Which hip has to be replaced?

The Harvard based surgeon  Atul Gawande is also a brilliant writer of matters medical. His MacArthur award is one testament to his skill in communicating the substance of a wide range of health-related topics from the huge discrepancies in medical costs in different parts of the country to an l examination of the trajectory of experiences that are needed to develop the skills (expertise) of a surgeon. One of his recent t articles became a book about the value of lists (The Checklist Manifesto: How to get things right. He points out the value of lists such as in the operating room and the operation of jet airliners. When it comes to the skies Gawande shows that when last year Sullenberger successfully avoided disaster touching down in the middle of the Hudson River what helped pull off the daring escape from death was the use of a flight emergency checklist. Apparently a similar checklist was not followed when the pilot of a 2 engine commuter airliner took off from a rural New York State airport with one engine on and the other off. The passengers and crew were lucky that the plane did not fall from the sky. Gawande cites the important work of Dr. Peter Pronovost, a critical care specialist at Johns Hopkins University Hospital. Pronovost championed the use of lists in the OR which included ‘obvious’  items such as wash your hands, sterilize the patient’s skin, wear a mask, and so on, the kinds of things that you would assume are always done unless someone forgets a step with the result of infections that need not have happened. For example following procedures on an OR check list made it possible to drop IV infection rates of 11% to zero. It is important to note that Pronovost’s lists were made up of items universally seen as the routine things to be done such as putting in an IV line. Medical centers throughout the US have made use of the check list idea and it has been highly successful.

What make well constructed lists useful? The answer lies in the interactions of automatic memory and attention and the kind of attention that requires effort, awareness one that has limited capacity. Automatic remembering and attention is useful because it requires no effort and therefore can be carried out while performing other cognitive activities at the same time. Obviously it helps to have automated gear shifting and use of the clutch while driving because if not much of the part of driving that requires thought and concentration would suffer. This analogy is particularly relevant for the complex thinking and decision making in the operating room. Unfortunately automated activities are not well tagged in memory as having occurred. It is not surprising that we sometimes wonder whether we unplugged the coffee. At the same time it helps to decrease the cognitive load when performing complex activities especially under stressful conditions. Following an available serial list of things to do is one less cognitive demand especially when having to work and think quickly such as figuring out what now when all the engines have failed and you as the pilot must decide what now. Making and using lists may be boring and pedestrian but useful.