTAM: Today on HIDDEN BRAIN, the subtle biases that cause very smart and very skilled people to become their own worst enemies and how innovators have found a way to help pilots, doctors, frankly any of us, perform at our best. It's a story of an ancient insight applied to modern life. And even though you might not know it, this innovation shapes life and death decisions that affect all of us.
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VEDANTAM: We begin in the depths of the Great Depression. It was a time of great suffering, and people were looking for inspiration. Many found it in the heroes who were inventing the modern age of flight. One effort in particular caught the public's attention. Boeing was developing an airplane that was said to be different from anything that came before it.
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UNIDENTIFIED MAN #1: Closely guarded, the Army's newest bomber and America's largest land plane is prepared for its first flight at Seattle.
VEDANTAM: In the press, the Model 299 was known as the flying fortress.
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UNIDENTIFIED MAN #1: It weighs 15 tons and is reported to have cost nearly half a million.
ROGER CONNOR: Something like the Boeing 299 was a huge story.
VEDANTAM: Roger Connor is a curator at the Smithsonian National Air and Space Museum in Washington, D.C. We're standing in a part of the museum dedicated to the Golden Age of Flight gazing up at a model of Boeing's flying fortress.
And is that the silver plane that we're looking at up high?
CONNOR: Right, so a very streamline, four-engine aircraft. And this was really a marvel of its day.
VEDANTAM: In other words, the Model 299 was a big deal, both for Boeing and for the United States.
CONNOR: It was a, you know, a success story in America that was really challenged by depression.
VEDANTAM: It was also a very big deal for the U.S. military.
CONNOR: By all accounts, it's a wonder of technology. So the Air Corps pilots that see it are in awe. It's a fantastic machine.
VEDANTAM: The plane arrived on the scene at a time when the nation was obsessed with the possibilities of flight.
CONNOR: Air racing was not just a niche activity for wealthy hobbyists. It was kind of a national craze and obsession.
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UNIDENTIFIED MAN #2: The fastest things on wings strut their amazing stuff.
CONNOR: You know, kids would obsess over who was leading the rankings at the Cleveland Air Races.
VEDANTAM: The military was obsessed, too, with the idea of long-range bombers, planes that could better protect the U.S. coastline and give the nation an edge if another great war erupted. In 1934, the Army Air Corps put out a proposal to the nation's aviation companies and challenged them to build a new long-range bomber for the military. The prototypes would go up against each other at a flight competition the following year.
CONNOR: The two leading competitors are Douglas and Boeing. Douglas was really starting to dominate the American aircraft industry at this moment. Their DC-2 was becoming the hot passenger airliner and was quickly putting Boeing into the background in that industry. So once the Air Corps announces this new bomber competition, Boeing is really eager to show off and demonstrate that they can lead the pack.
VEDANTAM: Boeing had a lot to prove. By the time the competition rolled around, it had an ace up its sleeve, the Flying Fortress. On October 30, 1935, the day of the competition, Boeing's streamlined silver behemoth was the clear frontrunner.
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VEDANTAM: The morning of the competition, flight teams from Boeing, Douglas and Martin assembled with military leaders at Wright Field in Dayton, Ohio.
CONNOR: Early in the morning - it was 9 o'clock in the morning and apparently, by all accounts, a very beautiful day. So kind of ideal conditions for a late October day in Ohio and a perfect day for a test flight, really.
VEDANTAM: A crowd watched as the Boeing 299 taxied to the runway.
CONNOR: Advances the power, the engine spool-up - it's rolling down the runway.
VEDANTAM: The beautiful airplane lifted into the air. It had all the makings of a winner.
CONNOR: And then the observers noted that the aircraft starts to abruptly pitch up. So as it takes off, rather than kind of gradually rising and building up speed, the nose just starts to pick up and up. And immediately, observers on the ground realize something is wrong.
VEDANTAM: Very wrong. At 300 feet, the aircraft stalled. As people watched in horror, the Flying Fortress began to plummet toward the earth.
CONNOR: It impacts the ground in a flat attitude and bursts into flames. There were five crewmen onboard. Major Ployer Hill, who was the chief of flight tests for Wright Field; Leslie Tower, who was the chief of flight tests pilot. There was also Donald Putt, who was acting as the co-pilot. There was a mechanic onboard, Mark Coogler and John Cutting, who was one of the aeronautical engineers involved with program.
VEDANTAM: Observers on the ground raced toward the wreck.
