Comment by brownbat | Hacker News Reader

Comment by brownbat | Hacker News Reader

Parent Full thread

> 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

Reply on news.ycombinator.com