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Help for Medical Glitches, Investor Cocaine Brain: Interview

Dr. Atul Gawande.
Dr. Atul Gawande. "The Checklist Manifesto: How to Get Things Right" offers Gawande's low-tech, list-making solutions to everyday workplace situations. Photographer: Fred Field/Henry Holt and Company via Bloomberg

March 29 (Bloomberg) -- As the global rates of surgery grew, so did the damage: A million patients a year died during medical procedures and more than 7 million were left disabled. The World Health Organization turned to Dr. Atul Gawande to come up with a low-cost solution.

He developed a pre-operation checklist, which the WHO tried out in eight hospitals with remarkable results. Deaths fell 47 percent, while complications dropped by more than a third. It didn’t matter how high-tech or how poor the hospital was -- the results were significant across the board.

In his latest book, “The Checklist Manifesto: How to Get Things Right,” surgeon and MacArthur Award winner Gawande argues that the complexity that now characterizes many fields, ranging from architecture to venture capitalism, can be tamed with a humble tool.

We spoke in a French cafe in New York’s Chelsea district.

Lundborg: How does a simple checklist help manage complexity?

Gawande: In medicine, we’re overwhelmed by the volume of knowledge and information we have to handle. A checklist fills in for weaknesses in our brains, like memory, and helps us work more successfully as teams.

Lundborg: Why does the checklist have such a bad rap?

Gawande: One is sheer embarrassment -- if you’re an expert, you’re better than that. It’s thought to dumb things down rather than being about the nuance.

Plus a lot of us hate following instructions. We’ve had experiences where it can get in the way, where the rigidity of rules makes for bad results.

Good Checklist

Lundborg: What’s a good checklist?

Gawande: This is where science comes in to it. A good checklist actually improves the ability of an expert to do a job well. It has to be tested in the real world with feedback from the people on the front lines.

When it works, it helps performance without any improvement in skill.

Lundborg: In the financial world, how does the checklist counter “greed mode” and “cocaine brain?”

Gawande: A group of investors studied mistakes, saw the recurrent patterns and devised a series of checks at certain pause points along the way.

Making an accurate assessment of the margin of safety is crucial. You are so sure you’ve got a winner -- you’re working against everything your brain is screaming at you about how fantastic this will be -- that you start to disregard risk or cut corners.

Lundborg: Clearly, not many in the financial industry were using checklists.

Gawande: The kinds of mistakes you will never prevent with a checklist are of values: if you know it and still do it, a checklist can’t stop that.


Lundborg: Does the checklist function differently in an emergency, such as when Sully Sullenberger successfully landed his plane in the Hudson?

Gawande: We wanted to say it was the heroism of the individual. He responded by saying it was about adherence to protocol and teamwork, so we said he was just being modest.

When the engines went out, he could count on the co-pilot to run through the checks, so he could focus on the one key thing that couldn’t be reduced to a checklist, “Where am I going to land this plane?”

Lundborg: In your New Yorker article on expensive health care in McAllen, Texas, you showed what happens when the patient is regarded as a profit center. What response did you get?

Gawande: I’ve never had an article so widely read. There is a battle in the culture of medicine between a desire to run a successful business and the recognition that the patient’s needs have to come first over any kind of business requirement.

Cost Factor

We have a health system where doing great at the medical business is not necessarily what is great for patients. The most damning thing about the costs of our system is that the doctors who get the best results are not the ones who are the most expensive. Often they are the least expensive.

Lundborg: So what can we do?

Gawande: We know that the existing way of paying doctors is both inflationary and unsuccessful for the best health of patients. We’re in a period of needing to undergo a series of experiments.

Do you pay doctors a salary? Do you pay a hospital a bundled rate for all the patients they take care of in a year? Do you pay a single price for asthma patients?

Lundborg: Doctors used to be gods. How are they faring during all this turmoil?


Gawande: Physicians are demoralized in many ways. We point to bureaucracy, battles with insurance and government, as well as changing expectations.

But what doctors are really responding to is the complexity of medicine. Starting a process involves multiple people, systems of care, and you are one part of that machine. We are not used to learning how to be leaders or teammates in the context of larger organizations.

We find it hard to grapple in this world where the enormous volume of information and knowledge exceeds our own abilities.

“The Checklist Manifesto” is published by Metropolitan Books (209 pages, $24.50). To buy the book in North America, click here.

(Zinta Lundborg is a writer for Bloomberg News. The opinions expressed are her own. This interview was adapted from a longer conversation.)

To contact the reporter on this story: Zinta Lundborg in New York

To contact the editor responsible for this story: Manuela Hoelterhoff at

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