Atul Gawande on why heroes use checklists

The sound track for yesterday’s run was a compelling talk by Atul Gawande about his new book The Checklist Manifesto, which grew from an article in the New Yorker. Although his story is grounded in the practice of health care, the lessons apply much more broadly to every field in which we grapple with complexity.

For most of human history, he argues, we were limited by lack of knowledge. We just didn’t know how to do things right. Now that knowledge is abundant the enemy is no longer ignorance but rather ineptitude — the failure to marshal and apply what we know.

The surprising thing Atul Gawande learned, and now passionately conveys, is that simple checklists turn out to be extraordinarily powerful tools for marshalling knowledge and for ensuring its correct use.

The biggest roadblock is pushback from highly-trained experts who are offended by the idea. After 8 years of medical school, and in a regime that already demands vast amounts of paperwork, why should a doctor have to check off basic items on a list? Because we are fallible in the face of complexity, Gawande says, and because checklists work. Although he led research in this area he was skeptical about adopting checklists in his own operating rooms. But when he did, he made two critical discoveries. First, well-made checklists are easy to use. Second, they almost always caught errors.

Most of those errors turned out to be non-critical. Only a few of the catches saved lives. That alone, of course, is enough reason to adopt checklist discipline. But it was shocking for the medical teams to discover that simple and basic procedures, which they thought were being carried out with 100% fidelity, in fact weren’t.

We are willing to tolerate failure when it results from unavoidable ignorance, Gawande says. If we really don’t know how to cure a disease, then OK. You tried your best, you failed, that’s how it is. But if we do know, and screw up, that’s unforgivable. What do you mean she died because somebody forgot to administer the antibiotic, or to wash his hands? Unacceptable.

The struggle with complexity I know best happens in the realm of software. What do our checklists look like? One obvious form is the test suite. If my software keeps passing its tests as I evolve it, there’s still plenty that can and will go wrong, but at least I know it still does what the tests say it does. Once, recently, I deployed a version of the service I’m building that failed in a way my tests would have caught. How did that happen? I was so sure I hadn’t changed anything that the tests would catch that I didn’t bother to rerun them. That’s an unforgivable lapse of discipline I don’t plan to repeat.

But software tests aren’t really the sort of checklist that Gawande writes and speaks about. Here’s something closer to what he means: Best practices in web development with Python and Django. That list comes from Christopher Groskopf, a web developer at the Chicago Tribune, who writes:

In our fast-paced environment there is little justification for being confused when it could have been avoided by simply writing it down.

We need to recognize and honor this kind of work. It is unsexy but heroic, and I use that word deliberately. The power of the checklist discipline, Gawande says, should prompt us to rethink our definition of heroism. Consider Capt. Chesley “Sully” Sullenberger:

It was fascinating to watch people responding to the miracle on the Hudson. All of us, staring in amazement, thinking what a hero he was. But none of us willing to listen to what he really was saying. He kept saying it wasn’t flight ability, but instead adherence to discipline, and teamwork. But it was as if we couldn’t process what he was trying to tell us.

Because there were checklists, and because everybody used them, Sully could rise above the dumb stuff and focus on the one key decision for which human judgement was required. The heroic part of that flight was not the flight ability of Capt. Sullenberger, it was the willingness of the entire team — including the flight attendants, who then acted through their protocols to get the passengers off that plane in three minutes — to acknowledge their fallibility, admit that they could fail by relying only on training and memory, and exercise the discipline to overcome that fallibility.

The talk raises important questions for practitioners in every field. What makes checklists easy to use? What makes them effective? In the realm of software, we have plenty of examples to look at: django, WordPress, C#, ASP.NET, etc. It might be fruitful to explore these, merge similar lists, and codify stylistic patterns that can govern all such lists.