Even Experts Need Help

January 10, 2010

By John Munce, Deployment Executive, The Tatham Group

There’s no bigger expert than a surgeon especially when performing major surgery.  I adhere to the definition of major surgery as “anything done on ME.”  I’ve had my share, ranging from minor whacks at the dermatologist to a big whack that severed a nerve controlling part of my right shoulder.  However, the consequences of surgery are not limited to what the surgeon cuts.

Dr. Scher, the surgeon who cut my nerve in the process of removing a cancer-filled lymph node, acknowledged that my biggest risk was from just being in the hospital. The opportunity for infection, for an untreatable MRSA infection for example, was high in the best of hospitals.   He agreed with advice I’d gotten that my wife should be bold about asking every person who entered my room whether he had washed hands.  She was relentless.  One time she was asking that question while I was asking the nurse if she wore fishnet hose.  Blame it on the anesthesia.

We chose Dr. Scher because he created a sense of trust in his competence.  He was a specialist in my particular problem.  He did this surgery many times.  He took time to answer my questions and to discuss Wendy’s worries.  Even in his examinations he created a sense of careful and skillful technique.  He was clearly an expert.

On the other hand, I never met the surgical team.  So the whole group that had my life in their hands might have been very different.  I presumed that Dr. Scher would only accept similarly competent people but I didn’t really know.  I met the anesthesiologist just that morning.  From my point of view, all depended on the expert, Dr. Scher.  A big assumption to make.

Another surgical expert has just published a book that hits directly on my experience and on process improvement.  Atul Gawande, a surgeon who wrote two books about his experiences in the operating room, is the lead for the World Health Organization Safe Surgery Saves Lives program.  The new book is The Checklist Manifesto: How to Get Things Right. A theme is “even experts need help.”

The checklist he discusses was developed to apply to any surgical procedure.  There are three parts: before induction of anesthesia, before incision, and before the patient leaves the operating room.  The questions are simple: “Is the site marked?” “Confirm all team members have introduced themselves by name and role.” “Specimen labeling (read specimen labels aloud, including patient name).”

You can see the surgical checklist (first and second editions) at www.safesurg.org.  Like many good solutions, it looks surprisingly simple. Such simple questions beg the response “Gosh, do they really have to be reminded?”

Notice that the checklist doesn’t mention anything about the content of surgery itself.  It presumes that the expert is focused on what needs to be done for the knee repair or the heart valve replacement.  In fact, that’s part of the value of the checklist.  Following the checklist–out loud—brings everyone up short.  Research showed these simple steps would prevent many errors, many complications, and even patient death.

Anyone who has worked with a team to improve a process in any business knows that experts are a problem.  Most experts think that other people need to change to make the process better but as for them, as my kids would say, “They don’t need no stinking checklist.”

Teams that come together for a particular activity but don’t work together day in and day out are in particular need of checklists.  The airlines have learned this over and over.  Several catastrophic crashes have focused attention on checklists that ensure all members of the team can take action to prevent errors, even if it means overriding the captain.

Surgical teams have similar characteristics.  They come together to perform a delicate and complex task.  They are part of a complicated organization on which they depend.  But complexity creates its own problems. Therein lies the need for checklists.  One nurse told the story of applying the checklist before a knee replacement surgery.  They discovered that the artificial joint was the wrong size.  In fact, the proper size was not even available in the hospital.  Talk about a catastrophe averted!

Experts demand data, not just anecdote, to convince them to take a new action.  While I might say one anecdote like the knee surgery would be enough to get me to change behavior, humans have an extraordinary capacity to rationalize their own decisions, as recent psychological and economic research shows.

When Dr. Gawande’s team asked surgeons whether the data was persuasive, 80% said yes.  But two out of 10 said no.  Dr. Gawande admits he was in the 20% who resisted.  Other people may really need it, but he was an exception.  He started using it simply to avoid being a hypocrite.  Since using the checklist, he says every week it has caught some potential error.

How does one persuade the 20% resisters? His team found a simple tool.  They applied my definition of major surgery as anything on ME.  They asked, “Would you want the surgeon operating on you to use this checklist?”  Agreement rose to 94%.

Remind me to ask my next surgeon if she uses the checklist.  I don’t want even the world’s renowned expert if he’s in that arrogant 6%.

  • Can’t wait to read the book. We have applied our method and checklist in the medical environment and the results were better than expected. With Health Care and Patient Safety an ever growing concern having doctors that think like Dr. Gawande will be essential.

    To learn more about the work accomplished at the Peel Regional Cancer Center read our blog posts: The road that has made all the difference & Paving a new road for cancer patients. September 2008.