Author Atul Gawande

Surgeon and author of The Checklist Manifesto explains how coping with complexity has become the biggest 21st-century struggle.

Dr. Atul Gawande is a surgeon who also loves to write. He's on the staff of Brigham and Women's Hospital and the Dana Farber Cancer Institute, as well as The New Yorker magazine. He's also associate professor of surgery at Harvard Medical School—where he earned his MD. Gawande was named by Foreign Policy magazine to its 2010 list of top global thinkers and served as a senior health policy advisor in President Clinton's campaign and administration. A Rhodes Scholar and best-selling author, he's written extensively on medicine and public health.


Tavis: Dr. Atul Gawande is a staff member at Brigham and Women’s Hospital and the Dana Farber Cancer Institute. He’s also a staff writer for the “New Yorker” and author of the best-selling book, “The Checklist Manifesto: How to Get Things Right.” The book is now out in paperback, and Dr. Gawande joins us tonight from Boston. Good to have you on the program, Dr. Gawande, thanks for your time, sir.
Dr. Atul Gawande: Great to be here.
Tavis: Tell me what it is that’s happened in our lives over the decades, the centuries, that make checklists so important these days to get things right.
Gawande: Yeah, our biggest struggle in this new century has become complexity. We discovered so much new knowledge in science, in how to build organizations, how to build buildings, that we’re now struggling with how to actually use that knowledge well.
I started digging into how people in aviation or in skyscraper construction got to be good at what they do, and what they use, in addition to lots of training, lots of technology, a core other tool is the simple checklist.
Tavis: What about people who think that checklists are so rudimentary, elementary, adolescent – I don’t need a checklist to get through my day.
Gawande: Yeah, what we have thought of the checklist for is to dumb things down. It’s for the people at the bottom of the totem pole. We don’t think of it as being for the very top people because they know what they’re doing. You couldn’t see a greater example than in surgery.
The idea that we’d pull out a checklist for doing an operation, it seemed crazy. But following the lead of what other people in other industries have done, we started trying it in surgery. We designed a checklist; we worked actually with Boeing to learn how to make a smart checklist rather than one that just dumbs things down.
It focuses on having a team that everybody knows each other’s name, making sure that the surgeon has spoken to the rest of the team about the goals for the operation. Executing on that checklist, we found that we reduced the chances of complications and deaths by more than one-third in our trial in eight hospitals.
Tavis: Wow. So checklists are really a matter, then, of life and death in some instances, you think?
Gawande: They’ve clearly demonstrated it to be the case. What turns out to be the story is that when you use a checklist you’re really expressing a certain set of values, and those values are humility – understanding that you can make mistakes. No matter how well-trained or smart you are, your brain’s not going to hold it all.
Second, teamwork – the belief in a group of people working together off the same page. Number three, the belief in discipline. It turns out to work, not just in surgery but in a wide variety of fields, and we’re only just now starting to take it seriously.
Tavis: I’m a believer in checklists, so I’m asking this question specifically to play devil’s advocate here. What about the notion that checklists make us lazy, kind of like – intellectually lazy, that is – kind of like our cell phones. We have everybody’s number who’s important to us programmed in our phone so that if you take somebody’s phone away these days and ask them someone’s number who’s close to them, they can’t even recall the number because we store everything in our phones.
So that said, how, then, why do checklists not, as you see it, make us lazy in the long run?
Gawande: Yeah, if you have a checklist that just dumbs things down it turns the brain off, and now you have a poorly designed checklist. Having a checklist that is not the same as having a recipe – a pilot in a plane, when they use a checklist, it is not a recipe for how to fly.
It is the top 10 things they have to do to make sure they haven’t forgotten everything, and in the operating room or in other fields where people are starting to use checklists, when they are effective it’s because they’re asking people, have you thought about, say in the operating room, what are all the major medical concerns for this patient?
Have you thought about what allergies they might have, whether you’re operating on the right side of the body? That’s not a recipe. It’s a series of questions that can make experts get great performance rather than just mediocre performance.
Tavis: Is there a distinction in your mind between a to-do list – people typically say they have a to-do list – is there a difference in your mind, however minute it might be, between a to-do list and a checklist?
Gawande: Yeah, there’s a fundamental difference, which is that a checklist, one that’s really going to be something you use every time, has a kind of do not go beyond phase. So one of the things that makes a checklist work is you have a pause point – a moment when you will use the checklist. If you find that there is an item that is missed on your checklist, you won’t move on until you fix it.
A to-do list can be all the things that you want to do, but how often do you end up skipping a few things on there because you run out of time? A checklist is about the killer items, the things that you cannot miss.
