THE CHECKLIST MANIFESTO by Atul Gawande. Metropolitan Books, $24.50 2009.

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Has the author chosen a relevant topic? Check.
Does he have passion for the subject?
Check.
Will the opening chapter grab the reader’s interest?
Check.
Are the characters three-dimensional?
Check.
Has something novel been given birth?
Check.
Is the writing descriptive?
Check.

No, the art of writing can’t be done by checklists. But what about medicine? In his important, and perhaps paradigm-changing The Checklist Manifesto, Atul Gawande suggests that regardless of whether medicine is an art, a science, or both, its practice will be greatly improved by the simple, unheralded, and largely untaught technique familiar to anyone who takes a Post-It sticky to the grocery store to make sure that the milk is not forgotten.

Is the book relevant? Unless you’ve been sleeping through the current health-care debate, and are not appalled by the unnecessary dollars and deaths that have informed that debate, you will be nodding yes to the relevance question. Gawande argues that the science of medicine is increasingly an art form that requires greater mastery if the dollars and deaths are to be contained. “The model of medicine in the modern age seems less and less like penicillin and more and more like … the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

What about the author’s passion for his subject? Gawande is one of those renaissance men who seem to bring energy to everything they touch. He takes his experience as a surgeon at Brigham and Women’s Hospital and as a professor at Harvard and applies it regularly as a staff writer at The New Yorker. Every few years, his writing is distilled in book form. And with The Checklist Manifesto we have a passionate distillation of his experience, teaching, and writing.

And how about that opening chapter? The rather pedestrian title of this chapter (“Introduction”) should not be interpreted as “skip this and proceed to the real stuff.” Indeed, if after reading this review you have questions about the vital importance of this book, read the anecdotes, theory, and mandate conveyed in the opening 13 pages. Gawande opens his book with two war stories that seem written for the television show ER: a patient who went to a costume party dressed as a soldier is stabbed with his own bayonet; cardiac arrest results from an anesthesiologist accidentally giving his patient a nearly lethal overdose of potassium. Beyond the stories, the introduction establishes the theory of the book, distinguishing ignorance (“we may err because science has given us only a partial understanding of the world and how it works”) from ineptitude (“the knowledge exists, yet we fail to apply it correctly”). The rest of the book establishes the case for Gawande’s checklist “eptitude” manifesto for medicine and other information-intensive professions:

“The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge that people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy …. It is a checklist.”

Any compelling characters here? Though this is a book of nonfiction, readers will still want fully fleshed-out characters. While that might be a bit difficult, considering that the protagonist is the lowly checklist, Gawande uses descriptive writing to infuse his book with memorable people. He takes case studies that might find their way into medical journals and breathes life into them. His technique is to recount a medical situation involving a real flesh-and-blood patient and abstract that to a larger concept. Early in the book, Gawande takes the reader through the hemorrhaging of Anthony DeFilippo, a patient who had been transferred to Gawande’s ICU after the surgeon, who was treating him for a hernia and gallstones, was unable to stop the bleeding. After Gawande and his team were able to resolve the presenting issues, they discovered that they had introduced an infection in one of the many lines inserted as part of their intervention.

In a bit of damning praise, Gawande writes, “This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication.

ICUs put five million lines into patients each year, and national statistics show that after 10 days four percent of those lines become infected ….  All in all, about half of ICU patients end up experiencing a serious complication and, once that occurs, the chances of survival drop sharply.” After learning these statistics, the grateful reader will never forget Anthony DeFilippo’s role in shedding light on the risks we and our loved ones face in the hospital.

Is this work of nonfiction truly novel? Perhaps not. Gawande himself acknowledges that there is nothing new about using checklists; indeed he takes the reader back to 1935 when a Boeing airplane’s crash was attributed to pilot error. As a result, a pilot’s checklist was born. Even Gawande’s more sophisticated extension of the checklist beyond simple, routine tasks like surgeons’ washing their hands to complicated and complex problems like the coordinated communication between specialized experts is not new; it has its roots in social psychology and organizational learning.

But does novelty really matter when lives are at stake? In a recent New York Times article about implementing checklists, Dr. Peter Pronovost (whose contribution Gawande  acknowledges) exclaimed that “You would have thought I started World War III.” He then asserted that having nurses check to ensure that doctors washed their hands has “gotten infection rates down to almost zero in the ICU.” With success like that, patients are probably saying, “Thank you very much, Dr. Gawande. Your manifesto may not be War and Peace, but it has saved more lives than Tolstoy’s novel.”

For NP Beck, Dr. Prasad, Dr. Rachamallu, Dr. Raman, and Dr. Singh who care for the Oza family by carefully coordinating communications with the very special and specialized Drs. Baker, Bhalala, Lewis, Kwai Ben, Nguyen, Ready, Yavorkovsky, and their teams.

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