Tag Archives: complexity

What Did We Miss? What Did We Forget? – Dr. Gawande Keeps Reminding Us Of Our Fallibility

Things were simpler when we knew less.

As I think about the books I have read, and especially the books I have presented, I always ask myself:  “what is the best book of the whole lot?”  I have presented synopses of a minimum of one business book a month for over 12 years.  There are some really good books:  books that have important lessons and principles to teach us, books that are good-to-great reads.  (By the way, I’m back to my old favorite as my “favorite” book of the 12+ years:  The Creative Habit by Twyla Tharp).  But, I am increasingly  convinced that the most important book I have read in this span is The Checklist Manifesto by Atul Gawande.

On the New Yorker website, you can read Dr. Gawande’s commencement speech which he delivered to Stanford’s School of Medicine: The Velluvial Matrix.  It includes numerous reminders of the core truth from The Checklist Manifesto.  Here’s the key paragraph from the book:

Every day there is more and more to manage and get right and learn.  And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it.
It is not clear how we could produce substantially more expertise than we already have.  Yet our failures remain frequent.  They persist despite remarkable individual ability.
(our) know-how is often unmanageable.  Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government.  And the reason is increasingly evident:  the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.  Knowledge has both saved us and burdened us.
That means we need a different strategy for overcoming failure…

In this speech, Dr. Gawande tells the story of a many who had his spleen removed.  The doctors who removed it did a great, remarkable job of saving his life under difficult circumstances.  A medical team rallied, pulled their diverse and comprehensive knowledge together, and performed a series of life-saving procedures successfully that saved the man’s life.  But…  they forgot something – something rather important..

Here’s the story:

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

In his work, his book, this speech, Dr. Gawande reveals the crisis of the era:

“What did we miss?  What did we forget?”

Because, the more we know, the more we have to “remember,” the greater the chance that we will not remember it all. And, thus, warning signs are missed.  And preventative steps are not taken.  (anybody heard of the Gulf Oil disaster?!)

The Checklist Manifesto is Dr. Gawande’s suggested solution — for medicine, for construction, for aviation…for every conceivable kind of job that requires mastering an array of complex elements.  Which is, by the way, every job!

So, here are two questions to add to your daily routine:

“What am I missing?  What am I forgetting?”

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You can purchase my synopsis of The Checklist Manifesto, with audio + handout, at our companion web site, 15minutebusinessbooks.com.

Gawande’s The Checklist Manifesto – Its Primary Value

After this Friday, I will have presented synopses of well over 200 books over the last twelve years.  This includes books presented at the First Friday Book Synopsis, the Urban Engagement Book Club, and quite a few “special commission” presentations.  For a number of years, I said that The Creative Habit by Twyla Tharpe was the best book/my favorite book.  Then, I shifted that assessment to Outliers by Malcolm Gladwell.

My reasons for such a personal ranking are obviously quite subjective.  One reason is this – after reading those books, I kept thinking about them, a lot.  I remembered their stories, and I pondered their implications.  Both of them became part of my thinking, and I “built” on such thinking with other books – notably, Talent is Overrated by Geoff Colvin as the logical follow-up to Outliers (the 10,000 hours requires very serious practice discipline/”deliberate practice” to maximize those hours), and a number of books on innovation that seemed to make more sense when preceded by the thoughts in The Creative Habit.

Well, I may move The Checklist Manifesto to the top spot in my own little ranking system.

Why?

I think the more deeply I delved into The Checklist Manifesto, the more aware I became of just how big a challenge modern day complexity really presents.  The title of the book may be misleading:  “The Checklist Manifesto” makes it sound like a simple book – just create and use a checklist to get things done.  But it is born of a deeper issue – complexity.  For example, in the book Atul Gawande describes how for most of human history, a “Master Builder” would oversee all of the big building projects.  Today, with our 80 + story high-rises, there is no “Master Builder” who could possibly know enough to get such a building built as the Lone-Ranger type expert.

Here’s a revealing excerpt:

Every day there is more and more to manage and get right and learn.  And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it.
It is not clear how we could produce substantially more expertise than we already have.  Yet our failures remain frequent.  They persist despite remarkable individual ability.
(our) know-how is often unmanageable.  Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government.  And the reason is increasingly evident:  the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.  Knowledge has both saved us and burdened us.
That means we need a different strategy for overcoming failure…

In other words, it is not the solution of the checklist that has most intrigued me about this book, although I think I am a true convert to his solution.  His case is absolutely compelling.  But it is his diagnosis that makes it so valuable.  And, this is no surprise – Gawande is a surgeon, and proper diagnosis is sort of critical in the process of successful surgery.

Recently, I mentioned a book entitled How to Read Slowly.  Let me recommend that you put The Checklist Manifesto on your reading list – and carve out a time to read it slowly.  I think it is that valuable.