CONNOR: Obviously, an aircraft like this has a lot of fuel on board. And so when - in this case, because the aircraft came down relatively flat - it only just started to spin in - it would have been fairly apparent to the people on the ground that there was a good chance of survivors. So it's kind of a worst-case scenario where you see the aircraft is involved in terms of being on fire but you know there's people on there that are likely still alive. So it's going to be a great hazard to both the rescuers as well as the occupants of the aircraft.
VEDANTAM: Three of those occupants survived, but two died. Ployer Hill and Leslie Tower. Both were highly experienced pilots. Almost immediately, people asked - what made the Flying Fortress crash?
CONNOR: This aircraft did have an autopilot. And not unlike a lot of accidents today, attention centered on that. So was the autopilot somehow engaged where it was overriding the inputs of the crew members? So that was one focus of the investigation. But very quickly, attention turned to a control locking mechanism, which was - that was one of the advanced features of this aircraft was that it had its own built-in mechanism for locking the elevator for when it was essentially parked on the ground.
VEDANTAM: The elevator determines the pitch of the plane, basically the movement of the nose up or down. For most planes at the time, elevator locks were on the outside, meaning ground crew had to unlock them before takeoff. But in the Model 299, the elevator lock was inside the cabin of the plane. The crew had forgotten to unlock it. And so after the plane took off, the pilots found they couldn't level off. The nose just kept climbing.
CONNOR: Unfortunately, in the, you know, just the matter of the few seconds that they're airborne, there's just not enough time to deal with it. So less than 20 seconds between the time the wheels leave the ground and the aircraft centering the stalls - it's just not enough time for that awareness to dawn, be able to reach the controls, particularly as the aircraft is beginning to stall and the ability of somebody to find the controls and solve the problem. It's too late, and they may not be able to physically do it because they're getting thrown around the aircraft.
VEDANTAM: The death of the two men was a crushing blow. For military leaders and the aviation industry, the crash prompted an unsettling question - if experienced pilots like Ployer Hill and Leslie Tower could make fatal mistakes with the Flying Fortress, what did that mean for the future of manned air flight? Were planes simply becoming too complicated to fly?
CONNOR: At this moment in mid-1930s, The performance of aircraft are changing so rapidly, there are so many new complex systems coming into play, rather delicate systems in some way - so everything from retractable landing gear to turbochargers for engines, all of which require their own detailed specifications for operation. And so now a pilot was beginning to become overwhelmed with the degree of complexity with all these systems and how they interface with one another. It became difficult to keep them straight.
VEDANTAM: To many of us the instinctive solution to this problem might be more training, spend more time in the plane, get to know it like you know your own home, understand its quirks inside and out. But Roger says that kind of thinking may not have saved the man who died in the crash. The pilots actually had lots of experience with the plane. They had been flying it for several months.
CONNOR: Things had become rather routine in testing this aircraft, so certainly, the crew both at Wright Field and with Boeing were fairly familiar with it. They had clearly become quite comfortable with the operation of the aircraft and were used to its quirks and how it performed.
VEDANTAM: So if more training wasn't the answer, what was? The solution that military leaders devised was fundamentally about human psychology. Pilots were not screwing up because they were incompetent. They were screwing up because they were very good, so good that they were completely sure they knew what they were doing. They didn't feel the need to slow down, go over the basics, like unlocking the elevator before taking off. The military responded with a new idea that was actually an old idea - the checklist.
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UNIDENTIFIED MAN #3: In the cockpit, you learn to follow the checklist because it helps you to keep your mind on your work. Detail's important when you're flying a big bomber, and using the checklist means you don't overlook a thing.
VEDANTAM: This is from a 1943 military training film.
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UNIDENTIFIED MAN #3: After you get the plane off the ramp and down near the runway, you're ready for the run-up, one of the most important checks of all.
Set her at an angle. That gets all your props safe over concrete for the run-up, and if there's a guy behind you, you won't blast him when you rev them up.
CONNOR: What's fascinating is you look at the effort that went into training these guys. The training videos that came out of that time are really magnificent. They're, frankly - you'd be hard-pressed to find something as well-produced today for the same purpose.
VEDANTAM: Checklists like these were widely implemented in the military in the years after the Boeing 299 crash. They covered tasks that to a trained pilot might seem mind-numbingly obvious - make sure your crew is in the right position and that the hatches are closed. Turn off the automatic pilot. Make sure your flight controls and tailwheel are unlocked. Check that your brakes have air pressure, that your warning lights work.
CONNOR: Supercharger, that it's set correctly to low blower, your altimeter's set to the correct field elevation, mixture controls. You have your full rich position, carburetor air - you want it in the cold position for maximum performance.
