seven

CHECKLISTS AND DANCE LESSONS

A shrill tune came from the consult pager on my belt. I slipped the pager from its holster and read the text message: “STAT consult. Pt uncontrollable. Aliens attacking.” Not wanting attacking aliens to gain control of the hospital, the city, or our proud planet, I holstered the pager, collected my medical student, and headed for the stairs and the uncontrollable patient.

The cardiac catheterization laboratory was on the other side of the medical center, so we walked quickly through the skyways and stairwells that connected one hospital tower to the next. I was a fourth-year resident on the consult service, available to physicians throughout the medical center when a patient had an urgent psychiatric concern. Calling a consult, as it is called, often feels like asking for reinforcements. You call a consult because you feel pinned down by your responsibilities. Many of my psychiatric consults were mundane—a surgeon did not know what to say to a despondent father, an internist wanted to know why a homeless woman was declining the expensive treatment he recommended—but others were momentous. I met with burn ward patients who were sneaking off the unit to smoke crack and obstetric patients doubled over with birth pains from delusional pregnancies. From the staccato text message on the pager, this consult sounded like it might be memorable.

When we arrived in the catheter lab, a nurse was holding the door open. “You with psych?” I nodded. “She’s all yours. Cuckoo-catchoo.”

Fifteen yards away, a woman was standing alone in the center of the room. Her head was tilted up, her eyes looking into the overhead surgical spotlight. She held her arms slightly out from her sides, taut as a pulled cord, so that even as she stood still, she appeared to be moving. She looked like a rocket pointing toward a horizon beyond the ceiling.

Ten yards away from her, the cardiology fellow stood with his arms crossed over the cath lab’s now-scuttled morning schedule. He turned, looked at me, and shook his head, as if to say, “See what happens when we take one of your patients?” He had the patient’s medical record pulled up on a screen, and I scanned it quickly. Public insurance. Distant address. Name, Aruna. Age, sixty-six. Admitted last night for a heart attack. No history of mental illness. A terse history and physical completed by an on-call intern. A few lines of abbreviations and acronyms signed by the cardiology fellow. Two EKGs. One pre-op cardiac catheterization checklist with a flurry of checkmarks.

Five yards away from her, a security officer stood in his interview stance, his hands resting above his gun, his body bladed forty-five degrees toward Aruna. We knew each other from around the hospital. He nodded in Aruna’s direction and put out his hands, silently asking me if he should put hands on her. I waved him off and stood opposite him, facing Aruna obliquely. She looked calm but determined.

“Aruna?”

“Not my name.”

“What should I call you?

“Shhh. Not telling.”

“Where are you from?”

“Not here.”

“Me neither. Where are you from?”

“Up there! Headed home.”

Aruna was determinedly alone in the middle of that thousand-bed hospital, growing city, doomed planet. She was waiting to leave us all behind, so my first task was to interest her in those of us still tethered to the ground.

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Visiting a contemporary hospital can feel a lot like being in an airport: the building is secured, the delays are unexplained, and you take your clothes off in front of strangers to prevent attacks from distant threats. Working in a contemporary hospital can also feel a lot like being employed at an airport: as medical practitioners, our time is regulated, our speech is scripted, and our interactions are impersonal. What surprises many patients and physicians is that these correspondences are intentional.

We talk all the time about coordinating care in contemporary medicine. In today’s clinics and hospitals, the care of patients is constantly being handed off among physicians, nurses, pharmacists, and other practitioners. So when we talk about coordinating care, we do not mean that these various practitioners should match their disparate plans with the desires of the patients. What we mean is that the cards—cardiology—nurse and the cards fellow and the psych consultant should work together the way engineers do: each of us works on a different part of the same patient, so we need to work in sequence to provide the complex procedures and services that constitute contemporary healthcare. The celebrated way that we do so is with processes adopted from industrial engineering, processes like the checklist in Aruna’s record.

