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Comment by heymijo | Hacker News Reader

An ophthalmologist I know is an attending physician, which means she teachers new resident physicians.

She described a few surgeries to me and her role in the room as the resident performs the surgery. Her brain is the checklist for the surgical procedure. The culture seemed to be, you should be good enough to memorize these complex procedures.

Meanwhile I'm thinking, why not just have someone else in the room reading and confirming the next step to the surgeon?

I suspect the culture of medicine, and especially the culture of surgeons does not jive well with checklist culture.

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This [1] is a great article that I think gets at this topic a bit. Basically, germ theory and anesthesia (ether) were both discovered around the same time. Yet anesthesia spread around the world in a matter of years, while germ theory is still a struggle for doctors and hospitals. I presume the reasons checklists are underutilized are similar, lack of immediate consequence, low probably of consequence, and added difficulty instead of simplifying things. We must do better.

[1] https://www.newyorker.com/magazine/2013/07/29/slow-ideas

Then it should also apply to the use of contraceptives

Lack of contraceptive use does certainly have a delayed and inconsistent effect, but when the effect does happen it does so in a way that is far more visible and traceable than any disease caused by dirty hands.

Ether was a new tool that lets you do something you couldn’t do before.

Checklists were a new tool that required you to submit that you’re stupid and should depend on inanimate paper to do what you already know.

Maybe part of medical training should include the difference between stupidity and fallibility then. If you made it to med school, you probably aren't stupid, but you are human.

I'd go with: part of any training for complex tasks. And even to kids in general. There are so many people I met who can't imagine that others make mistakes without any real reasons, which leads to unnecessary conflicts or workplace issues. It just happens - plan for people failing, not for punishing random failures.

> germ theory is still a struggle for doctors and hospitals

What do you mean by this? As written, it's total nonsense; germ theory is universally accepted.

https://en.wikipedia.org/wiki/Hospital-acquired_infection

The fact that patients get infected doesn't mean the hospital rejects "germ theory".

I suspect that what made the culture of pilots change is that their own lives are on the line. That, and the fact that the guys flying the coolest fastest planes had commanding officers who could simply ground them if they didn't like it.

My father was an AF pilot for 20 years. I've never known a more conscientious and careful man.

One day he was going through the landing checklist, and was interrupted by a radio call. He resumed the checklist, then was told by the tower that he was attempting to land with the gear up. The interruption had caused him to skip that step on the checklist.

After that, whenever he was interrupted in a checklist, he started it over again.

I've been flying a somewhat large UAV lately, and inspired by the "real" aviators and The Checklist Manifesto, I put together a series of checklists. One for packing, one for pre-flight, and a mission-specific one for the day.

Early on I was pretty lax about following them, and inevitably something bad would happen. I'd forget to pack something and not realize it until I had driven an hour. I'd forget to check for loose bolts and lose one. Or I'd completely forget one of the objectives for the day and have to go back out.

I've tightened up my process quite a bit, and do exactly what your father does: if I get interrupted, I start over. It's mentally hard to do when I'm already feeling late, but I've come to the conclusion that that's exactly when I need to be more disciplined about it; that's when you forget things!

I've seen the same principle at work in a pretty different activity: rock climbing.

There's a well known story of one of the best climbers in the world getting approached by someone while she was tying the rope to her harness right before a climb. After a brief chat she proceeded to climb the route, lean back on the rope, and promptly plummet to the ground.

After being interrupted she had forgotten to finish tying a knot she had done thousands of times before. It's a good reminder to avoid letting yourself get interrupted in the middle of simple but extremely critical tasks, it's just so easy for the brain to skip over part of the process it knows well and consider it done.

Proper climbing procedure states that partners should check each other's harnesses and the rope to make sure they're connected to the same rope, the knots tied properly, buckles are double-backed, etc.

I had a similar incident many years ago where my partner only tied into one harness loop. Luckily it was in the gym and she wasn't on lead, but after that, I always make it a point to thoroughly check my partner's equipment.

A little anecdote about the careful part. He flew ground attack missions in the Korean War. He didn't win any popularity contests on the ground. The leader for his squadron was one of the popular pilots. But when they were out of sight of the airfield, the squadron leader would radio my dad to assume the lead. He'd lead the squadron in and out, and when they got back near the base, he'd swap positions back with the actual squadron leader.