VEDANTAM: So, to be honest, as somebody who doesn't know how to fly an aircraft, a lot of this is gobbledegook to me, but I'm imagining that for most people who are pilots this stuff is actually completely routine, that this is no different than me getting into my car in the morning and saying open the door, sit down and close the door behind you, that it seems really basic stuff. And I would imagine that if someone were to tell me to do that when I got into my car each morning, I would say, what kind of bureaucratic nonsense is this? I know how to fly a plane. I'm an experienced pilot. Stop telling me how to do my job.
CONNOR: Certainly. So this has been a huge problem in aviation culture, and it's one that does crop up.
VEDANTAM: In other words, checklists can help experts slow down but only if the experts bother to listen. It turns out, lots of pilots didn't want to listen. How to make them - harness another large bias in the brain, our willingness to be swept up by stories.
CONNOR: There are so many accounts now of episodes where people have winged the checklists or not paid attention and something bad's happened. So particularly in commercial aviation and over the last half-century, there's been a very strong cultural emphasis on - really it's storytelling, that you look - go and look at these accidents. So Air Florida 1982 here in Washington, D.C., is a very famous one.
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UNIDENTIFIED MAN #4: Report of an airliner down off the 14th Street Bridge on Box 417.
CONNOR: There's the crash over the Everglades...
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UNIDENTIFIED MAN #5: Miami Tower, do you read Eastern 401? Just turned on final.
UNIDENTIFIED MAN #6: Eastern 401 Heavy, continue approach to nine left.
CONNOR: ...Where they were focused on the nose gear. There's a whole series of very well-known accidents that are brought up in training at various points that are discussed during simulator exercises and are omnipresent really in the literature. So there are inevitably a number of points where a commercial airline pilot will have witnessed these cockpit re-creations and seen the voice transcripts of various episodes where crews have kind of winged it. They've flown by the seat of the pants. They've not followed procedures, not used the checklist in the right way, and something bad's come up out of it.
VEDANTAM: The commercial aviation industry developed a culture of making and using checklists through training, simulations and storytelling. The minatory went a step further and harnessed broader themes - patriotism, freedom.
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UNIDENTIFIED MAN #7: America goes to war. Men of the Army, Navy and Marines reinforce the battlefronts on six continents to save the homes and ideals of free men from Axis domination.
VEDANTAM: Despite the crash in Dayton, the Army ended up ordering thousands of Boeing's Model 299, which it renamed the B-17. Once the nation entered World War II, thousands of young would-be pilots put up their hands to fly those planes.
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UNIDENTIFIED MAN #8: Each of the young cadets is to get real flying instruction under the Army's new plan of giving every undergraduate at West Point a certain amount of air experience. They're all for it, too, and what a fine looking group of young men they are. The cream of the country. Modern warfare will be fought as much in the air as on the ground, and the new War Department policy looks to the time when every Army officer will be trained to fly as an observer if not as a pilot.
VEDANTAM: Many of these new pilots were not officers, though. Many were young, enlisted men.
CONNOR: Most of whom were, you know, 19, 20 year olds literally fresh off the farm, you know, with not a great deal of training. And so they're going to be operating very complex systems. In a lot of cases, the aircraft are even getting more complicated than a Boeing 299.
VEDANTAM: For these new pilots, checklists served as a safety net. They helped them get these massive planes off the ground. They were used by flight teams to troubleshoot problems in the air, and perhaps most importantly, they helped exhausted pilots avoid mistakes while returning home from a mission. We can't know for sure how the use of checklists affected America's success in the war, but Roger is sure that they saved lives.
CONNOR: If those checklists had not been integrated to that level at the start of World War II, it's reasonable to assume that many hundreds and probably thousands of lives would have been lost due to that.
VEDANTAM: Today, checklists are essential to the aviation world. In fact, they're a big reason commercial aviation is significantly safer than driving your car on a highway. Checklists have become ubiquitous in lots of other fields, too, fields where the work is complex and the cost of mistakes is high. Construction crews now rely on checklists to build high-rise office towers. NASA has detailed to-do lists for astronauts. And then there's the world of medicine.
GAWANDE: I don't get through a week of surgery without us catching something that would have meant the patient didn't get as good care as they would have otherwise.
VEDANTAM: Coming up, how the powerful culture of aviation checklists has inspired and antagonized the field of medicine and how one grieving mother's question helped to change an entire culture. Stay with us.
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VEDANTAM: This is HIDDEN BRAIN. I'm Shankar Vedantam. Atul Gawande is a surgeon at Brigham and Women's Hospital in Boston and the author of "The Checklist Manifesto." When he began his career in medicine, checklists weren't something Atl spent a lot of time thinking about. He was drawn to the heroics of doctors, people, who through the force of their intellect and the rigor of their training, could triumph over death and restore patients to productive lives.
