The Checklist Manifesto

While I was writing my other post The Power of Checklists OR I Don’t Care How Many Years You Went to School, You Still Have to Follow the Process I was trying to learn more about Gawande’s view on checklists. So I started rereading The Checklist Manifesto. In the introduction of the book, he actually writes an actual manifesto which I’ll try to summarize here — quoting liberally.

In the 1970s, Samuel Gorovitz and Alasdair MacIntyre published a short essay called “Toward a Theory of Medical Fallibility” where they looked at the different ways that doctors fail. They broke it down into two categories: ignorance (not knowing something) and ineptitude (not able to do something well that you knew how to do).

First, let’s look at ignorance:

I was struck by how greatly the balance of ignorance and ineptitude has shifted. For nearly all of history, people’s lives have been governed primarily by ignorance. This was 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.

Consider heart attacks. Even as recently as the 1950s, we had little idea of how to prevent or treat them. We didn’t know, for example, about the danger of high blood pressure, and had we been aware of it we wouldn’t have known what to do about it. The first safe medication to treat hypertension was not developed and conclusively demonstrated to prevent disease until the 1960s. We didn’t know about the role of cholesterol, either, or genetics or smoking or diabetes.

Furthermore, if someone had a heart attack, we had little idea of how to treat it. We’d give some morphine for the pain, perhaps some oxygen, and put the patient on strict bed rest for weeks—patients weren’t even permitted to get up and go to the bathroom for fear of stressing their damaged hearts. Then everyone would pray and cross their fingers and hope the patient would make it out of the hospital to spend the rest of his or her life at home as a cardiac cripple.

But now we’ve conquered a good portion of ignorance — and greatly increasing the amount of ineptitude:

But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly. Just making the right treatment choice among the many options for a heart attack patient can be difficult, even for expert clinicians. Furthermore, whatever the chosen treatment, each involves abundant complexities and pitfalls. Careful studies have shown, for example, that heart attack patients undergoing cardiac balloon therapy should have it done within ninety minutes of arrival at a hospital. After that, survival falls off sharply. In practical terms this means that, within ninety minutes, medical teams must complete all their testing for every patient who turns up in an emergency room with chest pain, make a correct diagnosis and plan, discuss the decision with the patient, obtain his or her agreement to proceed, confirm there are no allergies or medical problems that have to be accounted for, ready a cath lab and team, transport the patient, and get started.

What is the likelihood that all this will actually occur within ninety minutes in an average hospital? In 2006, it was less than 50 percent.

And this goes beyond medicine:

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. You see it in the frequent mistakes authorities make when hurricanes or tornadoes or other disasters hit. You see it in the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screw ups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge.

Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. 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. What do you mean half of heart attack patients don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors? It is not for nothing that the philosophers gave these failures so unmerciful a name —ineptitude. Those on the receiving end use other words, like negligence or even heartlessness….

The capability of individuals is not proving to be our primary difficulty, whether in medicine or elsewhere. Far from it. Training in most fields is longer and more intense than ever. People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own—whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves. 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.

And then we get to the manifesto itself:

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things.

Nonetheless, that 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, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.

It is a checklist.

Questions OR Rosencrantz and Guildenstern at 40

Yale has a wonderful writing class called Daily Themes. This class has been taught at Yale for over 100 years and requires students to write a story each day of about 500 words. I always wanted to take the class but never did. So I started to do some of the writing on my own based on the prompts my friend Aaron Gertler online from the 2015 class.  My favorite one so far is:

Create a conversation between two characters in which everything said on either side is in the form of a question and every question advances the conversation. Avoid rhetorical questions and repetitions.

I hadn’t realized this but the instructor had put in a link to Rosencrantz and Guildenstern’s “Questions” game — which was what popped into my head as well. With that preamble, I now give you…

Rosencrantz and Guildenstern at 40

How did we get here?

Weren’t we promised a happy and fulfilled life if we just gave our life to the company?

Isn’t that why we went to business school?

Wasn’t that the promise once we got out?

Do you feel likely we have climbed a giant mountain up through the clouds only to see more mountain?

