I don't think people are trying to suggest doctors are maliciously saying "XYZ error rate is good enough, we don't need to do better", but more that there is some ego at play in the reactionary shunning of checklists, when in fact checklists can be a relatively easy way to produce better outcomes.
[1] http://www.nature.com/news/hospital-checklists-are-meant-to-...
I am now. The author of the research on which this article is based [0] is Marty Makary (MM). Marty claims to have co-developed the checklist which was further popularized by Atul in his book [1]
Marty advocates transparency in healthcare in his book "Unaccountable". He laments existing bureaucracy and his solution is more bureaucracy. I find this review illuminating [2]. The reviewer makes good points, and the replies he gets show how many missed his point.
This is the world of medicine. People get pumped up into believing the entire medical profession is flawed, there's a massive debate about how much money should be paid out, and the world keeps turning. In the middle of this, good doctors can become victims of stress induced by bureaucracy. That's a cost on which you simply cannot put a dollar figure. Patients can end up receiving worse care, and lawyers walk away happy to have drummed up more business.
I wrote more in my second response to brownbat in this thread. Basically, the checklist research hasn't been sufficiently replicated, and checklists do not guarantee focus and awareness. There is not a one-size-fits-all solution for increasing people's focus. It's not as simple as brownbat implies. Atul admits this,
"It turns out to be much more complex that just having the checklist in hand." [3]
[0] http://www.bmj.com/content/353/bmj.i2139
[1] https://en.wikipedia.org/wiki/Marty_Makary
[3] http://www.nature.com/news/hospital-checklists-are-meant-to-...
Medicine is not a static field. Evidence-based guidelines and checklists save time, money and lives. Time: because over-worked docs already have a hard time keeping up with new standards and guidelines. Money: because best practices reduce errors and poor outcomes, and ultimately reduce malpractice premiums. Lives: because good medicine is based on evidence that reduces harm, and not based statically on what was learned at the start of a career.
If you want to hold the most problematic doctors accountable, do away with the tort reform that protects them. The faster the incompetents are driven out (and not just relegated to a state with lower standards and more protection), the better we'll all be.
Overwork contributes to all kinds of problems, but it's not an excuse to avoid practices shown to produce better outcomes. It's roughly equivalent to a coder saying "I shouldn't have to run unit tests because I'm already working 60 hours a week and have 16 years of experience, and I got into this field because I like to write code." There are other ways to attack the cost of education and the doctor supply, but they are slow to gain traction because of professional protectionism.
Sorry, but no one is too good for checklists. Not doctors, not 747 pilots with 35 years of experience.
On the contrary, the amount of training training and job complexity that physicians deal with are actually good reasons to have checklists in the first place.
I have several family members in the medical field, nurses, physicians, surgeons, as well as colleagues who have worked in malpractice, some on defense and for insurers and hospitals who have fought to get hospitals to implement correct procedures.
> I'm not sure where you live where doctors do not wash their hands,
This is a massive and well studied problem in the US and around the world. If asked about the risks, sure, doctors admit they know them. They still don't wash their hands at safe rates. The CDC claims that medical professionals still wash their hands only half as often as they should. The Lancet found poor handwashing practices by medical professionals due to low compliance with recommendations worldwide. In American ICUs, handwashing compliance baselines at about 26%.
http://www.cdc.gov/handhygiene/
http://www.thelancet.com/journals/laninf/article/PIIS1473-30...
http://ajm.sagepub.com/content/24/3/205.abstract
> The solution isn't to add arbitrary checklists and make doctors more busy. The solution is to use the scientific method
The scientific method is exactly where these measures come from. Atul Gawande's work on checklists and the discussions of handwashing are more publicly known, but proper interventions against bedsores through patient turning and proper cleaning in hospital facilities by maintenance staff contribute to patient outcomes too, along with a hundred other boring procedural improvements. All of them are adopted or recommended only after examining outcomes with those procedures according to some scientific study.
> At first you argue against tort reform and then you argue for it.
For the record, the second bit was facetious. "Add reputational costs" isn't what people usually mean by tort reform.
EDIT: shortened
Has the work been replicated? My research indicates it hasn't yet been tested enough to be proven [1]
His book promoting checklists seems premature without sufficient replicated research.
My gut tells me that a checklist would improve patient care when the carer is focused on the list. I feel this is already known. The problem is not that medical professionals do not know cleanliness is critical, it's that they're not focused. Introducing a checklist does not guarantee focus. I feel Atul's research is colored by the fact that he's probably a good teacher and he is instructing those who are directing the studies. It seems unlikely to me that checklists will be the savior of doctors' lack of focus. Better for this is rest and increased awareness by doctors that they do sometimes lose focus and forget. We can do this by sharing research showing that basic steps are sometimes not followed.
