New York surgeon and writer Atul Gawande says the most effective way to organize and act on complex knowledge may be something as simple as a well-enforced checklist.
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Atul Gawande: Yeah, I mean, I wrote a whole book on checklists. You'd be -- you know, why in the world would anybody write a whole book on checklists? And it was the last thing I thought I would be writing about. But I've been fascinated by how we grapple with risk and complexity in medicine, and I got assigned a project to try to find a way to reduce deaths in surgery. We have been struggling with our performance, and so I started looking at how people in other fields grapple with the enormously increasing complexity that people in professional worlds are dealing with. And what I found was -- in aviation, in skyscraper building and other lines of work -- that there was something really fundamental going on; we had transformed from a world where ignorance was our biggest struggle as human beings -- this is the way it was for millennia; we didn't understand why the human body fails, how to build things really well, how to do many, many kinds of tasks in the right way; that knowledge was missing. Today, however, our biggest struggle is with what people call ineptitude, meaning the knowledge is there, but somebody's not doing it right. And in surgery, in other parts of medicine, what we're finding is that the amount of knowledge, the volume, the complexity, the tons of papers coming across the transom, the technologies that are proliferating -- that all of it has exceeded our abilities as individuals to hold it all in our head and do it right. And there are lots of fields, it turns out, where this has been happening: constructing buildings well, making good investment decisions with our hedge funds. And when I looked to see how people who actually are solving these problems were solving it, I thought you'd find that they had just trained in a different way, or they were training longer and harder, or they had a different kind of use of technology. Instead, what I found over and over again was, they used checklists, as simple and mundane as it sounds; that the checklists in a way filled in for weaknesses in people's brains, things that they forgot. It also filled in for weaknesses in making teams work. Teams constantly drop stuff between the cracks, and so we made a checklist based on what I learned. Actually, I got folks from Boeing to help us out. How do you make a checklist? I didn't think that that would be all that hard. It turned out to be hard. And one of the things they showed us was how to really focus on making it swift and usable. We made a two-minute surgery checklist; it had just 19 items. Some of them were just make sure you don't forget dumb stuff: make sure you gave antibiotics, make sure you have blood ready for a high-blood-loss case. And then there were other interesting parts: make sure everybody in the room has been introduced by name and role; make sure the surgeon actually explained to the team what their goals for the operation are; make sure the anesthesiologist and nurses had a chance to explain their plans for the operation. We put that checklist in eight hospitals around the world, ranging from rural Tanzania to Toronto and Seattle, and every single hospital we put it in had a double-digit reduction in complications. The average reduction in death was 46 percent. That made me realize there was something much deeper and more important going on here about this set of problems we're grappling with in the modern world. Well, on the one hand, you'd say zero percent. When you look at -- we have about 13,000 diagnoses we've recognized the human body to have. We have 6,000 drugs, 4,000 different kinds of medical and surgical procedures, and we know for each of them there's anywhere from half a dozen to many dozen steps that we should make sure are done correctly. And we just rely on human memory, the person in the office that you go to, to just remember what that stuff is. And we drop stuff all the time. A friend of mine went in for depression; she was just becoming really low. The doctor put her on an
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