Do you think we are at the top of the mountain and can finally see clearly?

Are we getting close to the end?

Do you feel like we are in that Tom Stoppard play “Rosencrantz and Guildenstern are Dead?”

Or maybe Godot?

So what do we do now?

Should we change our focus and get off the hedonic treadmill?

But what would we do then?

Don’t Zen monks talk about this problem?

Could we leverage some of that?

Why do you always have to talk in business speak?

Aren’t you afraid of death?

Aren’t we dying every minute?

Do you think that’s the secret – living completely in the moment?

Is there any other way?

Why don’t we treat every moment as our last by being fearless and vulnerable and not afraid to fail?

Are you saying failure is good?

How can you have anything valuable without failure?

What about love and courage and accomplishment?

Isn’t that what I’m saying?

Being OK With Uncertainty OR the Short and Tragic Life of Robert Peace

The Short and Tragic Life of Robert Peace (audible) is the amazing story of Robert Peace, a prodigy who grew up in inner city Newark, got into Yale, excelled there and ended up dead as a drug dealer back in Newark.

Robert Peace

It’s a journey into a world that I’ve never really known, except for the Yale section which seems pretty accurate. The author, Jeff Hobbs, Rob’s Yale roommate wrote this story mainly to understand what happened to Rob and to share it with others. After Rob’s funeral, many people saw this amazing man as just another drug dealer but Jeff started getting so many stories that he decided to write a book. Jeff does the most amazing job digging through the story. He interviews Rob’s drug dealer friends who were forbidden from attending the wedding. He interviewed Rob’s boss when he was a drug dealer. He interviewed Yale masters and deans. And he got a whole lot of material from Rob’s secret society friends who he’d told his life story.

What’s amazing is that as much as you’d like the author to give an answer, he doesn’t. It’s frustrating but makes it that much more worthwhile. It’s a book about listening, not talking. Jeff talks about not giving answers here:

Maria Popova talks about how rare it is to not give answers and live with uncertainty in the first of her 10 Learnings from 10 Years of Brain Pickings. She says that we live in a culture where people are pressured to have an opinion, even when they have no basis for that opinion. Because they’re uncomfortable saying “I don’t know,” they fake it and just regurgitate something they read or saw on TV. They don’t invest the time to truly have their own opinion because they don’t feel comfortable staying in that nebulous zone of uncertainty. But, she says, “It’s infinitely more rewarding to understand than to be right — even if that means changing your mind about a topic, an ideology, or, above all, yourself.” For a great little blog post on the value of uncertainty, read Maria’s musing on John Keats and “Negative Capability.”

If you want to see the opposite, take a look at this guy who thinks he has the answer. In one of the most jarring questions I’ve seen in a long time, he wants Jeff to comment on his theory that Rob Peace had a death wish. It’s clear that the questioner is not comfortable living with uncertainty.

Read the book and wallow in this unfamiliar space with wonderful characters, no answers and no heroes.

 

My Personal Contact Cards

About a year ago I made my own business cards. I wanted to have a personal expression of who I was rather than just me as an agent of a company. I wanted to make something I was proud of and made this:

It’s based on an Apple Store recruitment card which reads “Your customer service just now was exceptional. I work for the Apple Store and you’re exactly the kind of person we’d like to talk to. If you’re happy where you are, I’d never ask you to leave. But if you’re thinking about a change, give me a call. This could be the start of something great.”

Free Speech — A View From Yale

In the last few years, there’s been an increasingly polarizing discussion around freedom of speech and values in the US — especially on college campuses. It reminded me that in contrast to the he said / she said of political debate, Yale took a much more thoughtful view on the topic starting 4 decades ago.

Yale’s President Peter Salovey referenced these two issues in his freshman addresses of 2014: On Freedom of Expression at Yale and 2015: On Calhoun College. Most people haven’t dealt into these items so I’m summarizing them here.

The Press View vs. On The Ground — Yale Students As Separated As The Press Makes Them Out To Be

Two years ago, there was a big conversation at Yale around the treatment of people of color at Yale. Eventually this made it into the national news and from the news reports, you’d think that the campus had fractured irreparably into two sides — the free speech supporters and the protesters.

