What to trust in a 'post-truth' world

By Dr. Atul Gawande. This book can be found here. Dr. Atul shows the benefits of a simple checklist against the complexity of our lives.

Summary

Introduction

Three types of failures:

  1. Task itself is impossible
  2. failure due to ignorance
  3. failure due to ineptitude

Problem of extreme complexity

We are living in a world of super specialization. Even then there are mistakes committed due to extremely complex procedures and scenarios, especially in medicine.

The checklist

  1. our world/fields today have become too complex to be put into our memory
  2. example of WWII Boeing model 299 plane: Too complex for one pilot. But with a simple checklist the pilots were able to fly without accident
  3. two ways one fails in a complex environment: failure to remember steps - its easy to miss mundane steps when there are more pressing events at hand. Easy to convince ourselves to skip a simple step
  4. checklists are a way to discipline ourselves into following these steps
  5. they also help in our memory recall especially while under pressure

End of the master builder

Checklists are a cognitive net against our inherent flaws in memory, attention and thoroughness. 3 types of problems:

  1. simple: Like preparing a dish. Once a recipe is prepared that's good enough
  2. complicated: Like building rocket. Can be broken down into series of simple problems. But there are unforeseen issues even for the experienced.
  3. complex: Like raising a child. Experience in raising one's child well may not guarantee success with another. There's no recipe!
  4. master builder era is long gone. The complexity in today's world is too much for one guy to manage and track. The idea is to have experts in multiple sub-specializations manage individual problems. But the crucial aspect is that those experts need to get together to resolve any unexpected scenarios or issues that span across multiple specializations. Man is fallible not men less so! Fine example to this is the construction industry

The idea

In case of routine tasks and problems, we need a central authority who dictates what needs to be done to their subordinates. In case of complex, unforeseen circumstances, this power needs to be as far away from the center as possible. Best example was 2005's Katrina hurricane. Where government wasn't still sure who should provide help to stranded citizens, Walmart had supplied loads of help already. This worked because Walmart decentralized the power away from center to the local employees in wake of this incident. Under very complex scenarios decentralization of power is the right approach. Under cases of extreme complexity, which is behind anyone persons' capacity, we need to decentralize power and distribute it to respective front-lines.

The first try

The author recounts his experience while consulting for WHO regarding surgical safety procedures world wide. Describes various hospitals trying to implement checklists during surgery. And the importance of communication between the OR group. The author tries to give such a checklist a try in his own hospital. Also mentions a peculiar (yet intuitive) study where just by knowing the names of the members in a group increased the communication in it. But because of ambiguities and the length of the checklist, they had to stop using it!

The checklist factory

There are 2 kinds of checklists:

  1. bad ones - very long, detailed, treat people as dumb and list out every steps
  2. good ones - very short and precise, only list the most critical steps

But checklists can't make people to follow them!

  1. READ-DO checklist - people read items off the checklist, execute them and then tick them off
  2. DO-CONFIRM checklist - everyone executes a few steps from their memory and then pauses to confirm whether all items from the list have been executed or not.

A good checklist typically contains about 5 to 9 items. Most importantly the checklist should be tested out in real world, at least once, before deploying it widely!!

The test

Keeping the list minimal is the biggest challenge:

  1. prune too many items, checklist could be too short to be effective in preventing errors
  2. keep too many items, people hate to follow long lists

There's a delicate balance between brevity and effectiveness

Hero in the age of checklists

Its just not about ticking-off items in checklist, it is about teamwork. Even these checklists have found to be very useful in other fields like investing. But very few have become the fan of checklists, despite their proven checklists! We still think that people who follow their intuition are heroes and are real men!

The fear people have on checklists is rigidity:

  1. they think checklists will make them mindless automatons
  2. but in reality its the opposite!
  3. checklists take the routine (but important) stuffs off the brain's working memory
  4. thus checklists will enable us in our fields

Heroes in today's world are those who

  1. know when to improvise and when not to
  2. understand the importance of teamwork
  3. know how to work in today's complex environments

Checklists must aid, not hinder. We are meant to be for excitement and novelty. Never to give attention to details and be disciplined. That's where checklists come to help us. Under the complexity of today's world we have nothing else left but to try checklists!

The save

Interesting story of an operation where the author accidentally tore the patient's vena-cava. But due to checklist they followed and worked as a team they were able to atleast save the patient.