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LAURA INNES: (As Kerry Weaver) No, start a central line.
UNIDENTIFIED ACTRESS: (As character) BP is 90 over 50.
INNES: (As Kerry Weaver) Give four units...
GAWANDE: I went into medicine because I wanted to be able to understand, how does the body work, how does it go wrong, and then how can I come in and save the day? And what I was really drawn to was in surgery where, you know, it's especially visceral. It's like, how do I save this person with my own hands (laughter)?
VEDANTAM: Over the years, though, Atul started to realize that daring and intellect weren't enough, particularly as medicine has become more complicated and doctors have evolved into what he calls super, super specialists.
GAWANDE: I am one of those super, super specialists now. I am a general surgeon in my original training, but then I've narrowed into not only in cancer surgery but a focus on three specific tumors that make me, you know, feel like I have an area where I can know more than just about anybody, at least here regionally, right? So the problem is that even then I'm not necessarily able to pull together in that moment in time everything that might matter.
VEDANTAM: Even a super, super specialist can screw up. Having advanced training doesn't guarantee perfection. It's still possible that you'll forget something important, overlook a problem until it's too late or nick a blood vessel even though you've done the same kind of surgery dozens of times. Atul's search for a solution led him to the aviation world and its culture of checklists.
GAWANDE: We famously hold up the airline industry as an example of high reliability performance. You can have planes that are of now immense complexity, immense power. And we have a far lower crash rate than when they were far simpler. And, you know, less than 1 in 200,000 flights have any kind of a mishap and so on.
VEDANTAM: He studied that 1935 crash of the Flying Fortress. He couldn't help but compared the military's response to the way his own field responds to fatal errors.
GAWANDE: If we were looking at solving this problem the way we would solve it in medicine, we would say, well, let's have a four-year training fellowship in how to fly the B-17 bomber. And instead, what they did was they created a checklist for the most common ways that even an expert pilot could crash that plane. And that one-page checklist allowed them to fly that plane 2 million miles without a single mishap - no four-year specialized training program, get it all into your brain and make it work that way. It was just a whole different way of looking at things. And that's what was powerful to me.
VEDANTAM: Checklists were not, of course, completely absent from the world of medicine. Nurses have long used them in many areas of patient care. But Atul says for many doctors, the idea of relying on a checklist was demeaning.
GAWANDE: Our values as physicians or experts of any kind are that we believe in autonomy. Leave me alone. I've been trained. I know the best thing to do, and that is your best bet for getting the best results out of whatever you're turning to me for.
VEDANTAM: Leave me alone. I know what's best. That's a message that Peter Pronovost has heard a lot over the years.
PETER PRONOVOST: I'm an intensive care physician and the Johns Hopkins Medicine senior vice president for patient safety and quality and the director of the Armstrong Institute for Patient Safety and Quality.
VEDANTAM: Peter had a perspective on patient safety that many doctors don't. He was in his fourth year of medical school when his father was misdiagnosed with the wrong cancer, lymphoma instead of leukemia.
PRONOVOST: And by the time they got it right, he came home with hospice and not only did he die, but he suffered miserably in pain for a week being told, oh, he has enough pain medicines. And at that time, I became convinced that health care often lets our patients down, and they deserve more.
VEDANTAM: Peter was determined to do better by his patients. Figuring out exactly what that means in practice became a major goal of his work at Johns Hopkins.
PRONOVOST: The work really accelerated back in 2001 after an adorable little girl, Josie King, died of a catheter infection. And those infections, to give you a perspective, killed more people than breast or prostate cancer a year.
VEDANTAM: It was a very big problem. A year after Josie's death, her mother asked Peter a very difficult question.
PRONOVOST: Her mom, Sorrel, came to me and said, could you tell me that my daughter is less likely to die now than a year ago? And I looked at her and reflected and said, I can't.
VEDANTAM: A catheter is a thin tube that's inserted into the bladder to remove urine. Other times, catheters are put into the veins around the neck when a patient needs medicine or a blood transfusion. Hospitals around the world use catheters all the time, and those same hospitals routinely have problems when bacteria get into the tubing. Sometimes, the infections caused by those bacteria can be so serious they lead to death, as in the case of Josie King.
PRONOVOST: At the time, we just accepted those infections as the norm. That is, the story that we told about health care was that sometimes when you treat old or young or very sick patients, little girls like Josie are going to die.