When I went to campus and asked people about this, the real situation was very different. Most people said that they didn’t realize a lot of the issues that people of color were having and they wanted to learn and listen more. The news narrative was about picking sides, the reality on campus was about coming together.

Freedom of Speech and The Woodward Report

Yale has been thinking about freedom of speech for decades. The ’60s were a very hard time on the Yale campus — with important (and sometimes destructive) protests and counter protests. In order to thoughtfully determine it’s policy on speech on campus, Yale looked to C. Vann Woodward, a professor of the American South to come up with a policy on how to deal with this issue. President Salovey summarizes the report in his freshman address in 2014. The full report makes for a dry, but fascinating read on how similar issues of freedom of speech and protest were 40 years ago. The key points of the report is highlighted in the initial quotes:

And though all the winds of doctrine were let loose to play upon the earth, so Truth be in the field, we do injuriously by licensing and prohibiting to misdoubt her strength. Let her and Falsehood grapple; who ever knew Truth put to the worse, in a free and open encounter.

John Milton, Areopagitica, 1644

If there is any principle of the Constitution that more imperatively calls for attachment than any other it is the principle of free thought – not free thought for those who agree with us but freedom for the thought that we hate.

Oliver Wendell Holmes, Jr., U.S. v. Schwimmer, 1928

Here are some major points from the work:

  1. The purpose of a university is to create knowledge: “The primary function of a university is to discover and disseminate knowledge by means of research and teaching. To fulfill this function a free interchange of ideas is necessary not only within its walls but with the world beyond as well. It follows that the university must do everything possible to ensure within it the fullest degree of intellectual freedom.”
  2. Value the pursuit of truth over consensus:  “For if a university is a place for knowledge, it is also a special kind of small society. Yet it is not primarily a fellowship, a club, a circle of friends, a replica of the civil society outside it. Without sacrificing its central purpose, it cannot make its primary and dominant value the fostering of friendship, solidarity, harmony, civility, or mutual respect. To be sure, these are important values; other institutions may properly assign them the highest, and not merely a subordinate priority; and a good university will seek and may in some significant measure attain these ends. But it will never let these values, important as they are, override its central purpose. “

Woodward also talks about doing all of this in a forum that avoids malice and gamesmanship. We all need to be searching for the truth together.

The Renaming of Monuments and Calhoun College

This one is even more interesting because we were able to watch it unfold at Yale. John Calhoun was most famous for the espousement of slavery as a positive good for black people.

To follow some of the key points, President Salovey formally started the discussion in his freshman address of 2015 titled Launching a difficult conversation where he laid out the key issues. In a surprise decision, Yale decided not to retain the name of Calhoun College because it didn’t want to whitewash history and avoid the american legacy of slavery. However, this caused quite an uproar on campus. While the notion to remember an age of slavery is important to education, having to live in a college named one of this country’s most famous racists does not drive forward the best values of the university.

So President Salovey convened a renaming committee. The committee eventually decided to rename Calhoun after creating a set of principles  on renaming. These principles point to the naming of buildings and monuments as representing the values of the university. The monuments we have represent cornerstones of our culture and become of a formal representation of “Who we are.” The key findings of the committee are:

  • There is a strong presumption against renaming a building on the basis of the values associated with its namesake. Such a renaming should be considered only in exceptional circumstances.
  • Principles to be considered:
    • Is a principal legacy of the namesake fundamentally at odds with the mission of the University?
    • Was the relevant principal legacy significantly contested in the time and place in which the namesake lived?
    • Did the University, at the time of a naming, honor a namesake for reasons that are fundamentally at odds with the mission of the University?
    • Does a building whose namesake has a principal legacy fundamentally at odds with the University’s mission, or which was named for reasons fundamentally at odds with the University’s mission, play a substantial role in forming community at the University?

Going Forward

When looking at freedom of speech there’s a lot to be learned from thoughtful deliberation that we don’t get in today’s national conversation.

The Epistemology of Google

e·pis·te·mol·o·gy — the theory of knowledge, 
especially with regard to its methods,
validity, and scope
— Google Definitions

“Daddy, what is the meaning of life?” says the child.

