The Checklist Manifesto

Atul Gawante
Publish Date
Sep 11, 2023
Chapter 1. The Problem of extremic complexity
本章里提到的掉入冰湖超过30分钟仍然生还的奥地利小女孩案例非常有名,被改编成了电影 A Day for a Miracle 医学期刊上的原始论文: Resuscitaton in near drowning with extracorporeal membrane oxygenation // extracorporeal membrane oxygenation: ECMO For every drowned and pulseless child rescued, there are scores more who don’t make it—and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don’t get written up in the Annals of Thoracic Surgery , but they are the norm, though people may not realize it. This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection. After ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply. 医学的高度专业分工化(superspecialist)改善了人类福祉,然而即使这样也无法避免医疗过程中的失误(ineptitude / failure)。因为人类的生理和心智特征存在固有的极限(医生也是人),而专业化使得医生的心智负担越来越重。作者提出 Checklist 作为解决这个问题的方式。 但我认为最终的根本解决方案是用 AI、机器人等完全替代人类医生承担医疗工作。事实上所有生产力领域都可以、应该并且最终必然会由AI代替。
Chapter 2. Checklist
住院病人监护记录表格上的四种关键指标(Vital signs)就是一种形式的 Checklist: body temperature, pulse, blood pressure, and respiratory rate 5th vital sign: pain, as rated by patients on a scale of one to ten
Chapter 3. The end of the master builder
有两类复杂的问题: * complicated : 工程上的复杂问题。但解决方案可以完全重用。例如登月。 * complex : 实践上的复杂问题。相对于客体和环境高度个性化。例如养育一个孩子。 For most of modern history, he explained, going back to medieval times, the dominant way people put up buildings was by going out and hiring Master Builders who designed them, engineered them, and oversaw construction from start to finish, portico to plumbing. Master Builders built Notre Dame (巴黎圣母院), St. Peter’s Basilica (圣彼得大教堂), and the United States Capitol building (国会山). But by the middle of the twentieth century the Master Builders were dead and gone. The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them.
Chapter 4. The idea // checklist 也适用于解决 complex 类型的问题
Under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals. 这正是市场经济的本质。以及为什么共产主义(计划经济)必然失败。 no-brown-M&M’s clause : To ensure the promoter had read every single word in the contract, the band created the "no brown M&M's" clause. It was a canary in a coalmine to indicate that the promoter may have not paid attention to other more important parts of the rider, and that there could be other bigger problems at hand. 顶级厨师成功的秘诀也是 checklists.
Chapter 5. The (miserable) First try
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. 第一次试图在手术流程中引入checklist以改善手术效果(如较少并发症)的尝试失败了。因为 checklists 被做的过于复杂,包罗万象。
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. 人类大脑的工作记忆只能保持5-9个项目。 It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives. 两种 checklist: * DO-CONFIRM // pause point (关键点)之前确认所有必需准备已完成。例如手术切口(incision)之前 * READ-DO 英國航空38號班機事故
Chapter 7. The Test
For all the differences among the eight hospitals, I was nonetheless surprised by how readily one could feel at home in an operating room, wherever it might be. Once a case was under way, it was still surgery. You still had a human being on the table, with his hopes and his fears and his body opened up to you, trusting you to do right by him. And you still had a group of people striving to work together with enough skill and commitment to warrant that trust.
本章用航空业界的教训和案例引证 checklists 的重要性。主要案例是著名的哈德逊河上的奇迹航空事故 (2009年1月, 奥巴马第一个总统任期就职前夕)。 All learned occupations have a definition of professionalism, a code of conduct: * First is an expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own. * Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise. * Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges. The fourth: Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at. In summary, why we need checklists? 1. The (ever increasing) complexity of (our understanding and ability of) the world. 2. The fallibilites of humankind / humanity. (Admit it or not)
Chapter 9. The Save
Gawande is arguably the best nonfiction doctor-writer around. He’s prescient and thoughtful … the heir to Lewis Thomas’s humble, insightful, and brilliantly crafted oeuvre. Lewis Thomas: 刘易斯·托马斯, 医生,散文家。