Comment by mikestew | Hacker News Reader

Comment by mikestew | Hacker News Reader

Every time someone in the medical field tells me about how dangerous motorcycles are, I remind them of the woman I knew (world-class rider in some aspects of the sport) who was in a motorcycle crash. The crash didn't kill her, the people giving her the wrong drugs did.

Years later I read _The Checklist Manifesto_, only to be horrified that not only did medical personnel need to be told to use checklists, many resisted the idea. It's one thing to kill people because of a mistake, we all make them and thankfully the ones I make usually don't get anyone hurt. But it's quite another to kill someone because your industry is one step ahead of using leeches. I mean, suppose I make a commit that rolls into production and takes out production data. Someone asks, "did you follow the checklist?" If I say, "yes", it's unlikely that heads will roll and we'll update the list when we find out what went wrong. But if my answer is, "no. In fact, I don't even have a checklist/documented procedure, I just make sure my commit message is informative and hope I remembered everything", I'm likely to get fired. A doctor does it, shrugs it off with "we did everything we could", and a lot of time we all just go on about our day.

I can not think of a single good reason to avoid check-lists in the medical field. And the doctors who resist them may very well just be arrogant and elitist. But there may also be some other reason. I don't know because I'm not a doctor, but I do know there are always things I don't know to consider in unfamiliar fields.

Do we have any doctors on the board who could explain a defensible resistance on the part of doctors to using checklists?

Not a doctor, but familiar with some of the arguments.

Visible use of checklists damages patient trust. You may (correctly) argue that patients who see their doctors following checklists should trust them MORE rather than less, but most data shows otherwise. Patient trust is very important not just for improving outcomes (they need to follow your instructions after discharge) but also in selecting a physician. That's why checklist use is higher in the OR, when the patient is unconscious.

Checklist use is slower. Virtually all physicians are already overscheduled. Lengthening every visit by 30-50% so that the doctor can go over a checklist that only ends up mattering a tiny percentage of the time means fewer patients get seen.

That explanation is so backwards in reasoning it would be humerous if it weren't so pathetic. Sadly you see people citing data over common sense all the time. In this case, the choice between human life and hospital efficiency and "trust" produces a false trade-off: The dire consequences of one choice all but force you to take the other option.

Trusting "common sense" over data is irresponsible if not outright delusional.

Is that always true?

The problem of patients not trusting doctors who use checklists seems solvable , maybe via education maybe via other means. It's just a matter of will.

I hope so too. However, it is currently a problem.

I am not a doctor, but I do have several practical defenses (I don't want to go through political ones).

There are many business processes in the healthcare field, and the impact and ease of imposing checklists will be naturally very different for each:

* Diagnosis and treatment protocols / pathways - these span long periods of time (days to months), any checklist will probably be quite complex and redundant to the already existing longitudinal case notes.

* Procedures (like surgeries) - some parts like preparation can be subject to checklist. But the procedure itself may need >= 2 clean hands and good concentration, thus glancing over checklists multiple times during procedure, or worse attempting to tick off stuff might cause more harm than good. (don't tell me to add one more guy there - we need him to save another patient, and google glass is dead for now)

* Processes related to ordering, dispensing, and administering medicines: there are probably tens/hundreds of thousands of these processes happening in a hospital at any given day. If a checklist introduces speed penalty it will be rather burdensome for the facility (and patients too). Furthermore, an equivalent of a checklist (e.g. refusing to proceed unless certain required fields are filled) has usually been codified in the hospital systems being used. Also, I feel that adding a checklist for something that you do hundreds of times a day, will not achieve anything, because the muscle memory will take over - you will just do things as per usual and sign off "all done" on the checklist, because you always do them all the time whether you remember or not, right?

Handling of medicines has check-lists; surgery is moving that way too. Diagnosis is complex but also amenable to check-lists.

Surgical nurses can handle the checklists. Of course the surgeon himself will not be ticking boxes.

