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Checklists: Cookbook Medicine or Life Saving Tools?

Posted on Thu, Jun 19, 2014

by: Craig Smestad, M.D. Executive Vice President - EmCare South Division
I had bilateral sinus lift surgery with bone grafting, several extractions, and had two dentalchecklist blog implant posts placed in my maxilla - with many more to come. In short, I am having my entire dentition systematically replaced.

This is something I have always wanted to do, but have never managed to commit the time or dollars. The aging process, chronic bone resorption, and long-standing bad habits have now led me to have no other choice but to have this problem remedied. The entire process will take the better part of a year, but the end result will be both a wonderful smile and functional, pain-free teeth. You might be asking yourself, “Why is he telling me this, and who cares?” I promise – there is a point to this story.

My dentist is Dr. Jeffrey Bynum, referred to me by a colleague from EmCare. Dr. Bynum is an extremely intelligent and exceptionally talented dentist. His office is ultra-modern and equipped with high-tech equipment, including a C.T. scanner, large digital computer screens for patient teaching and consultation, and wireless communication between all providers. In addition, he has a wonderful staff that truly cares about their patients. This is the perfect environment for Dr. Bynum to foster trust and confidence from his patients.

Dr. Bynum spent a couple of hours with my wife and me during my initial consultation. Knowing that I needed the sinus lifts, but knowing I was not familiar with the procedure, Dr. Bynum explained in detail how he would open the bone in the roof of my mouth to gain access to the maxillary sinuses. He would then gently tease the Schneiderian membranes which line the floor of the sinuses upward, in order to create a space for bone matrix transplant. Dr. Bynum further explained that he would also use my own platelets and fibrin added to the matrix, which he would obtain via phlebotomy and subsequent centrifuge spin-down in his own office lab on the day of the procedure. Of course, intuitively knowing how delicate of a procedure this must be, I asked Dr. Bynum how difficult and complex of a procedure I should expect, what the likelihood of perforation of the membranes would be, and, should that happen, how a perforation would be addressed. Dr. Bynum answered all of my questions in detail, and explained that during his dental training, he practiced lifting the inner membrane off many chicken egg shells to become competent in the procedure. I found this both fascinating and quite comforting.

During subsequent office visits and prior to my sinus lift surgery, Dr. Bynum and I frequently discussed various facets of healthcare, including the inordinate number of serious and often preventable complications that too often occur in both medicine and surgery, as well as how the notion that “to err is human” is not an adequate excuse to justify such errors. After my surgery, as I was leaving, Dr. Bynum unexpectedly handed me a book that he thought I would enjoy: “The Checklist Manifesto: How to Get Things Right,” by Atul Gawande. Dr. Bynum has come to know me quite well, because I enjoyed the book very much.

Dr. Gawande is an endocrine surgeon at Brigham and Women’s Hospital in Boston, and author of several books. He has a passion for improving safety in health care, and he was instrumental in the development of the World Health Organization’s surgical checklist, which has been widely adopted across the Globe. Dr. Gawande is a Harvard Professor and has too many accomplishments and credentials to mention here. I found “The Checklist Manifesto” to be a fascinating book and a very quick read. In the book, Dr. Gawande presents numerous instances in modern-day life describing where and how checklists are used to avoid errors and to prevent catastrophes in problem-prone industries, including in the building of skyscrapers, in the aviation industry, in the restaurant industry, in the investment world and in healthcare, among other fields. He also includes examples of catastrophes in both health care and non-healthcare settings, and how they occurred when short cuts were taken and communication failed. It’s hard to put this book down.

I have always embraced the use of checklists as safeguards throughout my career. After all, when performing a chemistry experiment, or when baking a cake, the end result will not be what is planned or expected unless directions are correctly and closely followed. The same is true when placing a central line, when prepping a patient for surgery, or even when attempting to diagnose a patient. For example, the differential diagnosis is nothing more than a list of conditions that need to be considered and investigated relative to a sign or symptom, or a constellation of signs and symptoms, in order to arrive at a definitive diagnosis. Failure to consider any condition on the list could result in a missed diagnosis with variable consequences, including the most devastating consequence: the demise of the patient.

For decades, physicians have been reluctant to embrace checklists and recipes, referring to them as “cookbook” medicine. Thankfully, this recalcitrance is abating, and using checklists to help guide care of patients is slowly becoming more and more embraced. Order sets, for example, are not recipes or cookbook medicine, they are guidelines that afford doctors the opportunity to review evidence-based recommendations that need to be considered when caring for patients. The simple use of aspirin to reduce mortality in heart attack patients is no different from applying the brakes when driving, and coming to a complete stop at a stop sign. Failure to do either could result in a less than desirable outcome.

I feel fortunate to have been referred to Dr. Bynum for my dental surgery. His understanding of safety and quality of care puts me at ease. While some complications are indeed unavoidable, the likelihood of complications occurring is markedly reduced when healthcare providers embrace procedures geared towards reducing variability of outcomes. Dr. Bynum and Dr. Gawande understand this. We should all understand this. It is not that we have to embrace unproven processes or procedures because, as physicians, we have a responsibility to both question and scrutinize any new recommendations for modifying or changing our practices and how we provide care to our patients. However, when the evidence is clear, and the results prove the premise, we also have an obligation to practice medicine so as to afford our patients the least possible chance of errors, and the best possible outcomes.

ABOUT THE AUTHOR

SmestadDr. Craig Smestad is an executive vice president with EmCare’s south division. Dr. Smestad completed his undergraduate work at the University of Miami and completed medical school at the University of Puerto Rico School of Medicine. Prior to joining EmCare in September 2012, he served as chief medical officer for Brandon Regional Hospital in Brandon, Fla., Saint Charles Hospital and Rehabilitation Center of Port Jefferson, N.Y., and Saint Catherine of Siena Medical Center in Smithtown, N.Y. Dr. Smestad has also worked as house physician, E.D. physician, associate director of emergency services and a medical director at several other facilities.

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