VEDANTAM: There was a straightforward solution. The Centers for Disease Control and Prevention had rolled out a checklist to prevent catheter-borne infections. It included things like wash your hands with soap before inserting the catheter, cover the patients with sterile drapes, make sure that doctors and nurses wear gloves, hats, masks and gowns. The checklist seemed so obvious, so easy to follow. But Peter quickly found that creating a checklist is only the first step. There are lots of reasons for doctors and nurses to ignore it.
PRONOVOST: To get all the equipment needed with the checklist - a cap, a gown, a mask - doctors had to go to eight different places. Caps were in one place, masks were in another. And when the equipment wasn't stocked, and it often wasn't, the doctors made in their mind what was a rational economic decision. They said, if I go spend 10 minutes to run down the hall or to another unit to get this piece of equipment, that's 10 minutes I'm going to spend not caring for another patient or doing something else because there was no slack time.
And if I go without it, the infection is invisible. It's in the future, and it may not really be prevented anyways, so they often decided to go without it. So what we did was said, OK, let's make a cart. Let's get all the equipment we need, store it in one place, make sure someone's assigned to stock it, and now compliance with the checklist went from 30 to 75 percent.
VEDANTAM: But even when all the supplies were close at hand, there was a deeper problem that had to do with the culture of medicine, the power dynamic between doctors and nurses. Peter told nurses that they had the authority to stop physicians when they tried to put in catheters without following the checklist. It caused an uproar.
PRONOVOST: The doctors said you can't have a nurse question me in public. It makes me look like I don't know something, to which I said, welcome to the human race. We all don't know things. And the nurses said, I'm not going to question a doctor because if I do, I'll get my head bit off. I'm tired of being yelled at. It's too risky. And so I pulled the team together and said, do you all agree that harm should be prevented in this hospital? Yes, of course, Peter. We should never harm patients. And do you agree that the items on the checklist are scientifically sound, that patient should get them all the time? Yes, we agree with this, Peter. I said then OK, let me be clear - doctors, you have permission to forget to use an item on the checklist. We're human. We're going to. But you don't have permission to needlessly put patients at risk. So if you forget, nurse or patient or anybody else will question you, and you will go back to fix it - not because of power but because it's the right thing to do for patients. And nurses, please page me any time of day or night if you get your head bit off.
VEDANTAM: Peter wasn't paged. And the number of patients developing infections started to drop.
PRONOVOST: Compliance went from 75 percent with the checklist to around 98 percent. Infection rates went from five per 1,000 catheter-days to two. And so we knew we were on to something, and so we started investigating every infection as a defect - changing the narrative that no longer are these inevitable but they're preventable. And what did we find? We found now that the remaining infections were often in people who had catheters for a long time and it had nothing to do with how we inserted them - the checklist I had originally made - but how we maintained them, how the nurse has accessed them. So we made a checklist for that and made sure that they access the catheters the right way, and infection rates went to zero. Indeed, we went over a year without having any of these infections. And it was just a remarkable new narrative that with a disciplined focus and cohesive effort, harm could be eliminated.
VEDANTAM: Peter became an evangelist for checklists, but he was often asked whether the results he got at Johns Hopkins, one of the nation's top medical centers, could be replicated in smaller, cash-strapped hospitals. He got his chance to study the question in 2004, when the state of Michigan decided to try using the catheter checklist in more than 100 hospitals. The results, which were published in The New England Journal of Medicine, showed a dramatic drop in catheter-related infection rates in the state all the way to zero. Those results were maintained throughout the 18 months of the study and in a follow up study with 90 of the hospitals that was published in 2010.
In the years since then, many hospital systems have tried out versions of Peter's checklists. Some efforts have been successful; others not so much. Why? Checklists are really only as good as the teams that implement them. Peter says teams that work in a top-down bureaucratic fashion are simply less likely to benefit from checklists.
PRONOVOST: Too often, we tell people how to do things - that is, the checklist - without explaining why and what's important. I'll never forget I was working with a nurse manager putting one of our projects in. And the ICU attending, who are passionate about this stuff - they got religion. They picked up the Hopkins checklist and said Peter, this is great. We will go tell our staff that they will use your checklist. There is no question. We will force them to use it.
And I said, you'll - won't work. Do not do that. Have a conversation with them about why this is important. Ask them if little girls like Josie are dying in their hospital and if that's acceptable. Discuss that the goal of zero infection is, and then say let's figure out how to make sure patients always get this best practice - so engaging people to co-create the solutions and respecting their wisdom and autonomy is really important in how we do this.
VEDANTAM: Engaging people in this deep way, talking with them about shared goals, working together to translate those goals into a to-do list that they could use every day - all this takes a lot of work. Skeptics have asked Peter whether his system works only in relatively straightforward settings. You really can follow five simple rules when inserting a catheter. But what about when you're doing surgery?