The reason was pretty simple. He'd take the time to pour over the maps and intelligence to find the safest route in and out, and they'd get back with the fewest holes in the airplanes.

I.e. when it counted, the squadron would entrust him with their lives.

I don't think it's possible to have a greater honor.

Part of the problem is humans are all slightly different. Thus doctors need to understand the system because there is always something in the details that is unique and so the checklist needs to be deviated from. Once you are in the habit of this is different you quit using the checklist...

Checklists are very useful anyway because they let you focus on and remember the parts that are actually different. However when someone is highly trained it is easy to think you already know everything and not use the checklist.

Complexity probably has something to do with it. Every surgery is slightly different. So a reasonable size checklist would be missing enough items to kill the patient, and a complete one, the patient dies before you are 1% through it.

You, Bluegill, and pmiller make good points about the complexity of humans and surgery.

This is silly. Every surgery in the world requires "confirm which body part you are removing" and "make sure the scalpel is outside the patient before sewing up".

Yet people still cut off the wrong bits, leave things inside. Read this is you want to get mad: https://www.nj.com/hobokennow/2008/06/humc_suspends_doc_who_...

The doctor who did this is still practicing last I checked, as are the staff involved in covering it up, and the hospital he worked for was not informing patients of his history.

Another shockingly similar case: https://www.deseretnews.com/article/412903/HOSPITAL-SETTLES-...

Just two cases I remember reading about. Over a quarter million or more per year according to most sources.

Medical mistakes are the THIRD leading cause of death in the USA. Actually, conscientiously using a checklist to reduce that isn't too much to ask.

Yet people still cut off the wrong bits, leave things inside.

The checklist is basically the physical equivalent of asking "are you sure you want to remove this limb?" every single time, and people will just "click OK" before long.

Aviation proves that untrue. Mostly people follow them. That some will not doesn't invalidate their worth. I am always confounded by people who argue everything isn't good enough, and then nothing ever changes as a result.

Medical mistakes happen and are very common, and I wouldn't be surprised if there were 250,000 per year.

But "wrong site surgery" is a tiny subset of medical error, and I'd be amazed if that was more than 1000 per year.

Most medical error is in the form of medication error. Medication error is very common, and I'd be surprised if it was as low as 250,000 per year. I'd guess that number was the number of people harmed by a medication error.

These errors are serious and we need to work to stop them, but we also need to put them into context. There are over 800 million physician office visits in the US per year. There are over 140 million ED visits per year.

And these bits are put into checklist. In theory (and in my experience) they are performed at the beginning and towards the end of every operations. It’s the large decision space in between that struggles to be covered.

They have that last part. It's called the count.

I want my surgeon to know the procedure cold, but I would definitely not mind having a backup in the form of a checklist.

This is, I think, something that a lot of people who push back against checklists missunderstand. They feel that the checklist is meant as a replacement for their knowledge, skill and experience. An insult to their ability. But really it's just meant to help them not make very human errors of ommission or miss-sequencing that anyone, no matter how smart or experienced, can make.

Too many experts, in every field, stuggle with the idea that they too will make mistakes sometimes, and that this is perfectly normal no matter how good you are at what you do if you doo it often enough.

I struggle with this too— another way to think about it is that a checklist frees your mind to think of more creative/important things. By delegating the mundane to the checklist, your brain no longer needs to constantly track the basics and instead is free to focus on higher order thinking.

I find it takes a disproportionate amount of mental energy just to track even 5-10 items. Committing those items to a written list makes it easier for me to take that limited resource and be creative instead of constantly wondering if I completed step 3.

I like that way of phrasing it. I wish more people would think about things in this more positive light, but unfortunately whenever something like this comes up people start to get defensive.

On the flip side, I've seen with my two eyes, doctors watching a youtube version of the surgery before doing the real thing.

I wasn't in a position to verbally ask but it seemed common.

well, i heard in a podcast that surgeons -- not to pick on them but that was the example given -- don't have their own lives on the line and would likely ignore checklists. compared to say pilots.

yet, pilots make mistake too. examples were given when they rush and ignore the checklist or the second in command for example. rushing is usually the biggest mistake. and ignoring a lower ranking pilot is another big one.

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