Which leads us back to the airport. Checklists were first used by airlines as way to standardize the actions of a pilot to increase safety. Before entering the plane, the pilot would verify, say, that the wheel chocks were in place and the trim tabs were neutral. A good pilot would always have checked those things on his or her own. But even the best and the most experienced sometimes forget to check. Accidents occur when people forget, and the failure to use checklists, or the misuse of checklists, has been identified as a cause of many an airplane crash. Now, before they start engines, take off, or land a plane, a pilot and his or her crew complete a checklist, constantly reconfiguring the plane to match the checklist. The airline checklists draw on decades of evidence to protect the lives of passengers.1

The checklist in Aruna’s chart represented a similar attempt to operationalize the findings generated by epidemiologists over the previous half-century. Those findings were buried in thousands of articles, and, even when systematically summarized in something like a Cochrane review, the documents ran for dozens of pages. It is impossible to use such hefty tomes to coordinate the care of an efficient cardiac cath lab. A catheterization team has no more than twenty or thirty minutes to push a thin tube against the blood’s vital current and move upstream from an artery in the arm or groin or neck until it reaches the plaque in the artery that is damming up the current. Many things can go wrong—the serious issues include bleeding and infection—but a cath lab team can prevent most of them by following the known rules for the procedure. So as each patient waited to enter the lab, a nurse was responsible for filling out a checklist, based on a series of evidence-based reviews of the factors associated with adverse outcomes during cardiac catheterization. The nurse would ask if the patient had a history of bleeding or had recently taken any of a number of medications that increased his or her risk of bleeding. The cath lab team would not perform the procedure until the checklist was completed.2

Over the past decade, an obsession for checklists gripped medicine. We developed checklists for preoperative clearances and intra-operative procedures but also to assess symptoms of depression, to reconcile discharge medications, and to standardize everything we can.

The leading public advocate for the use of checklists in medicine has been the surgeon-writer Atul Gawande. In his academic career, he has piloted checklists for surgical procedures that have been endorsed by the World Health Organization and subsequently implemented in hospitals throughout the world. He also wrote a best seller, The Checklist Manifesto, about how checklists protect people from both anticipated and unanticipated problems when they are engaged in complex technical tasks that require coordinated efforts, tasks like flying a plane or catheterizing the vessels of a sixty-six-year-old’s heart.³

The checklist had been completed for Aruna, an elderly Thai immigrant. She spoke little English, so her daughter-in-law had provided most of the information. The nurse had verified Aruna’s name, the procedure, her cardiac history, her medications, and more. Check, check, check.

And yet the procedure failed in ways that the checklist could not have anticipated. Checklists excel at preventing the common errors associated with cardiac catheterization in the medical literature. In the peer-reviewed literature on cardiac catheterization, there are tens of thousands of published articles. The checklist was a single page that rendered this knowledge useful in the quick-moving cockpit of a contemporary cath lab.

The nurse had ten patients in the holding bay waiting their turn in one of the hospital’s procedural rooms. So as the nurse was making her rounds, she used the checklist to review Aruna’s allergies, medications, informed consent, healthcare proxy, and more, then signed off, clearing Aruna for takeoff from the preoperative suite. The checklist was necessary, but it was insufficient for Aruna’s case because it assessed only the potential for adverse effects associated with the scheduled procedure, not Aruna herself.

Mumbling was not on the nurse’s checklist, but Aruna’s mumbling was the first sign that she was not ready for catheterization.

When I arrived, the family—daughter-in-law, son, and three grandchildren—was still in the waiting room. I joined them in the hallway, introducing myself and asking for a little more background on Aruna. They told me she had spent her life in a small town in southern Thailand. She had seven children, six of whom still lived in Thailand. Aruna visited her oldest son in America annually, but she had always returned home until two months earlier, when her husband had died and she had moved in with her son’s family.

Aruna minded her grandkids when their parents were out, cooked most of the meals, and occasionally visited fellow Thai immigrants in the area. Her family insisted she had no history of strange behavior or unusual thoughts. She talked about wanting to return to Thailand, where her other children still lived, but never about returning to an extraterrestrial home.