Analogous: in a multi-crew aircraft, one pilot is flying, the other is managing/monitoring (including the checklists).

>>>Diagnosis and treatment protocols / pathways

Even with what you say, clinical decision support(which can be viewed as an automated system of double checking) have shown to lead to better care.

I completely agree, although the attitude at facilities where this has been done extensively is always "how can we reduce the alert/popup/notification burden" because it always invariably slows things down and annoys people. And after a while the muscle memory stuff comes in as well - a typical alert can pop up tens of times a day with very high false positive rate.

An automated "checklist generation" is easy via subscription to data vendors, whereas manual curation takes years (even when only codifying best practices). And we can't just have one set of alerts for the world because everyone's (patient demographics, risk appetite, clinical sophistication level, computer skills, political situation) is different.

>> And after a while the muscle memory stuff comes in as well - a typical alert can pop up tens of times a day with very high false positive rate.

Do the best tools able to solve this in a satisfactory manner(the tool issue, the organizational issue) ? How ?

>> whereas manual curation takes years (even when only codifying best practices)

Can't this be done in parallel ? and why are resources an issue for such an important thing with a clear health ROI and maybe financial ROI ?

> Do the best tools able to solve this in a satisfactory manner(the tool issue, the organizational issue) ? How ?

The best solution is I believe relentless continuous manual curation, which is discussed below. Automated tools are rather frowned upon in this area because I don't think there is any that is good enough until everyone is comfortable to rely on the black box.

> Can't this be done in parallel ? and why are resources an issue for such an important thing with a clear health ROI and maybe financial ROI ?

It definitely can be done in parallel. It takes years mainly due to political issues - like doctors arguing against each other which treatment/alert/option is the best, doctors/nurses/pharmacists arguing against each other who needs to look out for certain alerts, etc. We are not talking about tens of alerts, the number usually comes up to thousands.

Resource is an issue here because the best people to manually curate are the healthcare professionals themselves, but they are usually, you know, treating patients, so they are hard to find on their desks. And as mentioned elsewhere, the industry is highly hierarchical, so a bunch of minions can propose changes to alerts but everything needs to go to some higher authorities because the stakes are too great. Sometimes this "higher authority" does not decide without a formal consultation with some other authority. (nobody wants to be blamed if an error happens because the hospital just removed a perceived low-quality alert a week ago)

Coupled with the need to perform lots of research to produce high quality alerts, I would presume only large-ish hospitals / clusters (perhaps > 1000 combined bed capacity) can afford full-time people to look into this.

Thanks for the detailed response.

So it's hard to get the resources in a single hospital, what about collaboration across hospitals or even the department of health ? Seems like a worthwhile goal.

> If a checklist introduces speed penalty it will be rather burdensome for the facility (and patients too)

Dying is rather burdensome for the patient. I'll accept the speed penalty.

If only everyone has your mindset. Patients do complain - a lot. They never think that waiting another 1 hour is okay because it makes things safer - what they think is that they (or the insurer / government) have paid us handsomely, they want to be treated ASAP, anything slower means they don't get what they deserve. Less prominently but still important is that individual departments are usually under pressure to show that they are progressing to be both safer and faster / more efficient - thus they might make slippery and controversial trade-offs.

There are important KPIs related to patient health and public health that depend on speed, such as length of inpatient stay, transit time in the ER / ED, time to first antibiotic treatment, turnaround time for medicines and supplies. Compromising these KPIs may lead to non-optimal care too regardless of patients complaining.

> Patients do complain - a lot. They never think that waiting another 1 hour is okay because it makes things safer

Yup. This thread is full of folks who want to both have and eat their cake. Pick any two from the triangle {fast, cheap, high-quality}

It is likely the same reasoning behind why doctors for ages refused to wash their hands...arrogance.

> But if my answer is, "no. In fact, I don't even have a checklist/documented procedure, I just make sure my commit message is informative and hope I remembered everything", I'm likely to get fired.

Or even, the nurse has a checklist, but I don't need checklists, I'm a professional.

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