Are Medical Checklists Bad for Your Health?

Using checklists in medical care sounds like common sense. We’ve all heard the stories of the man who had the wrong leg operated on, and the woman who had a sponge left in her belly. Checklists are routine in other professions to standardize management, and we know they can prevent hospital infections and surgical error.

But can there be a downside to checklist medical care? Consider these two examples:

Scenario 1

You come into the ER after you dove to catch a softball. You’re pretty sure you have a bruised rib, but because you said the magic words of “chest pain”, you get whisked away to get blood drawn and then to get an EKG and a chest x-ray. You’re told this is all part of the “chest pain protocol”. But did you really need all of these tests done?

Scenario 2

You tell your doctor you’re tired and feeling run down. Your doctor does “routine blood work”, again following a checklist of things to look through: anemia, thyroid problems, and so forth. Everything is “normal”. The checklist is complete, so your doctor assures you that you’re OK—even though you know you’re not.

In my work as an emergency physician, I know that checklists can be helpful. They ensure complex procedures are done thoroughly and provide an extra assurance for safety. However, before undergoing the procedure or any treatment, you must first have a diagnosis. This diagnosis, and the subsequent treatment, needs to be personalized to you. A “cookbook” approach where you get the same recipe of tests and medications as anyone else will result in expensive, unnecessary care, and even misdiagnoses and harm.

Here are five tips to make sure you get the best, personalized care for you:

#1. Insist on telling your story. Studies have shown that 80% of all diagnoses can be made based just based on the story of your illness. Doctors have limited time to listen to your story, so you must make sure your doctor understands why you’re there. Don’t just say that you have “chest pain”; explain when it started, what you were doing, and how it felt. Write down key elements. Practice until you can tell it in 30 seconds or less. Then tell it to your doctor the moment you see her to make sure the doctor focuses on your individualized story.

#2. Give open-ended responses to close-ended questions. If you suspect that the doctor is going through a checklist of yes/no questions, try to get her to focus on you by adding personal elements to your answers. If you’re asked, “when did you start feeling so tired?”, don’t just say “two weeks ago.” Add that you’re normally very energetic and run 5 miles a day, but for the last two weeks, you can barely get out of bed to work. These answers help provide context to who you are.

#3. Ask about your diagnosis before you consent to tests. If you’re told you need to get blood drawn, ask why. Sometimes, that’s enough to stop the “cookbook” from taking over. Every test should be done for a specific reason, not just because it’s what’s done in this protocol, but because it helps focus the diagnosis. Also ask about what to do if the tests are negative. Just because they’re negative doesn't mean there isn’t anything wrong, so what should be next steps?

#4. Inquire about treatment options. In very few situations is there only one test that could work or one protocol that must be followed. If your doctor says you need to do this one set of tests, ask what your other options are. Often, watchful waiting is a perfectly acceptable alternative. Discussing options helps to remind your doctor to tailor the treatment to you.

#5. Let your doctor know that you want to be a partner in your decision-making. If you still think that your doctor is following a recipe rather than individualizing care, ask her to explain her thought process to you. Say that you respect her expertise, and you want to learn what it is that she is thinking. Your doctor may be so busy or so used to checklists that your request can help her to refocus on you and your individual needs.

This article was previously published in Women's Health Magazine (posted here with their permission).