The Power of Checklists in Psychiatry

The book “The Checklist Manifesto” was a game changer in risk management as it crystallised into words the importance of a systematic approach to risk management using checklists. This is something that the aviation industry has done for years. According to the author Atul Gawande…“Good checklists, on the other hand are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything–a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps–the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.”
This manifesto can be applied to several other industries to improve efficiency. It goes without saying though, that the aim is not only to minimise risk, but also to improve performance. This requires an additional component of improving insights. This was an important concept purported in Gary Klein’s book “Seeing What Others Don’t: The Remarkable Ways We Gain Insights”. In short, reducing errors plus improving insights is the basis of performance improvement. Checklists can help you achieve the first part (reduce errors), which then allows you time to develop the second part (improve insights) which is essentially what leads to creativity and progress. Without the first part, a disproportionate amount of time is spent in reducing errors in an inefficient manner which then allows little or no time to develop insights.

So why aren’t checklists common place in practice?

One reason is due to our excessive focus on the outcome without sufficient emphasis on the process. In giving exams we know we want to pass the exam (outcome) but do not spend sufficient time on the question of what is the most effective way of passing the exam (the process). Many think spending hours on textbooks is enough, I can assure you it is not; in fact it may be quite inefficient. The process of how you assimilate knowledge is more important and thinking about this process in detail and applying it successfully will help you achieve the desired outcome. In fact, the outcome is nothing but a byproduct of an effective process. This also applies to important things like money management and investing. People focus on the outcome saying “I want to become rich”, but how many focus on an effective process? I bring investing up, because it was Charlie Munger (Warren Buffet’s business partner) who articulated the importance of ‘the process’ extremely well and I believe his quotes apply to many things in life. Their company Berkshire Hathaway has comfortably outperformed the market year after year which is most likely the byproduct of a successful process.

“Checklist routines avoid a lot of errors. You should have all this elementary [worldly] wisdom and then you should go through a mental checklist in order to use it. There is no other procedure in the world that will work as well.” –  Charlie Munger

“You’ve got to have models in your head and you’ve got to array your experience – both vicarious and direct – on this latticework of models…. The first rule is that you’ve got to have multiple models because if you just have one or two that you’re using, the nature of human psychology is such that you’ll torture reality so that it fits your models, or at least you’ll think it does… And the models have to come from multiple disciplines because all the wisdom of the world is not to be found in one little academic department”- Charlie Munger

Wise words indeed!

Checklists in Psychiatry

Now let’s get back to back to psychiatry. If you think about it, the DSM is also based on a checklist of criteria but caution is to be exercised in applying it in a cookbook fashion. Clinical experience allows to add you to this checklist and expand it over time which is the process of developing insights referred to earlier. Checklists are very valuable for clinical practice to cover the basics in any task as it sets up a framework upon which other sophisticated tasks can be built. By having a checklist at hand to cover the important criteria and procedural elements within the task, the main task is completed efficiently which then allows the individual to ask “Is there any thing atypical about this case? , “Is there anything else I need to do?” or “Am i missing something? ”. This is a crucial step as I mentioned in one of my previous post on psychiatric formulation; The ability to distinguish between zebras and horses when one hears hoof beats relies upon a systematic process of exclusion of the impossible. This is exactly what a checklist allows you to do.
Since OSCE and CASC exams are a slice of clinical practice, checklists are indispensable. The smart thing of course is to ensure that questioning does not come across as a checklist , otherwise the patient may well question if they’ve come to the right place , or the examiner may think of you as an automaton. This will require interviewing skills ranging from redirection, transitioning, facilitation, etc.,  so that the questions are interwoven amongst elements of empathy and curiosity.
So to those taking the MRCPSych CASC, the RANZCP OSCE or RCPSC OSCE exams, ensure that for each of the possible scenarios you have a structured checklist in your mind which is your structure and strategy, which then allows you to adapt quickly to any tricky elememts that may be posed.
This is the basis behind psychinterview.com which has a over 600 minutes of video material with 45 lecture slides imparting a range of interview techniques which are interwoven amongst a lattice of checklists . The slides with checklists help you remember key points, so that once you have a structure deeply embedded in your implicit memory, you will always be able to fall back on it, no matter what situation you are faced with.

This article is written by Dr Sanil Rege. Sanil is a Consultant Psychiatrist in private practice on the Mornington Peninsula and co-founder of psychscene.com. He is pursuing an MBA at the Melbourne Business School. You can follow him on Google+

References:
1. The Checklist Manifesto: How to Get Things Right by Atul Gawande
2. Seeing What Others Don’t: The Remarkable Ways We Gain Insights by Gary Klein
3. A Lesson on Elementary, Worldly Wisdom As It Relates To Investment Management & Business by Charlie Munger (Lecture at USC Business School)


3 Responses to "The Power of Checklists in Psychiatry"

  1. Amit says:

    This is interesting. We acted after reading The Checklist Manifesto last year and built a product called Tallyfy that makes all this a reality, and addresses the practical problems too. We were funded by the Chilean and US governments. I think mapping the checklist and continous engagement is always a challenge. Also – governance, who owns a checklist or who owns updates/improvements – is a piece that must be in place.

  2. Hi Amit,
    Very interesting concept. I checked out your website. Will keep following progress. I wonder how you came across this blog?

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