How systems thinking has almost halved the death rate in surgery

Atul Gawande (pictured) is an American surgeon who posed the following question: To provide the best healthcare, do we need the most expensive experts, drugs, procedures, equipment, and so on? Using systems thinking, he came to the answer: No! Because the most expensive individual parts do not guarantee that the result is the best.

What if we built a car from the best parts? Brakes from Porsche, engine from Ferrari, bodywork from Volvo and the chassis from BMW. Assembled together, this results in a very expensive pile of scrap. And that's how it sometimes feels in medicine: It's not a system. (Atul Gawande)

Systems thinking comes from systems theory and deals with the question of how the whole can be more than the sum of its parts. Atul Gawande applies systems thinking in his field, surgery. His TED Talk How do we heal medicine? is worth seeing in this respect.

Growing complexity

In the 1970s, a patient admitted to hospital saw an average of two professionals during their stay - doctor and nurse. By the end of the millennium, there were 15! Doctors used to be generalists, but today every doctor is a specialist. But that used to mean that a doctor with a cowboy mentality could achieve good results. But today we need functioning teams.

We trained and rewarded our people as cowboys. But today we need pit crews for our patients. (Atul Gawande)

The result: something is overlooked in every second operation, with exploding costs. Decision-makers and doctors often comment: "That's the price of medical success". But fortunately, the most expensive treatment is not always the best. If that were the case, then we would really have to rationalize medicine.

We are obsessed with bringing together the best individual parts. We often forget the whole. This is a miserable design strategy (Atul Gawande)

Three important competencies

Once it was clear that the system idea required Atul Gawande three competencies for success:

As a specialist, it is easy to lose sight of the overall success. The right approach here is data analysis, a task that - for cowboys and doctors - is not particularly sexy.

If operations fail, this could be due to the surgeon's competence; however, if the problem exists elsewhere, then the surgeon's further training, for example, is not particularly effective.

Other industries understand this better. For example, checklists are used a lot in the construction of buildings. A good checklist is a tool that makes an expert even better.

Systems thinking from Boeing

Following this approach, Atul Gawande sought help from Boeing's Lead Safety Engineer. He helped the operations team to create effective checklists. Of course, this was not about "cooking recipes", but about not forgetting important things. This included finding the right times to use the lists to address potential issues before they become problems. The result was a 2-minute list consisting of 19 points. The result was dramatic:

We implemented the list in eight hospitals worldwide, in poor and rich countries. The result: 35% fewer complications, 47% fewer deaths. A dramatic success! (Atul Gawande)

But only the third competence makes success possible:

Despite the impressive result, checklists are not yet the norm in operations, not even in the USA. There is resistance: the introduction of such tools requires a change in thinking, and also the adoption of values such as modesty, discipline and teamwork. Unfortunately, this is not yet a matter of course for all doctors.

Image: atulgawande.com