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By Root 785 0

there are hundreds, perhaps thousands, of things doctors do that are as dangerous and prone to error as surgery. Take, for instance, the treatment of heart attacks, strokes, drug overdoses, pneumonias, kidney failures, seizures. And consider the many other situations that are only seemingly simpler and less dire—the evaluation of a patient with a headache, for example, a funny chest pain, a lung nodule, a breast lump. All involve risk, uncertainty, and complexity—and therefore steps that are worth committing to a checklist and testing in routine care. Good checklists could become as important for doctors and nurses as good stethoscopes (which, unlike checklists, have never been proved to make a difference in patient care). The hard question—still unanswered—is whether medical culture can seize the opportunity.

Tom Wolfe’s The Right Stuff tells the story of our first astronauts and charts the demise of the maverick, Chuck Yeager test-pilot culture of the 1950s. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock star status of the test pilots was gone.

Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, ICU medicine, and beyond—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The work of medicine is too intricate and individual for that: good clinicians will not be able to dispense with expert audacity. Yet we should also be ready to accept the virtues of regimentation.

And it is true well beyond medicine. The opportunity is evident in many fields—and so also is the resistance. Finance offers one example. Recently, I spoke to Mohnish Pabrai, managing partner in Pabrai Investment Funds in Irvine, California. He is one of three investors I’ve recently met who have taken a page from medicine and aviation to incorporate formal checklists into their work. All three are huge investors: Pabrai runs a $500 million portfolio; Guy Spier is head of Aquamarine Capital Management in Zurich, Switzerland, a $70 million fund. The third did not want to be identified by name or to reveal the size of the fund where he is a director, but it is one of the biggest in the world and worth billions. The three consider themselves “value investors”—investors who buy shares in underrecognized, undervalued companies. They don’t time the market. They don’t buy according to some computer algorithm. They do intensive research, look for good deals, and invest for the long run. They aim to buy Coca-Cola before everyone realizes it’s going to be Coca-Cola.

Pabrai described what this involves. Over the last fifteen years, he’s made a new investment or two per quarter, and he’s found it requires in-depth investigation of ten or more prospects for each one he finally buys stock in. The ideas can bubble up from anywhere—a billboard advertisement, a newspaper article about real estate in Brazil, a mining journal he decides to pick up for some random reason. He reads broadly and looks widely. He has his eyes open for the glint of a diamond in the dirt, of a business about to boom.

He hits upon hundreds of possibilities but most drop away after cursory examination. Every