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After hearing complaints about over-administration from healthcare workers, and, in particular, that the health community was binging on checklists, Science-ish knew something was awry when a poem titled Mister Tick-A-Box arrived in my e-mail inbox from an Australian surgeon-poet-friend.

Dr. Hessom Razavi turned to writing stanzas to vent his frustrations about the checklist culture he saw emerge at his eye clinic and operating theatre in Perth. He was being reduced to an automaton by the directives of “Mister Manager, a.k.a. Executive-Director-Consultant-Supervisor-Coordinator-Liaison Officer,” he scribbled. Instead of patients, he was dealing with “the boxes, the boxes, the cold creep of the b □ o □ x □ e □ s , just waiting to be ticked.”

The eye surgeon wasn’t the first to speak of checklist burnout, and “alert fatigue” over electronic health records is already a well-documented phenomenon. This led Science-ish to wonder about the evidence behind the much-lauded surgical checklist—made famous by the Harvard surgeon and New Yorker writer Dr. Atul Gawande in his book the The Checklist Manifesto. Exactly how effective is this modern medical panacea?

Science-ish rang up Dr. Marty Makary, the Johns Hopkins surgeon who helped to develop the original surgical checklist trumpeted by Dr. Gawande and ferried around the world by the World Health Organization. When asked about checklist fatigue, Dr. Makary voiced his concern that the original surgical checklist—which includes simple elements, such as confirming the patient’s identity while she is still awake; a “time-out” before skin incision, when the medical team checks in about antibiotics and possible critical events; as well as a sponge and instrument count at the end of the operation to ensure nothing is lingering within the patient—has been a victim of its own success, bloated by risk-managers and legal departments in hospitals. “Now, people have expanded them to the point where they are too burdensome, and expanded them to the point where front-line workers don’t find them helpful.” Worse still, “If they are too burdensome, people won’t use them,” he said. “Or they will just say they are using them, document they are using them, and not use them.”

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