The Checklist Manifesto. Chapter 2 The Checklist

Following our reading calendar, here is a short explanation of the contents of chapter two.

It starts with a very impressive example on how the humble checklist saved Boeing for a great financial loss, and how using a checklist allowed pilots to fly a plane slightly more complicated than those that were common in the 1930s. Now checklist are commonplace in aviation.

This is the main aim of this chapter: to convince us of the power of the checklist. He points out the two main psychological situations in which checklists can be of great help: first there is the “fallibility of human memory and attention, especially when it comes to a mundane, routine matters that are easily overlooked under the strain of more pressing events” (p. 36)

The other one is how you can skip steps that you already memorized because usually don’t matter. Until they do, of course.

The thing that most called my attention was to realize that we have to wait to 2001 to see the first attempts to introduce checklists in medicine (besides the basic constants which, as the author stated are a sort of proto-checklist). I was imagining that checklists were in operating rooms since decades ago, and as common in the medical world as in the commercial or military flying. But not at all. As the author explains, Pronovost -one of the early adopters of checklists in medicine- had to work hard to convince his colleagues on how important it is to have checklists in medicine.  However he was able to present very relevant numbers of the effectiveness of such procedures and convince more relevant people.

The chapters ends returning to the example in the introduction of the 3 year old  girl saved after drowning in icy water. This was another brilliant and very emotional example of the possibilities of the checklist.


Scandinavian Momentum

I have previously posted in admiring amazement about the slow television phenomenon in Norway. There seems to be the last place on earth where life goes with that 19th century rhythm that allowed those old novels to be written and read. Does anybody have time to read Tolstoy or Stendhal anymore? But the day has 24 hours as it had 150 years ago. In the accounting of our days we have traded the hours of reading Madame Bovary for other activities and I am afraid that if we were to sit down and write on a paper exactly the terms of the trade we would be ashamed.

But anyway, in this Facebook times, there are still the Scandinavians. Take this guy, for example, Karl Ove Knausgaard and his autobiographic work:

Mr Knausgaard is the author of one of the most idiosyncratic literary works of recent years: a six-volume, 3,500-page autobiography called “My Struggle”, after Hitler’s “Mein Kampf”. It starts with a portrait of his father’s alcohol-soaked death, ends with a meditation on Hitler and takes the author through the cycle of his life. Mr Knausgaard is now 45.

From wikipedia

The books have nevertheless received almost universally favourable reviews, especially the first two volumes, and were, even before the final book’s publication, one of the greatest publishing phenomena in Norway ever. In a country of fewer than five million people, the “Min Kamp”-series have sold over 450,000 books.

Professor Splash

In case last posts let you too worried about the complexity of modern medicine, here is something more refreshing.

David, if you could choose for next life, would you prefer to be Wittgenstein or Professor Splash?

Thanks to David Vidal for the link.

The Checklist Manifiesto: The Problem of Extreme Complexity.

(Our weekly reading according to our reading calendar)

This chapter is entirely devoted to show us how complex is the science and the practice of medicine in our days.

And this is done in a very effective and dramatic way by mixing actual descriptions of individuals’ dramatic clinical stories and typical daily routines of medical staff together with data and statistics that describe the magnitude of the phenomenon. The narrative effect of this combination is really successful in conveying a feeling of overwhelming complexity almost nightmarish.

Medicine is not about giving wonder pills that cure everything.

I think we have been fooled about what we can expect from medicine -fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. (p. 18)

Medicine didn’t turn out this way, though. (p. 19)

World Health Organization’s international classification of diseases has grown to distinguish more that thirteen thousand different diseases, syndromes, and types of injury (…) Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations.  (p. 19)

The daily experience of a doctor reflects all such complexity

 in one day, I’d had six patients with six completely different primary medical problems and a total of twenty-six different additional diagnoses (p. 21)

Over the course of a year of office practice (…) physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures. (p. 21)

All that tsunami of medical knowledge comes with and increased level of complexity in the procedures that have to be applied to the patients. A vivid description of the workings of the intensive care units (ICU) is offered. The difficulty in applying correctly the overwhelming number of procedures needed in a standard ICU treatment means that mistakes happen with, sometimes, fatal consequences.

To tackle this problem, the answer has been super specialization.

We live in the era of the superspecialist -of clinicians who have taken the time to practice, practice, practice at one narrow thing they can do it better than anyone else. (p. 29)

There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists, and many others.  (p. 30)

But, even this super specialization is not being enough.

We continue to have upwards of 150,000 deaths following surgery every year -more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.


What do you do when superspecialists fail? (p. 31)

The answer to this question is the subject of the book.

Forget about Formal Education

From Rework, Change the way you work forever

I have never let my schooling interfere with my education.


There are plenty of companies out there who have educational requirements. They’ll only hire people with a college degree (sometimes in a specific field) or an advanced degree or a certain GPA or certification of some sort or some other requirement.

Come on. There are plenty of intelligent people who don’t excel in the classroom. Don’t fall into the trap of thinking you need someone from one of the “best” schools in order to get results.


Too much time in academia can actually do you harm. Take writing, for example. When you get out of school, you have to unlearn so much of the way they teach you to write there. Some of the misguided lessons you learn in academia:

– The longer a document is, the more it matters.

– Stiff, formal tone is better that being conversational.

– Using big words is impressive.

– You need to write a certain number of words or pages to make a point.

– The format matters as much (or more) than the content of what you write.

It’s no wonder so much business writing winds up dry, wordy, and dripping with nonsense. People are just continuing the bad habits they picked up in school. It’s not just academic writing, either. There are a lot of skills that are useful in academia that aren’t worth much outside of it.

Why Are American Health Care Costs So High?

We have published several posts in our blog about the paradox of health care costs in U.S.A:
(links in spanish)

Now we have this fascinating video which I hope can shed a little more light on the issue.
Thanks to Arcadi Navarro for the link.