問題詳情

Not long ago, I walked in on a group of medical residents inserting a central line catheter into a patient in the intensive care unit. They were gowned and gloved, working quietly over the patient’s neck, exposed through a small hole in a sterile blue drape, where a thick needle was entering under the collarbone. I noticed they had neglected to drape the abdomen and legs, but at this point it didn’t seem wise to interrupt the procedure, so I let it go. They had also apparently forgotten to don face shields and caps. I let that go, too. Like them, I wanted to get the procedure over with as quickly as possible before something bad happened. After the senior resident pasted a clear sterile dressing over the insertion site, I congratulated him on a job well done. But two days later, the patient developed a fever and her white blood cell count shot up. The line had to come out. Bacterial cultures revealed it was infected.Doctors often overlook or omit steps in the multitude of tasks we perform every day. As Atul Gawande argues in “The Checklist Manifesto,” these are situations where a simple to-do list could help. For example, a five-point checklist implemented in 2001 virtually eradicated central line infections in the intensive care unit at Johns Hopkins Hospital, preventing an estimated 43 infections and eight deaths over 27 months. Gawande notes that when it was later tested in I. C. U.’s in Michigan, the checklist decreased infections by 66 percent within three months and probably saved more than 1,500 lives within a year and a half.Gawande, a professor of surgery at Harvard Medical School and a staff writer at The New Yorker, makes the case that checklists can help us manage the extreme complexity of the modern world. In medicine, he writes, the problem is “making sure we apply the knowledge we have consistently and correctly.” Failure, he argues, results not so much from ignorance (not knowing enough about what works) as from ineptitude (not properly applying what we know works). This is an important insight. Medicine has made great strides, but in many ways doctors have become victims of their own success. Taking care of patients is hard; there is often too much for one doctor to do. Medical care for common disorders like diabetes and pneumonia has been shown to meet national guidelines only slightly more than half the time.Medicine is not the only complex profession where lives are on the line. In making his argument, Gawande deftly weaves in examples of checklist successes in diverse fields like aviation and skyscraper construction. He maintain; that checklists not only help pilots and builders get the stupid stuff right, but foster the communication required to deal with the unexpected. His discussion of aviation accidents, including the emergency landing on the Hudson River last January (during which the copilot simultaneously managed checklists for restarting the engine and ditching the plane), makes for fascinating reading.But Gawande’s missionary zeal can give the book a slanted tone. For instance, there is almost no discussion of the unintended consequences of checklists. Today, insurers are rewarding doctors for using checklists to treat such conditions as heart failure and pneumonia. One item on the pneumonia checklist—that antibiotics be administered to patients within six hours or arrival at the hospital—has been especially problematic. Doctors often cannot diagnose pneumonia that quickly. But with money on the line, there is pressure on doctors to treat, even when the diagnosis isn’t firm. So more and more antibiotics are being used in emergency rooms today, despite the dangers of antibiotic—resistant bacteria and antibiotic-associated infections.Even when doctors know what works, we don’t always know when to apply it. We know that heart failure should be treated with ACE inhibitor drugs, but codifying this recommendation in a checklist risks that these drugs will be prescribed to the wrong patient—a frail older patient with low blood pressure, for example. Checklists may work for managing individual disorders, but it isn’t at all clear what to do when several disorders coexist in the same patient, as is often the case with the elderly. And checklists lack flexibility. They might be useful for simple procedures like central line insertion, but they are hardly a panacea for the myriad ills of modern medicine. Patients are too varied their physiologies too diverse and our knowledge still too limited.Gawande passingly notes that checklists could be used to improve weather prediction. But he doesn’t mention that weather is an inherently chaotic phenomenon small perturbations in initial conditions can result in big, unpredictable effects. When Gawand writes that an investment manager he knows believes a checklist can help him reliably beat the stock market, the case seems to have been pulsed too far. Yet despite its evangelical tone, “The Checklist Manifesto” is an essential primer on complexity in medicine. Doctors resist checklists because we want to believe our profession is as much an art as a science. When Gawande surveyed members of the staff at eight hospitals about a checklist developed by his research team that nearly halved the number of surgical deaths, 20 percent said they thought it wasn’t easy to use and did not improve safety But when asked whether they would want the checklist used if they were having an operation, 93 percent said yes.[!--empirenews.page--]
45. What type of writing does this article belong to?
(A) A social commemary
(B) A medical report
(C) A book review
(D) A travelogue

參考答案

答案：C
難度：困難0.230769
統計：A(1),B(7),C(3),D(1),E(0)

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