I asked whether she was on any medications. Aruna’s daughter-in-law said no. I asked about drugs or alcohol. Aruna’s son shook his head. My med student asked the family whether she took any herbal medicines or supplements. Aruna’s daughter-in-law nodded.

Aruna had felt constipated and fatigued lately, so a Thai acquaintance had given her kratom to alleviate her symptoms on the day before she was hospitalized. Kratom is a Thai herbal remedy that, like many drugs, works differently at different doses. At low doses, kratom is a stimulant, but at high doses, it is an analgesic; at low doses, it acts like cocaine, at high doses like opium.4 Aruna had her heart attack while using low doses but had continued to chew a supply of kratom in the hospital. While the nurse was completing the checklist, Aruna was mumbling because she was chewing enough kratom to experience its opiate-like effects. As she waited, she had become delusional and euphoric.

With time, rest, and some water, Aruna improved, but the catheterization had to wait. Her checklist cleared her for the procedure, but her intoxication meant that the procedure was delayed until Aruna returned to earth.

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A patient high on kratom is rare in contemporary clinics and hospitals, but inconsistent results from checklists are all too frequent. Often we complete our checklists but patients like Aruna still experience a bad outcome. Aruna did not have any of the bad outcomes the checklists were intended to prevent. She did not bleed out or develop an infection during her morning in the cath lab. But as checklists encourage physicians, nurses, and other practitioners to focus on common errors, they draw attention away from uncommon errors. Aruna was the victim of an uncommon error that was missed by the checklist. Checklist writers are aware of this reality and accept that in catching common errors they might miss some uncommon ones. Checklists are a utilitarian tool, designed to maximize benefit and minimize risk. To be useful, checklists have to be brief and can never include everything that might go wrong. These are accepted features of checklists.

Checklists offer distillations of evidence-based medicine into algorithms and scripts that improve quality and safety. And they can aid moral reasoning. But when a practitioner bases the entire encounter with a patient on checklists, they become obstacles to moral reasoning. Checklists also work better in some settings than in others because different settings rely more or less on people working together. Neither of these issues is an accepted feature of checklists, and neither is what those in the quality and safety movement have in mind when advocating for their use.

For the past twenty years, advocates in the quality and safety movement have argued that the problem with healthcare is that medicine does not consistently and safely deliver the best treatments.5 Their proposed solution is to transform the delivery of medical care using efficacious processes pioneered in high-risk industries like aviation. Medicine, like aviation, involves dangerous tasks that require coordinated efforts. Quality-improvement advocates like to quote a favorite analogy, first offered by the pediatrician Lucian Leape in 1994: the number of people who die because of errors in American hospitals each day is equivalent to the deaths from the crash of a full jumbo jet.⁶ The analogy had the startling force Leape desired. If a jumbo jet crashed every day, people would be outraged at the airline industry, and Leape’s analogy launched a cycle of public outrage—op-eds, Sunday night news shows, congressional hearings, and government funding—at the deadly errors occurring in medicine. Two decades later, leaders at every level of medicine agree that quality and safety need to be improved in hospitals and clinics, and the jumbo jet story is repeated like an origin myth for the reform of medicine through quality improvement. The rhetorical appeal of Leape’s logic has won broad support.

Regulators have certainly embraced this logic. Over the past twenty years, a growing group of regulators have promoted quality improvement techniques as the way to improve patient safety.⁷ Resident physicians are now required to conduct quality-improvement projects in order to complete their training.⁸ Governmental regulators and insurers assess hospitals on the basis of their performance on standardized quality-improvement measures, rewarding high performers and penalizing low performers. Legislators have enshrined quality improvement in healthcare reform measures.

