The Checklist Manifiesto: The Problem of Extreme Complexity.

(Our weekly reading according to our reading calendar)

This chapter is entirely devoted to show us how complex is the science and the practice of medicine in our days.

And this is done in a very effective and dramatic way by mixing actual descriptions of individuals’ dramatic clinical stories and typical daily routines of medical staff together with data and statistics that describe the magnitude of the phenomenon. The narrative effect of this combination is really successful in conveying a feeling of overwhelming complexity almost nightmarish.

Medicine is not about giving wonder pills that cure everything.

I think we have been fooled about what we can expect from medicine -fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. (p. 18)

Medicine didn’t turn out this way, though. (p. 19)

World Health Organization’s international classification of diseases has grown to distinguish more that thirteen thousand different diseases, syndromes, and types of injury (…) Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations.  (p. 19)

The daily experience of a doctor reflects all such complexity

 in one day, I’d had six patients with six completely different primary medical problems and a total of twenty-six different additional diagnoses (p. 21)

Over the course of a year of office practice (…) physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures. (p. 21)

All that tsunami of medical knowledge comes with and increased level of complexity in the procedures that have to be applied to the patients. A vivid description of the workings of the intensive care units (ICU) is offered. The difficulty in applying correctly the overwhelming number of procedures needed in a standard ICU treatment means that mistakes happen with, sometimes, fatal consequences.

To tackle this problem, the answer has been super specialization.

We live in the era of the superspecialist -of clinicians who have taken the time to practice, practice, practice at one narrow thing they can do it better than anyone else. (p. 29)

There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists, and many others.  (p. 30)

But, even this super specialization is not being enough.

We continue to have upwards of 150,000 deaths following surgery every year -more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.

(…)

What do you do when superspecialists fail? (p. 31)

The answer to this question is the subject of the book.

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One thought on “The Checklist Manifiesto: The Problem of Extreme Complexity.

  1. A very good job, Carlos. Thank you so much.
    Gawande has a gift to keep you excited and interested, converting a subject as dull as a checklist into a page-turner.
    I always had the impression that medicine had very explicit procedures, and done in systematic ways, so everything was pretty straightforward. I was very surprised to read how complex and challenging it can actually be.
    The first time I read the book, I remember worrying about -after finishing this chapter- whether the book would be completely centered in medicine, so it would not have any direct applications on my own work procedures. Fortunately, I was wrong…

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