Memorable quotes
The first is ignorance–we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude–because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses.
This is nowhere more clear than with the illnesses that befell us. We knew little about what caused them or what could be done to remedy them. But sometime over the last several decades–and it is only over the last several decades–science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.
Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result so has our struggle to deliver on them.
If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.
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.
Medicine has become the art of managing extreme complexity–and a test of whether such complexity can, in fact, be humanly mastered.
There is perhaps no field that has taken specialization further than surgery. Think of the operating room as a particularly aggressive intensive care unit. We have anesthesiologists just to handle pain control and patient stability, and even they have divided into subcategories. There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists. You really can’t do everything anymore.
Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually–the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year–more than three times the number of road traffic fatalities.
Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.”
Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. Multiple fields, in other words, have become too much airplane.
Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. You wouldn’t think it would make that much difference. But with the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident.
Two professors who study the science of complexity–Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto–have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex.
- Simple problems, they note, are ones like baking a cake from a mix.
- Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems.
- Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out.
Joe Salvia had earlier told me that the major advance in the science of construction over the last few decades has been the perfection of tracking and communication. But only now did I understand what he meant.
It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.
The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience.
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures–perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them.
It has come from finger-wagging health officials, who are regarded by surgeons as more or less the enemy, or from jug-eared hospital safety officers, who are about as beloved as the playground safety patrol. Sometimes it is the chief of surgery who brings it in, which means we complain under our breath rather than raise a holy tirade. But it is regarded as an irritation, as interference on our terrain. This is my patient. This is my operating room. And the way I carry out an operation is my business and my responsibility. So who do these people think they are, telling me what to do?
Good checklists could become as important for doctors and nurses as good stethoscopes (which, unlike checklists, have never been proved to make a difference in patient care). The hard question–still unanswered–is whether medical culture can seize the opportunity.
But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.
We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us–those we aspire to be–handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.
The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize where one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire.
Discipline is hard–harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.
We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.
We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber–a machine so complex no one was sure human beings could fly it. They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist.