Is your doctor using a checklist?
Lloyd I Sederer, MD
Written with Jeffrey A Lieberman, MD*
Let's face it. Medical care has become a whole lot more complex. The scientific knowledge base and practice of medicine has expanded exponentially as scientists have plumbed the human body and mind to reveal its genetic, molecular, anatomic, physiological and psychological mysteries and developed ever-more sophisticated means to diagnose disease, treat patients and prolong life. Although this acceleration in progress holds great benefits for an individual's health, it poses a daunting challenge to physicians trying to keep up with the latest findings and developments. Who can provide state of the art care and deliver complex treatments to numerous patients day after day without error? No one. It is simply not humanly possible to be error free.
This is the premise wonderfully rendered by Dr. Atul Gawande in his most recent book, The Checklist Manifesto: How to Get Things Right. Gawande gets our attention right away by taking us into an Intensive Care Unit (ICU) where as many as 178 procedures, from putting in a urinary catheter to placing a catheter in the vena cava, the major vein leading to the heart, are routinely done; missing a step in any one of these highly complex procedures is no small matter since the consequences are grave, sometimes deadly. You would think that doctors would welcome anything that would help to ensure that they get it right -- including something as simple as a checklist. Sorry, yes is not the answer.
Airlines do it (and their safety record is legendary), builders do it, and even some financial institutions do it. But doctors? Not readily, is Gawande's conclusion. And he is right, proving his point scientifically using the example of the "19 Point Safe Surgery Checklist" that he pioneered through the World Health Organization (WHO). When this checklist was tested in eight very diverse countries it reduced deaths by 47 percent and post-operative complications by 36 percent! To make his case personally, Gawande tells the story of how a patient he was operating on would have died of a complication during surgery had he not used his own checklist. But has this checklist been adopted universally, even if not welcomed? Not at all. Only 10 percent of US hospitals employ or are planning to employ checklists.
The tale of the challenge of checklists has immediacy as my agency (Dr. Sederer is the Medical Director of the New York State Office of Mental Health) develops and pilots a checklist for prescribing antipsychotic medications (used to treat those serious mental disorders where people lose touch with reality). We developed this checklist with a group of experts after evidence became overwhelming that antipsychotic medications, while essential, carry many risks and are far from being prescribed according to the knowledge that exists about them. They are also very costly and a dollar spent unnecessarily on this treatment is a dollar less to spend on another treatment. The checklist is a set of eight questions that begins by asking a prescribing doctor (or nurse with prescribing authority) whether the patient has a diagnosis that warrants the use of this class of medications. It goes on to ask about side-effects, patient preferences, using multiple medications at the same time (called polypharmacy), and the physical health of the patient. The checklist, which we call SHAPEMEDs (an acronym or abbreviation using the first letter or portion of a key word for the eight questions), does not tell the prescriber what to do. Instead it asks whether the doctor has considered a set of essential aspects of quality care. Key information that supports the principles that underlie these questions is supplied on the back of the form or by a roll-over hyperlink on its electronic version.
As we pilot and implement this checklist we know it will be a challenge, as Dr. Gawande cautions. Why the reluctance?
First, no one likes being told what to do, including doctors. A common reason for not doing what is proven to work is the rejection of "cookbook medicine." That cry is amplified by statements that rigid rules constrain the art of medicine. But what will reduce what is called the "science to practice gap" in medicine (the gap between what doctors know and what they do)? In the delivery of mental health services, for example, as few as one in six people with depression receive minimally adequate care -- even though detection, diagnosis and effective treatment can be routinized and vastly improved. This level of performance can be improved, and must be. Careful thinking has somehow been confounded with mindless requirements.
Second, doctors are anxious about being sued. Anything that may be used as 'evidence' in malpractice law suits can evoke fear that it will become red meat for ravenous personal injury lawyers ready to pounce. While we will be silent about lawyers we will say that checklists and other means by which doctors demonstrate, in writing, they tried to do the right thing is the best best protection should they be brought to court.
Third, there is the time argument. Agreed, doctors do not have enough time to do all they need to do. Ironically, it is the lack of time, the rush to do all that needs to be done, that increases the risk of error, as doctors look for shortcuts and may make unfounded assumptions and decisions. A simple checklist has what engineers call a "forcing function," an inescapable path that truly reduces errors. And reducing errors always saves time, if not now then surely later.
And while there are other explanations for not using a particular checklist, one more bears mention -- namely when a checklist does not work: when a checklist does not produce the benefits it purports to deliver. This important argument can only be settled by evidence that the checklist, if used, will make medical care safer, better and cheaper. The WHO Safe Surgery checklist has been proven do so. As my agency pilots SHAPEMEDs in a sample of our 26 hospitals we will evaluate its impact and refine it so that it becomes worth its while.
I (Dr. Sederer) recently had a minor ambulatory surgical procedure and asked the anesthesiologist if he used a checklist. He is an accomplished doctor. But he did not use a checklist. I know that if SHAPEMEDs proves to be beneficial that I will encourage every patient and family I know to ask the doctor "...are you using a checklist when you prescribe an antipsychotic medication?" Wouldn't you want medicine to be as safe as science can make it be?
The opinions expressed herein are solely my own as a psychiatrist and public health advocate. Lloyd I Sederer, MD
*Dr. Lieberman is Chairman, Department of Psychiatry, College of Physicians and Surgeons, Columbia University and
Director, New York State Psychiatric Institute.