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Are you familiar with the work of Atul Gawande (a surgeon) and related work around checklists? [1] I would highly recommend you take a look at those and see if you still feel the same way about checklists. They are not about minimizing physicians' training & expertise. They're about procedural rigor, process standardization, and reducing inevitable human error. They're about shifting mental loads away from "rote" or "routine" tasks which are amenable to checklists and instead over to those complex thought processes that really need the specialized years of training.

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-...

> Are you familiar with the work of Atul Gawande (a surgeon) and related work around checklists?

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

[2] http://archive.is/9SYXz

[3] http://www.nature.com/news/hospital-checklists-are-meant-to-...

> They are already educated and don't have time for checklists to remind them of every little detail they learned during their 10-year long training program.

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.

>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.

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.

> Speaking as someone whose father was a physician, I feel a few of your comments are unfounded.

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

It's great that Atul feels checklists improve his work, and that he's been able to show efficacy in studies he directed.

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-...

Why would anyone be against promoting a technique that has demonstrated a real reduction in fatalities? Sure, in some implementations, there has not been as much reduction. But, I didn't read anything that said the risks increased. Did I miss that?

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.

Checklist proponents in this thread oversimplify the issue [1]

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.

[1] https://news.ycombinator.com/item?id=11641970

>don't get paid very well for the debt that they incur.

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.

>Doctors have too many patients and too little time.

Thanks in part to artificial caps by the AMA.