The Checklist Manifesto_ How to Get Things Right - Atul Gawande [4]
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.
This is not an unusual example. These kinds of failures are routine in medicine. Studies have found that at least 30 percent of patients with stroke receive incomplete or inappropriate care from their doctors, as do 45 percent of patients with asthma and 60 percent of patients with pneumonia. Getting the steps right is proving brutally hard, even if you know them.
I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It is not money or government or the threat of malpractice lawsuits or insurance company hassles—although they all play their role. It is the complexity that science has dropped upon us and the enormous strains we are encountering in making good on its promise. The problem is not uniquely American; I have seen it everywhere—in Europe, in Asia, in rich countries and poor. Moreover, I have found to my surprise that the challenge is not limited to 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.
For those who do the work, however—for those who care for the patients, practice the law, respond when need calls—the judgment feels like it ignores how extremely difficult the job is. Every day there is more and more to manage and get right and learn. And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it. That’s why the traditional solution in most professions has not been to punish failure but instead to encourage more experience and training.
There can be no disputing the importance of experience. It is not enough for a surgeon to have the textbook knowledge of how to treat trauma victims—to understand the science of penetrating wounds, the damage they cause, the different approaches to diagnosis and treatment, the importance of acting quickly. One must also grasp the clinical reality, with its nuances of timing and sequence. One needs practice to achieve mastery, a body of experience before one achieves real success. And if what we are missing