GAWANDE: There is no recipe for doing an operation. There are a million ways that things can go wrong.
VEDANTAM: When we come back, we're going to go into the operating room. Stay with us.
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VEDANTAM: This is HIDDEN BRAIN. I'm Shankar Vedantam. Surgeon Atul Gawande has quite literally written the book on the power of checklists to help us grapple with complicated tasks. But there was a time not long ago when Atul would routinely perform a complex surgery without a checklist. Sometimes he wouldn't even know all the people he was working alongside in the operating room.
GAWANDE: I would just walk in. It was kind of expected to be a silent place where people didn't ask a lot of questions. They're just supposed to know what they're doing, and then you just proceed. And then when something goes wrong, you'd be like - you know, why didn't you guys know what the hell you were doing? And either - you know, that kind of ridiculous lack of preparation was the typical story.
VEDANTAM: Atul, like Johns Hopkins physician Peter Pronovost, became interested early in his career in the routines and assumptions embedded in medicine. How much was the success of a surgeon about talent and training? How much of it was about having strong procedures and teamwork? Atul began to look for answers to those questions.
GAWANDE: I'd done a study with several other researchers while I was in my training, where I got to look at data from a team that had gathered information from hospitals across Utah and Colorado. And they were looking at people who had had a major complication or a death during a hospital admission. And I found two things in examining the data. Two thirds of the patients who'd had a major disability or death as a bad outcome from their care were surgical patients. And furthermore, I found at least two thirds of those patients turned out to have died from a problem where we had the answer but didn't execute on it. In fact, it was a very tiny percentage of patients who had a major disability or death that was due to a problem that we hadn't discovered the answer for. It was mostly a problem of lack of execution.
VEDANTAM: People were suffering and in some cases dying because surgical teams were making preventable errors, overlooking basic steps that could make an operation safer. Atul realized that the unsexy task of developing better surgical procedures was actually the most important work he could do.
GAWANDE: The volume of surgery had exploded around the world, as people lived longer, to more than 300 million operations worldwide, one for every 20, 22 or so human beings. But the death rates were 10 to a hundred times higher than in childbirth. So that meant that we needed to look at this as a public health problem.
VEDANTAM: Atul started looking more deeply at the problem. He was intrigued by this study Peter Pronovost had conducted in Michigan. Peter had found that using a checklist could dramatically reduce catheter infections. Atul decided to develop a checklist for surgical teams.
GAWANDE: We worked with a variety of teams - experts in anesthesia, infectious disease, surgery, nursing and so on.
VEDANTAM: He also went to Seattle to meet with airline safety experts at Boeing.
GAWANDE: And one of the key points that the Boeing folks emphasized to us is that it has to fit into the workflow and cannot be a distraction from the core things you're doing and make matters worse. So if you're launching a rocket into space, you have all the time in the world. You get one shot at this thing - right? - whereas we do 50 million operations per year in the United States. We have a lot of people we have to take care of. And you know, if we only get through half of them, we have a whole lot of people who end up being harmed along the way.
So we set some terms around this. We have two minutes total for a check before the patient's put to sleep, a check before the incision's made and a check before the person leaves the room. And then can we run through it in such a way that you're identifying the killer items? You want to chunk it because, you know, the brain can only handle five to nine items at a time. And so we had to chunk it into components that allow people to, you know, run through it in a reasonable way - while having a potentially emergency patient on the table in front of you.
VEDANTAM: Once he had a basic checklist in hand, it was time to test it out. Surgical teams in eight cities around the world agreed to give it a try.
GAWANDE: Rural Tanzania, a city hospital in Delhi to some of the wealthiest places - University of Washington Medical Center in Seattle, St. Mary's Hospital in London, Toronto General Hospital - and in every hospital, you had a reduction in complications. The average reduction in complications was 35 percent. The reduction in deaths was 47 percent.
VEDANTAM: A 47 percent reduction in deaths. Checklists, it seemed, could be as powerful in a surgical setting as they were in reducing catheter infections. Since Atul published those findings, checklists have become a standard part of surgeries in hospitals around the world, including at the hospital where Atul works.
(SOUNDBITE OF ELECTROCARDIOGRAM BEEPING)
VEDANTAM: Operating rooms at Brigham and Women's Hospital in Boston are crowded and busy places. You have lots of surgical equipment and monitors and lots of people in motion.
UNIDENTIFIED WOMAN: And he reported...
VEDANTAM: Atul Gawande and a group of colleagues are preparing to perform a surgery. Their patient is a woman named Heather Parsons (ph). They're reviewing Heather's medical history and the plan for her surgery. One member of the team asks Heather to confirm the procedure they're about to perform.
