Thursday, January 14, 2010

It Can't Be That Easy

The Checklist Manifesto: How to Get Things Right, by Atul Gawande, is a very short little book about how surgery around the world--in America's best hospitals and the Third World's most overworked--can have improved outcomes with a simple checklist. The frame of the book is the WHO's committee on improving surgery outcomes, given the fact that even simple surgery is statistically more dangerous than it needs to be.

It's such a simple argument, based around two points. 1) Some things are so complex that even the smartest, most talented, best trained people make silly mistakes, because there's so much to hold in your mind at every key moment. 2) Most things (like surgery) are done by a team, but teamwork is often not adequate to meet the group's needs. It's amazingly easy to establish a baseline level of teamwork with a simple, three minute introduction and briefing session before people work together.

That's the book, basically. There are interesting anecdotes about places where checklists are used successfully. (Pilots use huge numbers of checklists, and they make a remarkable difference.) You also get guidelines on putting together a good checklist. (It should be short. It should include things that need to be done and things that need to be communicated. The "pause point," where you stop to use your checklist, should be made explicit.) You get great anecdotes from different fields about places where the checklist can actually make a difference.

In general, this short book is an intriguing read. The thing that really sticks with me, though, and that I'm most glad to have read, is the author's analysis of complexity. Things can be simple, complicated, or complex. He gives examples: simple is making dinner--a few ingredients, a few steps, a few basic skills. Complicated is building a rocket to fly to the moon--lots of in-depth knowledge, lots of working parts that go together and areas of expertise. But once you've built it, you know how to do it and can do it again. The physics is there, and with all the ingredients, steps, and skills, it can be done.

Complex is raising a child. Each one is slightly different. There are no rules or laws, and there are things that affect the outcome that you have no idea are part of the project. You can do the same exact thing with two different children and get different outcomes. It can't be sufficiently broken down. Surgery, he points out, is complex. Two patients going into the same surgery, treated with the same level of skill, can have different outcomes. Their bodies are different; the differences in the surgery itself that will affect the outcome can be so subtle as to be unidentifiable. It's complex.

I can't quite explain why this discussion--why the very idea that skilled, talented surgeons need a checklist, need to run through their to-do list--affects me so strongly. I think it might be that I feel exonerated for a lot of my own failures. I'm a bright person, and when I make "stupid" mistakes, I feel like I'm failing on a really deep level. I should be able to do this, to remember that, to handle it. Sometimes, though, it's really complex. Even the best minds need help. I'm doing okay.

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