The Checklist Manifesto is not just a great book and a valuable resource for all who read it. It is a warning sign on the slippery slope to technological disaster. My first thought, even before I finished this book, was to buy a number of copies, carry them on my various visits to doctors, ask if he or she has read the book, and, if the answer was no, then hand a copy to that doctor and say, "Please read this, my life may depend on it." It's that important, and may save your life, too.
Phrases like the following show he's aware of the problems:
". . . the volume and complexity of what we know has exceeded our individual capacity to deliver its benefits correctly, safely, or reliably."
"Medicine has become the art of managing extreme complexity-and a test as to whether such complexity can, in fact, be humanly mastered."
I could add more, but you get the idea. However, the key question, once framed by Mark Twain, is not where we stand but whether we're gaining or losing. For all the good ideas in this book, the answer is still in doubt.
Here's why: As good as this book is, and as important as checklists are, neither are sufficient to the problem at hand. In fact, we don't really know the dimensions of the problem (the most important of these is obviously time). It's not just managing complexity; it's more like triaging complexity. Triage is something doctors like Gawande know about, but here it is in brief for those who might not. On a battlefield someone has to decide quickly (given the circumstance and the resources) if the wounded soldier who just arrived either a) will be worth those resources, or b) won't be (too difficult to save), or c) will probably survive if left alone.
Of course, these categories don't apply exactly to the problem we're discussing here. But there has to be some comparable, and simple, classification system we can use to begin managing this problem. For example, a) can the immediate situation be handled with our standard procedure, or b) do we need to refine our procedure, or c) do we need to completely rethink our approach. If we rephrase Pareto's Principle (more commonly known as the 80/20 rule), we could say 80% of situations can be dealt with using standard procedures (20% of our effort). Fine, but how do we deal with the remaining 20% of situations? We can't simply say they deserve 80% of our effort because it may take more than just effort. It may take a extensive revision of all our procedures.
What we need to understand is that checklists are just the first crude defense — albeit effective — against the increasing complexity of modern technology (especially computers). Checklists are just the first step toward addressing the safe flow of the exploding information that necessarily accompanies expanding technological complexity.
Yet, as good a job as Atul Gawande does in telling this story, it is shocking to note he doesn't see the opportunity for our potential extrication. He has discovered that medicine is lacking a much-needed discipline. However, he seems unaware that discipline already exists in abundance and is taught around the world. That discipline is engineering. He touches on this in Chapter 3 ("The End of The Master Builder") about the problems of complex structures. But he doesn't refer to any of the classic engineering books on failure, books designed to improve the discipline (for example see Henry Petroski). Nor does he make the obvious connection between the needed safety of these buildings, the safety we all desire for commercial aviation, and the medical profession: they are all responsible for millions of lives. Nor does he offer any insight as to why the medical profession has been so lax in recognizing the safety procedures of these other industries.
He doesn't but I will. One reason is that I've been told by many doctors, "What we do is not so much science as art." Therein lies the problem. Medicine may be part art and part science, but what it mostly needs to be is engineering. And what it needs to do — and The Checklist Manifesto is a good first step in the right direction — is learn from various engineering applications and (as he rightly acknowledges) acquire their discipline. Medicine must acknowledge it can benefit from the methodology of engineering. Only then can doctors exercise the self-discipline necessary to use that methodology.
—Lee Frank