The intentions are good—to eliminate common mistakes by adopting quality and safety measures such as checklists—but the efforts have inconsistently translated into improvements. Despite two decades of growing attention to quality and safety, the most recent estimates are that the equivalent of two to five jumbo-jet-loads of patients now die each day in American hospitals from preventable errors.9

The leaders of the quality movement are aware of this and concerned. Mark Chassin, the president and CEO of the Joint Commission, the leading regulator of American hospitals, recently wrote that even though “hospitals have devoted considerable time, energy, and resources to solving safety and quality problems . . . improvements have been slow and have not spread.”¹⁰ Chassin expressed frustration that quality and safety measures have failed in hospitals worldwide, even though similar measures have led to remarkable successes in other industrial sites that, like hospitals, have large staffs tasked with dangerous activities. While Chassin and other quality-improvement leaders lament the results, they insist that the solution remains the adoption of quality and safety techniques pioneered by engineers in industries like aviation. They have a point: two to five jumbo jets do not crash daily.

Industrial engineers have greatly increased the quality and safety of industrial processes in many industries in part by employing the quality-improvement principles developed by W. Edwards Deming, an American mathematician who helped revive Japan following World War II. During the reconstruction of postwar Japan, Deming became familiar with a generation of Japanese leaders through his work conducting a census for the U.S. Army. Then, in a series of lectures, he taught thousands of Japanese engineers how to use statistical methods to improve industrial processes by controlling variations in performance. These lectures became the basis for Deming’s later career as a business school professor and author; he summarized his lessons in bulleted messages: Fourteen Points for the Transformation of Management, a four-part System of Profound Knowledge, a list of eight Lesser Categories of Obstacles, and the Seven Deadly Diseases of Management.¹¹

Deming’s students and intellectual heirs have applied his principles to many different industries, and some, like Lucian Leape, have applied them to the practice of medicine in an attempt to reduce adverse outcomes and improve the efficiency of healthcare. The trouble is that, as near as I can tell, Deming himself never worked in healthcare or applied his principles to healthcare, and healthcare has important differences from the other industries in which he did work.

Still, I share the frustration of quality-improvement leaders with our ongoing failure to protect the lives of our patients. At Denver Health, I work as a physician quality officer, responsible for identifying errors small and large, reporting them to the relevant agencies, and developing processes to prevent the recurrence of these errors. We ought to prevent these errors, and what I admire about the quality improvement movement is that it is attempting to prevent not just some but all preventable errors.

What I question is the assumption that principles designed for industries like aviation will work best in medicine. The safety record of airplane travel is admirable, but I appreciate little else about the experience. When I fly, the pilot speaks to me, not with me, through an overhead speaker. I usually feel less like a person and more like cargo along for the ride. If we continue to apply this kind of quality improvement to hospitals and clinics, will the interactions between physicians and other practitioners with patients become as anonymous and pragmatic as the relationship I have with pilots? Will physicians, nurses, and other practitioners believe that we have done our job as long as we complete our checklists even if, as with Aruna, we miss what is going on with the patient?

I hope there is something about medicine that makes being a healthcare practitioner different from flying an airplane. In pursuit of that difference, we have to look beyond industrial engineering and its checklists. We need dance lessons.

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Though Deming never worked in medicine, Ludwig Wittgenstein, another twentieth-century intellectual who studied engineering, did. Wittgenstein was, by many accounts, the most original philosopher of the twentieth century, but when World War II broke out, he resigned his post as a philosophy professor at the University of Cambridge to work as a porter in a London hospital. While Cochrane spent the war doctoring a prison-camp population and Deming spent it expanding industrial processes, Wittgenstein spent it caring directly for the ill. He transported patients, dressed wounds, and prepared ointments.12

I am fascinated by his decision to shift as a student from engineer to philosopher and then, as a professor, to shift from philosopher to porter. I have spent my adult life climbing the lower rungs of the medical ladder and find Wittgenstein’s voluntary descent baffling. Who gives up an endowed chair to ferry patients around the hospital?

