“The Checklist Manifesto” by Atul Gawande

This book is titled a “manifesto” and it certainly seems like it. This is Gawande making his case for surgeons and those in medicine to adopt a checklist for use in their operating rooms to make sure that they don’t forget the little details in their work. Having said that, it reads more as a narrative about how he came to the conclusion that checklists would be beneficial (almost essential) in medicine.

This narrative starts with Gawande wondering how big buildings and other works of architecture are built. It’s not that different from surgery after all, you have a project that needs to be completed within a time frame, and mistakes could be disastrous. Turns out that construction workers use an enormous checklist with everything that has to be done, and when. The amount of knowledge involved in constructing a building is far beyond any one person’s capabilities, so there is input from all of the different utilities and builders in forming the list. Then to deal with unexpected problems, they have a schedule of when people will meet with each other and discuss aspects of the building before moving forward. Even their collaboration is built into the schedule!

From there, Gawande describes how pilots and air crew have a similar game plan, and their training is such that they always turn to a checklist when taking off, landing, or dealing with crises. They also have a solid foundation in teamwork when flying. That’s why occurrences like the miracle on the Hudson happened, the entire crew worked together to make it happen. And the pilots had a checklist.

In the early 2000s there was a series of meetings involving physicians from around the world to make surgeries safer. Gawande suggested a sort of checklist to standardize procedures and remind surgeons of the basics. There were many pitfalls, such as cutting the checklist down and not including everything in it, but in the end the trial of the checklist system was a rather unexpected success!

Of course, some doctors are loathe to use it. As far as I can tell, their main objection is pride. They think that they don’t need these little reminders, they are on top of things. However as numerous anecdotes point out, yeah, you do need the checklist. Gawande himself shares an instance where using the checklist saved his patient’s life. He also points out that if we had a drug that improved performance as much as the checklist, hospitals all over the world would be fighting for it. But since it’s a boring checklist, implementing it has been a struggle.

Besides thinking about checklists, this book also made me think about leadership. Gawande doesn’t hesitate to point out the fact that most surgeons run their operating rooms like a dictatorship and often nurses are reluctant to point out when they might have forgotten something. Using a checklist and going through the items as a team created a better sense of unity in the OR and fostered teamwork. As a leader, you have to think of the balance between you telling people what to do and everyone working together. Gawande argues for more collaboration, especially within medicine. Architects have learned that there is too much information for one person to know everything, but medicine has yet to catch up. Where do I fall on that scale? I like to think that I’m very collaborative, but where could I improve? Clearly the checklist system has implications beyond those suggested here, and is an important tactic for anyone in a leadership role.