The Checklist Manifesto (13 page)

The checklist also included what they called a “team briefing.” The team members were supposed to stop and take a moment
simply to talk with one another before proceeding—about how long the surgeon expected the operation to take, how much blood loss everyone should be prepared for, whether the patient had any risks or concerns the team should know about.

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 out of the room and tried to get him suspended for insubordination.) No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. But in medicine, we see it all the time. I’ve seen it in my own operating room.

Teamwork may just be hard in certain lines of work. Under conditions of extreme complexity, we inevitably rely on a division of tasks and expertise—in the operating room, for example, there is the surgeon, the surgical assistant, the scrub nurse, the circulating nurse, the anesthesiologist, and so on. They can each be technical masters at what they do. That’s what we train them to be, and that alone can take years. But the evidence suggests we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to what ever problems might arise.

I had assumed that achieving this kind of teamwork was
mostly a matter of luck. I’d certainly experienced it at times—difficult operations in which everyone was nonetheless firing on all cylinders, acting as one. I remember an eighty-year-old patient who required an emergency operation. He had undergone heart surgery the week before and had been recovering nicely. But during the night he’d developed a sudden, sharp, unrelenting pain in his abdomen, and over the course of the morning it had mounted steadily in severity. I was asked to see him from general surgery. I found him lying in bed, prostrate with pain. His heart rate was over one hundred and irregular. His blood pressure was dropping. And wherever I touched his abdomen, the sensation made him almost leap off the bed in agony.

He knew this was trouble. His mind was completely sharp. But he didn’t seem scared.

“What do we need to do?” he asked between gritted teeth.

I explained that I believed his body had thrown a clot into his intestine’s arterial supply. It was as if he’d had a stroke, only this one had cut off blood flow to his bowel, not his brain. Without blood flow, his bowel would turn gangrenous and rupture. This was not survivable without surgery. But, I also had to tell him, it was often not survivable even with surgery. Perhaps half of the patients in his circumstance make it through. If he was one of them, there would be many complications to worry about. He might need a ventilator or a feeding tube. He’d already been through one major operation. He was weak and not young. I asked him if he wanted to go ahead.

Yes, he said, but he wanted me to speak with his wife and son first. I reached them by phone. They too said to proceed. I called the operating room control desk and explained the situation. I
needed an OR and a team right away. I’d take what ever and whoever were available.

We got him to the OR within the hour. And as people assembled and set to work, there was the sense of a genuine team taking form. Jay, the circulating nurse, introduced himself to the patient and briefly explained what everyone was doing. Steve, the scrub nurse, was already gowned and gloved, standing by with the sterile instruments at the ready. Zhi, the senior anesthesiologist, and Thor, his resident, were conferring, making sure they had their plans straight, as they set out their drugs and equipment. Joaquim, the surgery resident, stood by with a Foley catheter, ready to slip it into the patient’s bladder as soon as he was asleep.

The clock was ticking. The longer we took, the more bowel would die. The more bowel that died, the sicker the man would become and the lower his chance of survival. Everyone understood this, which by itself was a lot. People don’t always get it—really feel the urgency of the patient’s condition. But these people did. They were swift, methodical, and in sync. The case was far from easy, but for what ever reason, it seemed like nothing could thwart us.

The patient was a big man with a short neck and not much lung reserve, making it potentially difficult to place a breathing tube when Zhi sent him off to sleep. But Zhi had warned us of the possibility of trouble and everyone was ready with a backup plan and the instruments he and Thor might need. When Joaquim and I opened up the patient, we found that the right colon was black with gangrene—it had died—but it had not ruptured, and the remaining three-fourths of the colon and all the small bowel seemed to be okay. This was actually good news.
The problem was limited. As we began removing the right colon, however, it became evident that the rest of the colon was not, in fact, in good shape. Where it should have been healthy pink, we found scattered dime-and quarter-sized patches of purple. The blood clots that had blocked off the main artery to the right colon had also showered into the arterial branches of the left side. We would have to remove the patient’s entire colon, all four feet of it, and give him an ostomy—a bag for his excreted wastes. Steve, thinking ahead, asked Jay to grab a retractor we’d need. Joaquim nudged me to make the abdominal incision bigger, and he stayed with me at every step, clamping, cutting, and tying as we proceeded inch by inch through the blood vessels tethering the patient’s colon. The patient began oozing blood from every raw surface—toxins from the gangrene were causing him to lose his ability to clot. But Zhi and Thor kept up with the fluid requirements and the patient’s blood pressure was actually better halfway through than it had been at the beginning. When I mentioned that I thought the patient would need an ICU, Zhi told me he’d already arranged it and briefed the intensivist.

Because we’d worked as a single unit, not as separate technicians, the man survived. We were done with the operation in little more than two hours; his vital signs were stable; and he would leave the hospital just a few days later. The family gave me the credit, and I wish I could have taken it. But the operation had been symphonic, a thing of orchestral beauty.

Perhaps I could claim that the teamwork itself had been my doing. But its origins were mysterious to me. I’d have said it was just the good fortune of the circumstances—the accidental result of the individuals who happened to be available for the case and their particular chemistry on that particular afternoon. Although I
operated with Zhi frequently, I hadn’t worked with Jay or Steve in months, Joaquim in even longer. I’d worked with Thor just once. As a group of six, we’d never before done an operation together. Such a situation is not uncommon in hospitals of any significant size. My hospital has forty-two operating rooms, staffed by more than a thousand personnel. We have new nurses, technicians, residents, and physician staff almost constantly. We’re virtually always adding strangers to our teams. As a consequence, the level of teamwork—an unspoken but critical component of success in surgery—is unpredictable. Yet somehow, from the moment we six were all dropped together into this particular case, things clicked. It had been almost criminally enjoyable.

This seemed like luck, as I say. But suppose it wasn’t. That’s what the checklists from Toronto and Hopkins and Kaiser raised as a possibility. Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork—a kind of team huddle, as it were. So was another step that these checklists employed, one that was quite unusual in my experience: surgical staff members were expected to stop and make sure that everyone knew one another’s names.

The Johns Hopkins checklist spelled this out most explicitly. Before starting an operation with a new team, there was a check to ensure everyone introduced themselves by name and role: “I’m Atul Gawande, the attending surgeon”; “I’m Jay Powers, the circulating nurse”; “I’m Zhi Xiong, the anesthesiologist”—that sort of thing.

It felt kind of hokey to me, and I wondered how much
difference this step could really make. But it turned out to have been carefully devised. There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do. And Brian Sexton, the Johns Hopkins psychologist, had done studies showing the same in operating rooms. In one, he and his research team buttonholed surgical staff members outside their operating rooms and asked them two questions: how would they rate the level of communications during the operation they had just finished and what were the names of the other staff members on the team? The researchers learned that about half the time the staff did not know one another’s names. When they did, however, the communications ratings jumped significantly.

The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.

These were limited studies and hardly definitive. But the initial results were enticing. Nothing had ever been shown to improve the ability of surgeons to broadly reduce harm to patients aside from experience and specialized training. Yet here, in three separate cities, teams had tried out these unusual checklists, and each had found a positive effect.

At Johns Hopkins, researchers specifically measured their checklist’s effect on teamwork. Eleven surgeons had agreed to try
it in their cases—seven general surgeons, two plastic surgeons, and two neurosurgeons. After three months, the number of team members in their operations reporting that they “functioned as a well-coordinated team” leapt from 68 percent to 92 percent.