HEATHER PARSONS: They are doing a partial thyroidectomy on the right side.
UNIDENTIFIED WOMAN: OK. So the right side, the side that has been marked right there, is the correct side that we're working on. We're all in agreement?
UNIDENTIFIED WOMAN: OK. So I'll take over from here.
VEDANTAM: Heather and the team agree that they're going to do a partial thyroidectomy on the right side of her body. It can be a little hard to hear everything here. Microphones are not very easy to sterilize, and since infection control is a major concern, we had to record some distance from the action. The team goes over concerns they had in the lead-up to the surgery, and they tell Heather how they plan to address those concerns. Then they begin anesthesia.
LAUREN GAVIN: So I want you to breathe out. Then - and when I tell you to, I want you to go (inhaling), and breathe in, OK? So breathe out. Open wide. Breathe in.
VEDANTAM: After Heather goes to sleep, the team formally begins their surgical safety checklist. They again review her full name, date of birth, allergies and the plan for the surgery. And then they do something that might not occur to those of us who've never watched a surgery. They do introductions.
GAVIN: Lauren Gavin, anesthesia sent me.
BRAD: Brad (ph), surgical tech.
JILL: Jill (ph), surgical...
VEDANTAM: They confirm that they have all the equipment they need, and they double-check that there are no other medical concerns that need to be addressed. Then with George Michael's song "Faith" in the background, they begin the surgery.
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GEORGE MICHAEL: (Singing) Faith, faith, faith, I got to have faith, faith, faith.
VEDANTAM: It might seem obvious that surgical teams should run through a routine like this. Of course, each person should know the name of everyone else on the team. Of course, everyone needs to be on the same page about the surgery they're performing and the potential risks. But until checklists became a rule, these obvious things weren't always put into practice. Atul says it's worth remembering that checklists have not been universally successful. They only work if medical teams tailor them to their own needs and their own local cultures.
GAWANDE: When we ask people for their copies of the checklist, looking at 100 checklists, virtually every one of them has been changed and customized in some way that they've done locally. And I've seen checklists that take our 19 items and made them more than 80 items, and administration had taken over the control of the checklist. They'd piled all of these things on, and then everybody ignored - had start ignoring them because you just couldn't make it work in a day where you had to get through taking care of the patients.
VEDANTAM: One big cautionary tale, he says, is how the surgical checklist was rolled out in Canada.
GAWANDE: So in Canada, in Ottawa, they deployed it by making it a law. You have to do this in the hospital. And the hospitals then would sign off that they'd followed the law. And they got a 0 percent improvement in death because there wasn't an actual implementation program.
VEDANTAM: Contrast this to what happened in South Carolina. The state's hospital association reached out to Atul to ask him for his help in launching a surgical checklist initiative. Atul says South Carolina's program, unlike Canada's, was voluntary. There was a lengthy process to make sure teams at each hospital understood the point of the checklist. They were encouraged to change it, make it their own. There was also a game plan to deal with hospital politics.
GAWANDE: Expect you're going to have some surgeons who say, this isn't such a great idea, I don't want to do it. And we had a strategy for approaching those folks, which is simply to go in, and see them one-on-one and just ask, will you help? And more often than not, people will.
VEDANTAM: In the end, about 25 percent of South Carolina's hospitals, which take care of 40 percent of the state's population, took part in the checklist effort. Atul says those hospitals saw a 22 percent reduction in patient deaths.
GAWANDE: And that was as many lives saved as would've died in car accidents in that population.
VEDANTAM: These results, the first large-scale study of surgical checklist use in a general patient population, were recently published in the journal Annals of Medicine. Atul has spent a lot of time thinking about checklists. Yes, they can reduce deaths, and they can reduce hospital infections, but they can also do something else that's surprising. They can generate a feeling of teamwork and shared purpose.
GAWANDE: Operating rooms are often people who are getting together and - at the start of a day as a completely new team. You will have people coming together in combinations that sometimes have never really worked together before or haven't worked together in a long time - you know, the nurse on duty for the day, the anesthesiologist on duty for the day, a resident participating. And so you have to quickly make that team jell and coalesce.
The act of people speaking up and just hearing themselves say their name in the room - studies have shown that when people have had that chance to introduce themselves, they're much more likely to speak up later. And that's what we're now recognizing, is that the - that when you just stand and watch a team that has used the checklist, there is much more likelihood that people will raise questions, feel comfortable saying, hmm, I don't quite understand why X, Y, Z or - is happening. And in general, you see much more equality of voices in the room. You have as much talking to be likely from a nurse, a surgeon and an anesthesiologist rather than one or another dominating.
