Today was one of the first days in a long time that I had some morning traveling time: I had to drive to Cary, about twenty miles away, for an appointment with my eye doctor, which meant I got to drive home with my eyes dilated and NPR on the radio. I only stopped once: I pulled over to make some notes to come back to this evening.
“Our great struggle in medicine these days is not just with ignorance and uncertainty,” Gawande says. “It’s also with complexity: how much you have to make sure you have in your head and think about. There are a thousand ways things can go wrong.”
At the heart of Gawande’s idea is the notion that doctors are human, and that their profession is like any other.
“We miss stuff. We are inconsistent and unreliable because of the complexity of care,” he says. So Gawande imported his basic idea from other fields that deal in complex systems.
“I got a chance to visit Boeing and see how they make things work, and over and over again they fall back on checklists,” Gawande says. “The pilot’s checklist is a crucial component, not just for how you handle takeoff and landing in normal circumstances, but even how you handle a crisis emergency when you only have a couple of minutes to make a critical decision.”
This isn’t the route medicine has traveled when dealing with complex, demanding situations. “In surgery the way we handle this is we say, ‘You need eight, nine, 10 years of training, you get experience under your belt, and then you go with the instinct and expertise that you’ve developed over time. You go with your knowledge.’ “
To see if surgeons might perform better if the intricate steps necessary to avoid catastrophe were made explicit, Gawande and a team of researchers studied what happened when doctors used a reminder — what Gawande calls “a bedside aide” — to navigate complex procedures. (Click to see a sample Surgical Safety Checklist.)
“We brought a two-minute checklist into operating rooms in eight hospitals,” Gawande says. “I worked with a team of folks that included Boeing to show us how they do it, and we just made sure that the checklist had some basic things: Make sure that blood is available, antibiotics are there.”
How did it work?
“We get better results,” he says. “Massively better results.
“We caught basic mistakes and some of that stupid stuff,” Gawande reports. But the study returned some surprising results: “We also found that good teamwork required certain things that we missed very frequently.”
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
I got a great stack of books for Christmas. The one I picked up first was Ed Dobson’s The Year of Living like Jesus: My Journey of Discovering What Jesus Would Really Do, which is a collection of his journal entries from his year of trying to live and eat and worship and treat people the way Jesus did. The entries are honest and interesting. I find myself a bit surprised that his life appears to be more complicated, rather than simplified, by his decision to live like Jesus. He does trim some things from his existence and learns to observe Shabbat and some of the dietary laws, all of which seem simpler, but he also picks up some things that have nothing to do with Jesus’ life in Palestine two millennia ago and yet seem to fit right in. Part of his commitment is to read the Gospels every week and to pray. His search for Jesus and for prayer has led him to learn how to pray with a rosary, an Orthodox prayer rope, and Episcopal prayer beads, all of which are new layers of life for a retired evangelical pastor with ALS.
I had just finished a section about the different prayer beads when I was called in to see the doctor and was intrigued by the ordering of thought and focus the different strings of beads and knots brought to Dobson’s prayers. He doesn’t write as one who understands everything he’s doing; he just writes down what he feels and experiences. When I heard the checklist story, I wondered if the beads didn’t provide some of that function: an ordering of what needs to happen in prayer for the heart to find its way home. (I don’t have the answers either – I’m just writing things down, as well.)
One of the prayers he talks about is the “Jesus Prayer”: “Lord Jesus Christ, Son of God, have mercy on me, a sinner.” I first remember learning that prayer during a revival when I was on staff at University Baptist Church in Fort Worth. James Fanning was our preacher and, among other things, spoke at breakfast each day; one of those mornings he talked about the Jesus Prayer. Later that week, the wife of one of our staff members was killed when the propane tank attached to the house in the country where they were soon to retire exploded. I remember her husband saying the only words he found that kept him connected at all were those in the prayer, which he said over and over for hours in the night. I grew up in a tradition that taught me written and memorized prayers weren’t real prayers; Spirit-filled prayers were the ones made up on the spot. Following Dobson as he counts beads and knots, saying prayers passed down for centuries, and thinking of my colleague who found solace in those same well-worn paths to God, challenge me to think, as one who struggles with how to pray, I would do well to lean into these spiritual checklists, if you will, that are about far more than habit.
What Gawande says of hospitals is true of life: our great struggle is not just with ignorance and uncertainty, but also with complexity and how much we have to make sure we have in our heads and think about. One of Ginger’s touchstone book was also written by a Bostonian: It’s Hard to Make a Difference When You Can’t Find Your Keys: The Seven-Step Path to Becoming Truly Organized by Marilyn Paul. She offers what she calls the “thirty second check” on the way out the door – keys, wallet, phone, etc. – as a way to make sure you leave the house prepared for your journey, wherever it may be.
I have more to say about checklists and where the story took me than I can fit in here. As one who works in a world that thrives on prep lists (as we call them) to make sure we have everything ready for dinner, and as one who is committed to being a part of a community of Christian believers that are not as aware of how some checklists might help us, I’ve probably got a couple more posts around this idea to pass along as they ripen. For now, I go back to Gawade’s regard for pilots.
One of the things that struck me about the “Miracle on the Hudson,” when “Sully” Sullenberger brought the plane down that saved 155 people after it was hit by geese over Manhattan and landed it in the river was that over and over again we wanted to say, “Look at this hero who piloted this plane down,” and the striking thing was how much over and over again he said, “There was nothing that hard about the physical navigation of this plane.” Instead he kept saying “it was teamwork and adherence to protocol.”
Protocol may not be a particularly theological word, but ritual is: intentional repetition. Those pilots landed that plane safely in the river because they knew the steps to follow. My colleague found in the Jesus Prayer the ritual that gave his broken heart some sense of God’s comfort and love. We shared Communion together Sunday, and the deacons came early to practice how we do it: to go over our checklist, to remind us that nothing can separate us from the love of God that is ours in Christ. May we repeat ourselves as though our very lives depended on it.