It was the checklist in Aruna’s chart that started me thinking about Wittgenstein the porter. Wittgenstein had an aphorism—“Obeying a rule is a practice”—that reminded me a bit of the checklists. After all, what is a checklist but a kind of rule? But what does the aphorism mean? Does Wittgenstein mean you have to practice rule following? If so, which rules? Whose rules? Wittgenstein’s aphorism is dense, a bit of gnomic wisdom folded in upon itself, seemingly nothing like the declarative instructions on a checklist. Thinking about it, I went searching for my old copy of the philosopher Charles Taylor’s essay “To Follow a Rule,” in which he explored Wittgenstein’s aphorism.¹³

In the essay, Taylor observed that for two or more people to follow a rule, they need to share certain understandings that cannot be stated in the rule itself. These shared and assumed understandings, Taylor showed, are the social practices that make the rule possible. Yet Taylor observed that today we tend to focus on the rules rather than the social practices upon which they depend. We imagine a person following the rule without considering how the person relates to other people or to his or her own body. To understand Wittgenstein’s aphorism, Taylor argued, we have to fully consider these relationships and how they affect our ability to follow rules.

Taylor’s essay clarified for me one problem with how we are attempting to use checklists in hospitals today. When we apply rules developed by one group of people to a second group of people, we do not adequately consider the different social practices of the first and second groups. We focus on the outcomes resulting from applying the rules in different communities, but we neglect the context in which we apply the rules. So one problem with checklists is that they are developed in one social context and exported to other, different contexts. A checklist that works in Milan may not work in Muleshoe.

By this logic, it is less surprising that checklists are not transforming medicine in the hoped-for way. For a checklist to be a successful social practice in healthcare, it must account for many different relationships: that between the physician or other practitioner and other employees of the hospital or clinic, that between the physician and patient, that between the physician or practitioner and his or her own body, and that between a patient and his or her own body. Physicians and patients are abstractions, but when people participate in these social roles, they are embodied in particular bodies and particular social roles. What my reading of Taylor made clear to me is that medicine is a social practice. To renew medicine, we need to learn less from industrial engineering processes, whose goal is to produce the same outcome each time, and more from other social practices.

In his essay, Taylor offered dancing as a paradigmatic social practice because it involves a constant interplay between people, a give-and-take. We could likewise see offering and receiving medical care as a social practice akin to dancing. Viewed this way, medicine requires a common rhythm between physician and patient. Each has a body—an illness can exist only within the body of a patient—and each stands in relationship to the other: a physician needs an ill person to care for. Taylor wrote, “A very important feature of human action is rhythming, cadence. Every apt, coordinated gesture has a certain flow. When you lose this, as occasionally happens, you fall into confusion, your actions become inept and uncoordinated.”14

Following Taylor, one way to account for my meeting with Aruna in the cath lab is that we were engaged in a kind of dance. She was deciding whether she could trust me, and I was trying to keep up with her—not with her mind or her racing thoughts, but with Aruna in her body. You cannot dance with an idea, only with a partner in relationship with yourself, and to dance together you have to develop a common rhythm.

At the same time, comparing dancing to medicine may seem difficult because two dancers are perceived as equals in the relationship, whereas a physician and patient are perceived as engaged in an imbalanced relationship controlled by the physician. That day in the cath lab, Aruna was an immigrant grandmother in the strange world of the hospital. Each of us present in the room stood in a different relationship to her. The nurse was thinking about how to quickly and safely prepare Aruna and nine other patients for the procedure. The cards fellow was thinking about the arteries of her heart. The security officer was thinking about whether Aruna posed a danger and needed to be restrained. I was thinking about how to calm her so the cath lab personnel could go about their business and I could head to the next consult. And all of us were foreign to Aruna. Perhaps it should come as little surprise that she received the whole situation as alien and desired to rocket away.

Years later, I wonder how Aruna’s care would have differed if someone had explained the steps of the procedure, as a lead dancer might explain them to his or her dance partner when they were learning a new dance. I wonder whether telling Aruna, or her daughter-in-law, why we were asking the questions on the checklist could have stopped her from chewing the kratom and launching on her psychotic journey.