VEDANTAM: Is it - is the idea of the checklist, you can basically do away with the expert now? In other words, if you can come up with a list of things to do, can I be the surgeon that you are or the pilot that, you know, flies Boeing planes?
GAWANDE: Yeah, no, absolutely not.
VEDANTAM: (Laughter) Oh, darn.
GAWANDE: Right. So one of the amazing things of just looking at these checklists is they're made for experts use They're not an algorithm. They're not a recipe for flying a plane. They are the - you know, here in this moment are the five most common ways that things go wrong. It's put into a very professional, terse language. You know, it's almost like one word or two words. Check, have you got this? Have you got that? Check. And then you move on. It's aimed to be a supplement to your brain, both activating it and advancing it. And that's, to me, some of the coolest aspects of it because this is what enables a professional to function at this incredible level of performance.
There are a million ways that things can go wrong, but there is a recipe for being ready for how to handle it. Does everybody understand why you're here, what the background medical issues are of this person? Do we all understand what each other's roles are? Do we know how long the case will take? Are we ready for the unexpected? And by doing that, that's putting you in an entirely different place.
VEDANTAM: It's a place that he says doesn't have to be reserved only for doctors or pilots or people in high-stress jobs. Atul thinks we could all benefit from checklists.
GAWANDE: The reasons checklists are fascinating to me is that they're the oldest, most simple system human beings have invented for dealing with the limitations of our brain and also the limitations of working together as a team. I got to talk about this on "The Colbert Report."
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STEPHEN COLBERT: Americans don't need checklists. We [expletive] it, OK? All right? Check one - show up to work. Two - be American.
GAWANDE: I thought, that's so cool. I get to go on.
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COLBERT: Do you use a checklist?
GAWANDE: So we...
COLBERT: Do you use a checklist?
GAWANDE: I finally began using a checklist in the last couple of years.
COLBERT: What do you do with the checklist?
GAWANDE: Well, it turned out one of the - the main reason he wanted me on was then to talk about - he said, hey, is there a checklist for what we do? Because this drives me crazy. Every day, we have planned out the whole show. Then around 3 o'clock, there'll be some breaking news thing, and you have to completely remake the jokes, and it always ends up falling apart. And there are mistakes left and right because we're remaking the show half the time on the fly. How would we have a checklist for breaking news comedy (laughter)? And, you know, it's totally doable. You can look at what happens every time, what are the things that go wrong, and how can you have a series of checks so you're not making the same mistakes over and over and over again?
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VEDANTAM: Surgeons, pilots and parents often have to race to get things done. The more we rush, the easier it becomes to trip over something and take a fall. Checklists won't necessarily solve all problems of modern living. Airplanes and space shuttles will still crash despite elaborate checklists. Surgeries will still go wrong even when a team takes the time to anticipate the risks. Merely setting up checklists won't mean that we follow them. We can set up a calendar alert reminding us of a 5 p.m. project deadline and then procrastinate all the way until 4:45 before we try to get it done.
Checklists can also be so long and complicated that they become self-defeating. You can draw up a comprehensive list before heading to the supermarket, and then come home and find you forgot to get the coffee. But what checklists do accomplish is they get us to focus on things that are most likely to trip us up. Over time, preventing the most common errors will have the biggest impact on our lives. Perhaps most important, checklists are one of humanity's oldest tools to combat our blindspots and our arrogance. The humble checklist reminds us of the importance of humility because, in the end, we're only human.
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VEDANTAM: This week's episode was produced by Tara Boyle. Our team includes Maggie Penman, Jennifer Schmidt, Rhaina Cohen, Parth Shah and Renee Klahr. We had original music composed by Ramtin Arablouei. Our unsung heroes this week are Atul Gawande's colleagues Deborah O'Neill, Tanya Palit Husain, Lori Schroth, Angel Ayala and Samuel Kim. Figuring out how to get audio from Atul and his colleagues in surgery was not easy. There were all kinds of hurdles around infection control and patient privacy. Deborah, Tanya and Lori spent many hours working to overcome those hurdles. They also managed to carve out time in a busy surgeon's schedule for not one but two interviews. Angel and Sam got the sound you heard from the operating room at Brigham and Women's Hospital. Many thanks to all of you.
You can find more of our reporting on Facebook, Twitter and Instagram. If you liked this episode of the show, one request - please make your own checklist of all the friends you think might enjoy HIDDEN BRAIN, and share it with them. I'm Shankar Vedantam. See you next week. Transcript provided by NPR, Copyright NPR.