“It’s complicated,” says the dad.

“Why don’t you ask Google?”

Laugh if you will but the question makes perfect sense to kids. Google knows everything doesn’t it? “What’s the weather?,” “How do I get to San Francisco?”, and even  “Why is the sky blue?” The big question is: “What doesn’t Google know?” Or, stated another way, “What knowledge can’t we outsource to Google?”

Knowing Facts vs. Gaining Understanding

It really comes down to two different kinds of knowledge: knowing facts and gaining understanding. The Farnam Street blog has a good description of this  and there’s a great video of Richard Feynman explaining it.  In summary:

  • Knowing Facts. You know what something is called and what it looks like. This is the type of information that Google is very good at.
  • Gaining Understanding. Taking various bits of information and really making it your own? This is the type of thing that you can’t ask Google because it’s about changing who you are (i.e., learning).

One good way to know the difference is the difficulty of what you’re reading or watching. If you can read it quickly you’re probably reading for facts. Reading for understanding requires you to sit down at the foot of the author and realize that things may not make sense in the beginning. I think of true learning as fundamentally changing myself. Kind of like in the Terminator 2 movie where the T-1000 changes his shape in the face of adversity.

Knowing Facts

So what does Google know:

  • Define a word (like epistemology)?
  • What’s happening in the news?
  • Who starred in the princess bride?
  • When is Mothers Day?
  • How many teaspoons are in a tablespoon?

Rad Bradbury had a great section on knowing facts in Fahrenheit 451. The book is a metaphor on how books can be explosive with ideas. But the government can provide so many facts that people don’t have room for ideas:

“Give the people contests they win by remembering the words to more popular songs or the names of state capitals or how much corn Iowa grew last year. Cram them full of non-combustible data, chock them so damned full of ‘facts’ they feel stuffed, but absolutely ‘brilliant’ with information. Then they’ll feel they’re thinking, they’ll get a sense of motion without moving. And they’ll be happy, because facts of that sort don’t change.”

Filling in the Gaps

Data and facts can be useful but you need a framework to use them. William Poundstone has a great book on the topic called Head in the Clouds: Why Knowing Things Still Matters When Facts Are So Easy. Poundstone’s key point in the book is that Google can’t teach you what you need to Google. In order to do that, you need a framework of understanding.  Facts are like bricks in a wall of knowledge. There can be some gaps and the wall will maintain its structural integrity. But if we remove too many, you have bricks hanging in midair and the wall collapses.

Gaining Knowledge

Gaining knowledge is about more than gathering facts. The best guide to gaining knowledge is from How To Read A Book by Mortimer Adler and Charles van Doren. The book was written in 1940 and revised in 1972 and it holds up incredibly well. The key idea is that to read a book well, you don’t just read the words or learn the key points. You need to understand the knowledge inside that book and let it change you — which takes effort. For a summary of the key points, the Farnam Street blog does a good write up. But if you really want to learn from these guys, you really have to read the book.

In short, the book says that an engaged reader needs to ask the following questions:

  1. What type of book am I reading? What do I hope to gain by reading it?
  2. What is the author’s high level points / argument?
  3. How does the author make this argument? At this point you don’t agree or disagree with the author by bringing any predefined prejudices to the argument.
  4. After reading the whole argument, going back and asking “Is it true in whole or in part?”
  5. For the pieces that you find true, “What are you going to do about it and how does it change your world view?”

In Fahrenheit 451, Bradbury talks about what makes an engaged reader. These are the people the government is concerned about. As one of the rebels says, there are three things needed to engage with a book:

  1. Quality Information: “What does the word quality mean? To me it means texture. This book has pores. It has features. This book can go under the microscope. You’d find life under the glass, streaming past in infinite profusion. The more pores, the more truthfully recorded details of life per square inch you can get on a sheet of paper, the more `literary’ you are. That’s my definition, anyway. Telling detail. Fresh detail.”
  2. Leisure: “[When] you’re not driving a hundred miles an hour, at a clip where you can’t think of anything else but the danger, then you’re playing some game or sitting in some room where you can’t argue with the four wall televisor…. It tells you what to think and blasts it in. It must be, right. It seems so right. It rushes you on so quickly to its own conclusions your mind hasn’t time to protest, ‘What nonsense!'”
  3. Action: “The right to carry out actions based on what we learn from the inter-action of the first two. “

If this all sounds difficult, that’s the point. You can’t expect to have other people do your thinking for you. You need to pose questions and answer them. You need to argue with the author once you’ve understood him or her.