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Engineers design, implement, and correct a process. They judge its success by how efficiently and effectively it produces a desired outcome. Using the checklist with Aruna in the cath lab produced the desired outcome—she neither bled out nor developed an infection—but the checklist clearly missed what was going on with Aruna. She was actively chewing kratom while the nurse completed it. Aruna and the nurse were physically close to each other but remained strangers, and maybe the problem with the checklist was that it was too much like a written rule for an engineering process and not enough like a dance lesson.

We often conceive of medicine as controlling the body, which is why analogies to industrial engineering, where a worker is responsible for the inanimate object he or she manipulates, carry such currency in contemporary medicine. We compare physicians to airplane pilots, implicitly likening our bodies to airplanes, machines controlled by physicians. An airplane pilot is responsible for flying a plane, but patients and practitioners have a mutual responsibility to care for a body. When we remember that medicine is a human activity like dancing, we can account for the mutual responsibility of both dancers.

We could also remember that just as a dancer may lead at one moment and be led at another, our roles as patients and physicians are fluid: all of us who are physicians at present will some day be patients ourselves and will have to learn those unfamiliar steps. Remembering the way our roles change over time—from patient to physician to patient—is part of understanding medicine as a social practice with common rhythms. We learn medicine through participation in relationships that are like dances—formed by apprenticing to expert physicians and listening to patients—with rules learned through social practices.

In psychiatry, the technical name for the relationship, or dance, between a physician and a patient is the therapeutic alliance, the shared commitment between physician and patient to seek the well-being of a patient. Even though we have ample evidence that developing therapeutic alliances improves health outcomes, quality and safety measures such as checklists are rarely used to assess therapeutic alliances.15 Quality and safety measures improve easily quantifiable outcomes but are poorly designed for assessing and encouraging the social practices through which outcomes improve.

To borrow Taylor’s words, one way to explain the problems of contemporary medicine is to say that we have lost the shared rhythms and coordinated flow of the physician-patient relationship; we have become “inept and uncoordinated.” If we formulate the problem of medicine this way, the solution would not be more rules like checklists, but something akin to dance lessons—practices that would rehabituate physicians and patients to the rhythms of a therapeutic alliance. Perhaps if we want to obey our well-intentioned rules for patient safety and quality, we first need to look closer at practices like the therapeutic alliance. In establishing a positive relationship between physician and patient, the rules could begin to seem more like fluid steps of a dance than the measured steps of an engineering process. For Aruna, it would have meant developing enough of a relationship with her before wheeling her into the cath lab that she would have disclosed her use of kratom.

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Around the same time I was learning from Aruna, the most esteemed teacher in Chapel Hill finished teaching a similar lesson. Dean Smith, the legendary coach of the University of North Carolina basketball team for more than three decades, was beloved around town for helping to integrate its restaurants and its athletic conference, for setting aside the sponsorship money he received from shoe companies to help his players, and for insisting that his basketball players be students. His players remembered him as the best teacher they ever had. They said that even though he retired as the winningest coach in college basketball history, he never talked about winning. Instead of discussing the outcome of a game, he described its process, telling his players, “Play hard. Play smart. Play together.”16 In fact, his players remember that the only time they heard him talk about winning was after an unexpected defeat in the national championship semi-finals. He retired soon afterward and never coached again. When I heard the story from his players, I wondered whether it meant that Dean Smith retired when coaching became less about process and more about outcomes. I never had a chance to ask him. By the time I arrived in Chapel Hill, he was often mentioned around campus, but rarely seen.

And the university’s medical center, like medical centers across the world, was shifting from processes to outcomes. To fix our clinics and hospitals, we were told to run them like factories. To fix healthcare, we were told to perfect our checklists and scripts. No one mentioned dance lessons, or therapeutic alliances, or an old coach’s emphasis on process over outcomes.