Thomas H. Jones, MD
Neurosurgeon and
Medical Director
Santa Barbara
Neuroscience Institute


Dear Colleagues,


As Atul Gawande, a general surgeon and bestselling author, stated in his recent book The Checklist Manifesto, “medicine has become the art of managing extreme complexity.” To date, we seem to be struggling with that task.


A study of the Harvard Vanguard clinic’s medical records, over the course of a year, discovered that their physicians, on average, dealt with 250 different primary diseases/conditions and these

same physicians’ patients had more than 900 other active medical problems that had to be factored into their care algorithms. These physicians prescribed 300 different medications. They ordered over a hundred different laboratory tests and performed more than forty types of procedures. In addition, the study points out that existing EMR software programs haven’t evolved quickly enough to keep up with the, almost exponentially, growing diagnostic categories. Consequently, one of the most common daily diagnoses was “Other.” The ICD-9 Book currently lists 13,600 diagnoses.


To underscore the level of complexity of care in the ICU setting, Dr. Gawande refers to a 15-year-old Israeli study that discovered that the average ICU patient required 178 nurse and / or physician actions per day. He reminds us that there was only a 1 percent error in these activities. However, this still amounted to 2 errors per patient per day. Studies show



•    Director's Letter
•    In-Flight Stroke Care
•    Brain Metastases
•    Obstructive Sleep Apnea
•    CFIT
•    TBI Monitoring
  Syringomyelia Treatment
  2010 Saving the Brain Symposium

>> Download PDF


that half of ICU patients experience a serious, often life-threatening, complication. Surgical outcomes seem even more alarming. Of the 50 million operations performed in America annually, the death rate approaches 150,000 per year. This is three times the death rate on our roads! The literature suggests that at least half of these peri-operative deaths and major complications could be avoided. 


In summary, it appears clear that the quality of our care, its growing complexity and cost are all inextricably linked. I believe that we have passed the inflection point and should abandon the disjointed, largely heuristic medical model of the 19th century. Dr. Gawande refers to this as our entering the B-17 phase of medicine. He summarized this beautifully in “The Velluvial Matrix,” his recent address to the graduating class of Stanford Medical School (posted June 16, 2010, at “Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce better service and results for people at the lowest cost for society.”




Tom Jones, MD