Why is this Important?

Google in many ways is like the world’s most awesome encyclopedia or your friend with a photographic memory who watches TV all the time. He’s  a great guy to have around but not someone you should trust with important decisions. In an age when you can type a few keystrokes and feel like you’re changing the world it’s hard to put in all that effort.

But getting back to the original question, the reason that Google can’t answer “What is the meaning of life?” is that it needs to be figured out by living. It’s a question that’s only answered by learning and discussion. Basically, it requires gaining knowledge throughout your life.

Amusing Ourselves to Death

One of my favorite books is Amusing Ourselves to Death by Neil Postman. 30 odd years ago Postman wrote about the transition from written media to visual (or now digital) media — at the time focusing on the move to radio and television from print. It holds up surprisingly well even as the move accelerates. Postman’s son wrote a great piece about how the book holds up after 30 years in the Guardian “My dad predicted Trump in 1985 – it’s not Orwell, he warned, it’s Brave New World. The ascent of Donald Trump has proved Neil Postman’s argument in Amusing Ourselves to Death was right.” The forward of the book is one of the most interesting pieces I’ve ever read so I’m reprinting it here:

We were keeping our eye on 1984. When the year came and the prophecy didn’t, thoughtful Americans sang softly in praise of themselves. The roots of liberal democracy had held. Wherever else the terror had happened, we, at least, had not been visited by Orwellian nightmares.But we had forgotten that alongside Orwell’s dark vision, there was another – slightly older, slightly less well known, equally chilling: Aldous Huxley’s Brave New World. Contrary to common belief even among the educated, Huxley and Orwell did not prophesy the same thing. Orwell warns that we will be overcome by an externally imposed oppression. But in Huxley’s vision, no Big Brother is required to deprive people of their autonomy, maturity and history. As he saw it, people will come to love their oppression, to adore the technologies that undo their capacities to think.

What Orwell feared were those who would ban books. What Huxley feared was that there would be no reason to ban a book, for there would be no one who wanted to read one. Orwell feared those who would deprive us of information. Huxley feared those who would give us so much that we would be reduced to passivity and egoism. Orwell feared that the truth would be concealed from us. Huxley feared the truth would be drowned in a sea of irrelevance. Orwell feared we would become a captive culture. Huxley feared we would become a trivial culture, preoccupied with some equivalent of the feelies, the orgy porgy, and the centrifugal bumblepuppy. As Huxley remarked in Brave New World Revisited, the civil libertarians and rationalists who are ever on the alert to oppose tyranny “failed to take into account man’s almost infinite appetite for distractions”. In 1984, Huxley added, people are controlled by inflicting pain. In Brave New World, they are controlled by inflicting pleasure. In short, Orwell feared that what we hate will ruin us. Huxley feared that what we love will ruin us.

This book is about the possibility that Huxley, not Orwell, was right.

Tips Not Answers

From Lewis Menand’s review of Smart, Faster, Better, I learned that all self help books have the same goal — to get us to be the people we know we should be. These books don’t have have any new solutions — they just reiterate common sense through the current cultural or businesses lenses. Menand points out that Dale Carnegie’s famous book How to Win Friends and Influence People (which I love) could be summed up in the sentence “If you are nice to people, they will like you.” But, he continues, the purpose of these books is not “What would Jesus do? but How, exactly, would He do it?” Carnegie’s book has some great tips on how to be nice to people like, “Be a good listener and focus on what the other person is interested in.” To me, it’s a fundamental point that none of these books, as much as they try, have the answer — we already know the answer. But they do have some good tips and tricks on how help us anyway.

Stop The Things That We Own From Owning Us