Safety blog posts: Blog post Number 5 Experts, checklists, and attention to detail

Specialization and super-specialization have their good points but all of us are aware the bad points. Seeing the big picture can be a problem for the specialist who may become tunnel visioned. The tendency to seek specialization in the cradle of medical school only worsens this problem. Patients lament the absence of an all around knowledgeable family physician however is it possible to find such a well-informed physician any more or has the complexity of medicine made the mastery of such an expansive knowledge base all but impossible for mere mortals?

Atul Gawande, M.D, a well known author of medical and popular literature treated this subject in his book “The Checklist Manifesto”. Dr. Gawande compares the master builder of yesteryear to the team of construction professionals who must coordinate their team members to build complex modern skyscrapers of today. This excerpt is taken from a book review of “The Checklist Manifesto” at

“Centuries ago, he writes, builders used to be a lot like today’s doctors, where a “Master Builder” was given total autonomy to construct projects like Notre Dame and the U.S. Capitol building. But making skyscrapers became so mind-bogglingly complex that no one builder could handle it. So builders created elaborate production checklists (they “ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way”) and, more important, specified key communication tasks between experts like elevator installers and engineers. Today, less than 0.00002 percent of buildings fail though they’re more complex than ever.”

Two concepts identified above apply to this blog post about patient safety. One is the issue of total autonomy of a person with a project (you and your medical problem are the project) and the other is the introduction of the concept of key communication tasks and elaborate production checklists to help prevent building failure. We will come back to this book and Dr. Gawande again more than once in future blog posts.

So we have a problem. The family physician of the past who knew quite a bit about everything medical and surgical had the advantage of not being overwhelmed by the mind-boggling complexity of modern medicine. The family physician or surgeon of today when compared to the master builder finds it necessary to seriously ramp up communication and should realize that reliance on checklists simple or elaborate is not a sign of weakness, but a way of paying attention to the details of patient care in an increasingly complex medical and surgical universe. The doctor who professes to know everything about all medical fields is either a rare genius or a fool. Observation power coupled with being a real expert physician is what counts. BY THE WAY my definition of an expert physician or surgeon: An expert knows what he or she does not know. Taking this analogy a bit further, the general surgeon finds him or herself practicing surgery in the increasingly complex field of general surgery. Years ago general surgery included a not previously existent field called orthopedics. Today no general surgeon in the USA would or could practice most types of orthopedic surgery but will be called upon to recognize or observe the existence of orthopedic problems that may masquerade as general surgery problems, e.g., groin pain from a back problem rather than from a hernia.

Your assignment as the patient student of safety surgical safety: to learn to recognize the expert surgeon who pays attention to details and who knows what they do not know.