The thing that's worked best for me to increase my focus has been meditation and hobbies like running that take my mind off of everything but what I'm doing at the moment. That may not be true for everyone. The same can be said for checklists.
From the article titled "Hospital checklists are meant to save lives — so why do they often fail?" [1]
> Some experts suspect that the failure to replicate could be a matter of how the initial trials or the follow-up studies were designed. Gawande's pilot study of the WHO surgical checklist, for example, was not randomized and had no control group. Instead, it compared complication and death rates before and after the checklist was introduced. Critics say that this makes it difficult to determine what other factors might have influenced outcomes.
> Gawande acknowledges the limitation, which was due to cost restrictions, but he points out that many subsequent trials, including ones that were randomized, have also demonstrated large reductions in complications and mortality following the introduction of the checklist. The list works, he says — as long as it is implemented well. "It turns out to be much more complex that just having the checklist in hand."
Atul himself says it is not so simple as you and he originally implied.
[1] http://www.nature.com/news/hospital-checklists-are-meant-to-...
Or, put another way, instead of 100% chance of reducing fatalities by 50%, you get a X% chance of reducing fatalities by 50%. Still seems like a great improvement.
The reason I comment is not to support or disapprove of the use of checklists.
I'm saying, it's more involved than that. Checklists should be a part of a process that includes evaluating their efficacy wherever they're introduced. Pushing the idea that it is simple takes away from the value of the original implementation by Peter Pronovost. Poor marketing can cause what was initially a good idea to fail.
Risk adjusted returns on that financial investment into their education and training is one of the best, if not best career routes available given the very low volatility of the profession compared to industries like finance (up or out, layoffs), tech (cyclical layoffs), or law (contracting industry).
That being said, the physical and emotional toll of that training is something I would not wish upon anyone.
Thanks in part to artificial caps by the AMA.
Generally, I think there must be a way to hold most problematic doctors accountable while not causing excessive burdens for most good doctors. Also, any system will not be perfect, and the goal should be to maximize the health of most patients.
> it's a problem of "business as usual." It's a thousand doctors following procedures with a 0.1% error rate and 999 thinking, "nothing bad's happened to me so I must be doing everything fine,"
I see no evidence of this, and I doubt you have the audacity to say this in the presence of your own physicians.
> they could each reduce that to a 0.001% error rate with a simple checklist or by actually washing their hands
I'm not sure where you live where doctors do not wash their hands, or how you know that they do not, but wherever I have been, doctors wash their hands vigorously. Infection in hospitals is common. Everything needs to be super sterile. It's more than just washing hands. Everything needs to be packaged air tight and used once in one part of the body, and then thrown away. It's already much more involved than you're suggesting.
Doctors complete between 11 and 16 years of training [1]
Doctors spend an average of 60 hours working per week. They work on average 1.5 times more than the average American [2]
Doctors have too many patients and too little time.
They are already well educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program. They don't sleep much and don't get paid very well for the debt that they incur.
Many doctors got into the field because they want to help people.
My father was a physician until 2004ish, and the stress induced by bureaucracy nearly killed him. He was a great doctor. You're suggesting making the system more complex. I'm saying, that's going to make patient care worse, not better.
If you choose to look only at court cases and do not read medical research, then trust is required in this system. Any procedural changes should be vetted by researchers using the scientific method, not bureaucrats who seek to make unscientific sweeping changes based on anecdotes to further their own political careers.
> Put another way, if you put someone's life in your hands and you're not focusing a significant percentage of your efforts on procedures designed to radically reduce risk, then you're engaged in gross negligence.
This is the job of a doctor. They focus on reducing risks to your health.
The solution isn't to add arbitrary checklists and make doctors more busy. The solution is to use the scientific method to add doctors, make our population healthier and capable of maintaining their own health, and reduce the load of patients per doctor.
> So my medical malpractice reform would make medicine more like other industries with far better safety records. It would include a requirement that hospitals post their mistakes on their front door as people walk in.
At first you argue against tort reform and then you argue for it.
I think things like Zocdoc will help good doctors be recognized and allow patients to self select their level of care. Reviews are just one thing. It's a complicated system that needs to balance many factors in order to maximize patient health.
[1] https://www.google.com/search?client=ubuntu&channel=fs&q=how...
[2] https://www.google.com/search?safe=off&client=ubuntu&hs=o9p&...