Computers take numerous tasks off our hands – such as tasks of calculation, processing, storage, and transmission; and technology undoubtedly increases our capabilities, accepts Atul Gawande in ‘The Checklist Manifesto: How to get things right’ (www.henryholt.com). “But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building, perform a lifesaving operation,” he adds.
In many ways, technology has complicated these matters, by adding yet another element of complexity to the systems we depend on and giving us entirely new kinds of failure to contend with, feels Gawande.
He rues that a key characteristic of modern life is our dependence on systems – on assemblages of people or technologies or both, and that among our most profound difficulties is the making of these assemblages work! “In medicine, for instance, if I want my patients to receive the best care possible, not only must I do a good job but a whole collection of diverse components have to somehow mesh together effectively.”
The author, a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston, sees meaning in the analogy of car for health care. For, “In both cases, having great components is not enough.”
Anyone who understands systems will know immediately that optimising parts is not a good route to system excellence, reads an insightful quote of Donald Berwick, president of the Institute for Healthcare Improvement in Boston, cited in the book.
A famous thought experiment that Berwick speaks of is the idea of trying to build the world’s greatest car by assembling the world’s greatest car parts. “We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. ‘What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.’”
The trick, therefore, is to study our routine failures – be they in teaching, law, government programmes, or finance – look for patterns of our recurrent mistakes, and then devise potential solutions, rather than trying harder and harder to catch problems and clean up after them, argues Gawande.
An interesting discussion in the book is about ‘professionalism.’ Studying the definitions of the word, stated or just understood, in learned occupations, the author finds three common elements.
First is an expectation of selflessness, that we who accept responsibility for others – whether as doctors, lawyers, teachers, public authorities, soldiers, or pilots – will place the needs and concerns of those who depend on us above our own, he begins.
Next is the expectation of skill, that the professional will aim for excellence in his or her knowledge and expertise; and third is an expectation of trustworthiness, that the professionals will be responsible in their personal behaviour towards their clients.
Digging deeper, Gawande discovers that aviators add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. “This is a concept almost entirely outside the lexicon of most professionals, including my own. In medicine, we hold up ‘autonomy’ as a professional lodestar, a principle that stands in direct opposition to discipline.”
In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for, the author urges. “What is needed isn’t just that people working together are nice to each other. It is discipline.”
Discipline is hard – harder than trustworthiness and skill and perhaps even than selflessness, he concedes. “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 for.”
Imperative addition to your reading list.
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