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Vol. LXI, No. 8
April 17, 2009

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From Mystery to Checklist
Gawande Speaks on Art, Science in Medicine

On the front page...

In a sweeping campaign to improve medical performance, Harvard Medical School’s Dr. Atul Gawande has taken the battle beyond the operating room.

A distinguished surgeon, author and White House advisor, Gawande’s research focuses on reducing deaths, complications and disparities in surgery in the U.S. and abroad. And when he’s not in scrubs or writing his New Yorker column, Gawande directs the World Health Organization’s Global Challenge for Safer Surgical Care. He recently visited NIH to give back-to-back lectures, each to a packed house.

“We all want medicine to be an orderly field of knowledge and procedure,” he said. “The going words these days are ‘precision medicine’ or ‘personalized medicine’…and that conjures an image of this being a world of orderliness. But it’s not.”


  Dr. Atul Gawande talks about art, science in medicine.  
  Dr. Atul Gawande talks about art, science in medicine.  

His first talk, “The Art of Failure in Medicine,” one of the CC’s Great Teachers Series in Lipsett Amphitheater, explored “what happens when understanding doesn’t yet exist.” Gawande segued with “The Science of Failure in Medicine,” the Rall Cultural Lecture in the Wednesday Afternoon Lecture Series in Masur Auditorium.

Even if errors were eliminated and mysteries solved, Gawande said, “Medicine’s ground state remains uncertainty.” Wisdom for both patient and doctor is to find how one copes with it.

“The Art” wove together three stories: an elderly patient who refused lifesaving surgery; Gawande’s own daughter, in the ER with a raging fever; and a young woman who might—or might not—have a deadly infection.

The patient who refused surgery was still (astonishingly) alive and well a year later. Gawande’s daughter was sent home from the hospital, all tests negative, yet in fact had influenza A. And the woman with a foot infection—this was the cliffhanger. Could she have necrotizing fasciitis, a virulent infection that destroys tissue beneath the skin?

The patient balked at a biopsy. The “second opinion” came, saw and hedged. Lab tests were inconclusive. The surgical team then had a choice: take the patient to the OR or watch and wait.
NIH deputy director for intramural research Dr. Michael Gottesman (l) welcomes Gawande to NIH.

NIH deputy director for intramural research Dr. Michael Gottesman (l) welcomes Gawande to NIH.

“We want to trust in judgment, but human physician judgments are all over the map,” Gawande said. According to “the blind algorithm,” an analytical calculation of risks and benefits, not doing surgery would be appropriate.

Yet “we had a hunch”—based on experience—“and this is hard to ignore,” he said.

With the patient’s consent, the surgeons set to work. And there it was: necrotizing fasciitis. Amputate or not? Gawande, then a surgical resident, said yes; the attending physician resisted. Another uncertainty. After multiple procedures, they saved the leg and the patient recovered.

“She’s the single greatest save I’ve ever gotten to be a part of,” Gawande said.

Yet in this case, so rife with ambiguity, he still thinks they got lucky: “I don’t think we in medicine have explained or understood our fallibility,” he said. “There’s science to be done on how we cope with uncertainty…very, very important. We also must examine the reality, and the only way to do that is in the details, and the best way to do that…is art.

“In writing about these matters, here’s what surprised me the most,” he continued. “People have found hearing about these details more reassuring than they’ve found them frightening… They know we will never achieve perfection. But they also want to know that we’ll never cease to aim for it.”

How do you aim for it? That’s where his second talk, “The Science of Failure of Medicine” fits in.

Surgical safety is a major public health concern. Out of the 230 million operations performed worldwide in 2008, “three percent resulted in major disability or death,” Gawande noted. “At least half the time, those [adverse events] are preventable.”

His team developed a “surgical safety checklist” for operating room staff to share information quickly, consistently and efficiently. Inspired by pilot safety checklists used before takeoff and landing, the surgical checklist includes such items as staff introductions (by name), whether antibiotics have been given before the first incision and an estimate of how much blood the patient is expected to lose.
At one of two lectures Gawande gave at NIH, he chats with Gottesman.

At one of two lectures Gawande gave at NIH, he chats with Gottesman.

Over a year-long study on 7,688 “checklisted” surgical patients in 8 cities, the death rate dropped from 1.5 percent to 0.8 percent; complications fell from 11 percent to 7 percent.

Gawande also discussed the work of Dr. Peter Pronovost who designed a checklist for the insertion of central lines—catheters placed in large blood vessels, such as the vein that runs beneath the collarbone. Thanks to the list, the reduction in infection rate was dramatic.

“It’s not that a checklist is the be-all and end-all,” said Gawande. “The core idea is that knowledge must change behavior…A checklist is critical. Without it you can do things correctly most, but not all, of the time.”

And we must measure outcomes. One of the most disturbing things, he said, is cuts in funding for health statistics.

In a system of extreme complexity—a hospital in the real world, “where we still have trouble getting people to simply wash their hands”—a checklist can also help manage the complexities of the intensive care unit. Gawande recounted how an Austrian hospital saved a 3-year-old girl who suffered a near-drowning after 30 minutes in freezing water.

“I had a chance to talk to the surgeon who saved that little girl,” he said. The case was in a community hospital in a rural area where, every year, they would lose patients from hypothermia.

“When [the surgeon] saw the problem, a lack of speed [in hospital team response], he made a checklist. He gave it to the person with the least power, the telephone operator,” who called seven people on her list.

The telephone operator deployed the team.

“And with that,” said Gawande, “they had their first survival.” NIHRecord Icon

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