Lists. Shopping lists, laundry list, to do lists. They’re some of the most boring things in the world. But lists are also one of the most powerful tools we have for dealing with the ever multiplying complexities of modern life.
The Brooklyn born son of two Indian American physicians, Gawande is a surgeon at a top Boston hospital, an associate professor at Harvard in both medicine and public health, a Rhodes Scholar, a MacArthur fellow, director of a World Health Organization medical program, and somewhere in there he found time to get married and have children. <g>
TCM belongs to the fairly new non-fiction subgenre that uses science and really good writing to examine a narrow topic and give readers interesting new insights. The books tend to be quite short, so you can read them quickly and come away feeling virtuous, entertained, and better informed. While such books may be criticized for being simplistic, they’re still fun to read.
Godfather of this mini-genre is Malcolm Gladwell, author of the bestselling books The Tipping Point, (about the “social epidemics” that create sudden change, Blink (the complex judgments that go into quick decisions), and Outliers, (about factors that help people really excel.)
Gawande’s thesis is that some errors stem from ignorance—we simply don’t know enough about a particular topic. But many others stem from not properly using what we do know because the sheer volume of information is so overwhelming. The subtitle of The Checklist Manifesto is How To Get Things Right.
Hence, checklists to ensure that all the critical steps are taken, and in the right order. In hospitals and surgery, one of the top items is washing hands to prevent the spread of infection. Everyone knows this needs to be done, but far too often, busyness or inconvenience interfere with basic hygiene, hands don’t get washed, and potentially lethal diseases are spread.
Gawande’s writing really reeled me in. It’s witty, accessible, and full of human stories. (It's that staff writer for The New Yorker thing.)
As a doctor and surgeon, he deals with complicated medical procedures all the time, and knows how easily critical steps can be missed. He starts with the gripping story of a little girl who spent half an hour in an icy pond in Austria. She was pulled out pulseless and essentially dead, yet enormously complicated procedures over several weeks saved her life. And this was done not at one of the world’s famous medical centers, but an average rural Austrian hospital.
That’s the spring board Gawande uses for a wide ranging discussion that goes from medicine to aviation to building skyscrapers. The spine of the book is the author's part in developing checklists to improve operating room outcomes all over world. Think of the challenge to develop checklists that will benefit hospitals from the West’s best to third world institutions that are desperately short of supplies and personnel! Watching that operating room list being developed was fascinating.
Gawande's research into improving outcomes takes him to one area where checklists are really well established: aviation. In 1935, the prototype of the B-17 Flying Fortress bomber crashed during a competition for the army because the highly experienced pilot had so many things to remember that he forgot to release the lock on the elevator and rudder controls.
Two men died, including the pilot. It was thought that the aircraft might too complicated to be flown, even with experienced pilots.
But the military wasn’t about to give up a great airplane without trying to solve the complexity problem. The solution was a checklist, and they’ve become mainstays of aviation at all levels. (I think that even Han Solo and Chewbacca used checklists when flying the Millennium Falcon.)
TCM has a whole riveting chapter on the “miracle on the Hudson,” when a USAirways jet was landed on the Hudson River with no casualties after the engines were knocked out by a flock of geese. The pilot, “Sully” Sullenberger was considered merely modest when he said that that the fortunate outcome was a result of teamwork, but as Gawande shows, it truly was a team effort—and checklists had a lot to do with the miraculous results.
Effective checklists have to be short enough that they won’t be ignored, and they have to hit the salient points, which means a lot of experimentation. I loved reading about how Gawande and his team devised checklists for operating theaters and the adjustments that were made after testing.
The bottom line on The Checklist Manifest is that A) checklists can be incredibly valuable, and B) people often hate to use them. A successful investor on Wall Street uses a checklist when evaluating potential buys, and does very well. He’s made his list widely available, but virtually no one else uses it. There is something about the boring routine of checklists that makes it easy for attention to wander. Some people feel checklists crush creativity and intuition, and they’re boring.
Plus, experts who have spent years developing their skills don’t like to be told that they might miss a crucial step. That’s why implementing the surgical checklists had to be a team effort. Some of the surgeons surveyed sneered at the idea that checklists were needed in THEIR operating rooms.
Yet tellingly, when the same surgeons were asked if they would want checklists used if they themselves were being operated on, 93% said yes. Because the checklists work.
Gawande ends the book with an example of an operation he performed when he knows with absolute certainty that the checklist saved the life of one of his patients. The point involved seemed so unnecessary that it was almost skipped, but Gawande and his team followed their own rules, and a life was saved.
The book got me thinking about checklists in daily life. When I was the art editor of a small magazine in England in the old-fashioned days of paste-ups, every page had a checklist of items that must be looked at—headers, page numbers, photographs, etc. A friend of mine always uses checklists when evaluating autistic children.
Heck, a recipe is a form of checklist. Checklists can be really useful when packing for a journey so you don’t end up in Moscow with no winter coat. (And yes, I know an absent-minded professor who did this because it wasn’t cold at home when he left. <G>)
So how do you feel about checklists as a tool of managing life’s complications? Do you work in a field that uses them? Do you think you might profitably apply them in some area of private life?