Tavis: I mentioned earlier in this conversation, Dr. Gawande, that I’m a believer in checklists. I operate personally off of two things every day. I have a schedule that my assistant, Dawn, prepares for me every day. That is really my to-do list. These are the things that I have to do today. I’ve got to be in the studio at this time for TV, I’ve got to be in the radio studio for radio at this time. I’ve got a meeting here.
So I have a to-do list which is my schedule every day, but I also have a checklist that I operate off of as well. I have found, and I’m curious as to your take on this, that for those who think checklists are a little silly, when you use a checklist, in my case in tandem with my schedule, I actually find that on any given day I get more done than a lot of my friends, a lot of folk who I know, because I use that checklist in tandem with the things I have to get done that day.
Gawande: Yeah, this is fundamental. One of the core things that you’re experiencing, which I hadn’t experienced until I actually tried a checklist in my own operating room, is it let your brain not focus on the dumb stuff. Am I operating on the right side of the patient, am I – you can rest reassured when you’ve gone through the checklist that the dumb stuff’s taken care of and you can focus on the higher-level things that you’ve got to think hard about.
I saw this on the “Miracle on the Hudson,” the U.S. air flight that landed in the Hudson, where Sully Sullenberger, the captain who managed to pilot the plane down. They use checklists that allowed them to know that his copilot was going to be handling trying to restart the engines and run through a bunch of things that he did not have to worry about, and that meant that his brain could focus on the one question that no checklist could answer: Where am I going to land this plane?
Tavis: I guess what I’m getting at is whether or not checklists allow us simply to do things right or to do more things right.
Gawande: Yeah, it’s probably the combination of them. It lets you do – it lets you be more quick in making sure that all the key things you’ve got to think about happen, it gets your team together when you’ve got a checklist for a whole team, and it lets you do more things right.
One of the striking things in our work in medicine is finding that people were not only having lower complication rates coming out of something like surgery but finishing the day sooner, having less overtime, having – they were able to do more things right.
Tavis: What do you make of the fact, and I’ll ask you to set your modesty aside for just a second, but what do you make of the fact that a book that has as its message the simple notion of living by a checklist, how does a book that simple in a very complex world become a best seller, you think?
Gawande: Yeah, I’ve been as gratified as anybody else, but surprised. Look, I start the book off with a guy who gets stabbed in the belly at a Halloween party, and so I am trying to attract people and understand how do people cope with incredible complexity in medicine or in building skyscrapers or in flying airplanes.
But it’s a hard sell. Why should you care about checklists? That’s not sexy. It doesn’t necessarily grab people until you realize coping with complexity has become our biggest struggle in the 21st century.
Tavis: You referenced a couple of times in this conversation if you have a good checklist, if you have a good checklist. How do you know that your checklist is good versus bad?
Gawande: Well, there are a couple ways that you know. One is do people actually use it? (Laughter) People can make a checklist, and one of the things that happens, as soon as you make a checklist you start putting every single thing on there and then you actually bring it to your team and nobody uses it, or you try yourself and you find that you’re ignoring it. That’s not a useful checklist, or a very good one.
The second sign is that if the checklist ends up distracting people from the job that they need to be doing. It’s really paying attention – does it help you get better results?
Tavis: Finally, is there any reason to believe from your perspective that as a society, given the complex nature of life these days, that we are getting better embracing the notion of using checklists to get things done and to get them done right?
Gawande: I can watch the news and become depressed almost every day. When you see the oil rig disaster that happened, for example, a few months ago in the Gulf, what shocked me was that they didn’t have a plan in place for how to deal with a fire erupting that allowed a team of people who’d never faced it before to say, okay, here are the top five most important things that we have to accomplish.
We see that over and over and over again, and yet there are places like watching what happened in the shooting in Tucson, Arizona, where the first responders had their checklists and managed to be able to take a group of more than a dozen people who’d been shot, bring them into one hospital, get them there in the right place and the right time, and save lives like wasn’t even possible a decade ago. Those are the heartening moments to me.
Tavis: So we all know that life is complex, and if you haven’t tried living by a checklist, maybe now is the time.
The new book out in paperback, I should say, from Dr. Atul Gawande is called “The Checklist Manifesto: How to Get Things Right.” Dr. Gawande, thanks for the text and good to have you on this program, sir.
Gawande: It’s great to be here.
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Last modified: April 26, 2011 at 12:28 pm