40 pages • 1 hour read
Atul GawandeThe Checklist Manifesto: How to Get Things Right
Nonfiction | Book | Adult | Published in 2009A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Chapters 8-9Chapter Summaries & Analyses
Chapter 8 Summary: “The Hero in the Age of Checklists”
Gawande begins Chapter 8 by discussing the value of checklists in medicine and reasons why people are generally reluctant to use them. His claim echoes Chapter 3, which argues that the medical field has been stuck in a traditional top-down command structure. Gawande also suggests ego and vanity are driving factors for why the field is resistant to something as simple, yet effective, as a safe surgery checklist. He then examines how checklists are useful in the world of finance. He interviews three money managers, each in charge of successful firms: Mohnish Pabrai, Guy Speirs, and a third under the pseudonym Cook. Gawande discusses how these financiers research possible investment opportunities and how many people are susceptible to impulsive investments. He calls this impulse “cocaine brain” and describes how the prospect of making money involves the same neural pathways as a person who struggles with cocaine. Money manager Mohnish Pabrai is able to resist these impulses by using developed checklists and pause points—protections against impulsive investments. Like Gawande, Pabrai develops these checks based on his own experience and the mistakes of others, including Warren Buffet and his company, Berkshire Hathaway.
Gawande describes an investment gone awry by Warren Buffet’s partner Charles Munger, and suggests that a checklist could have prevented the failure. He compares Pabrai’s mental checklist to Cook’s more definitive “Day Three Checklist,” noting that Cook’s list is far more methodical than Pabrai’s. After describing Cook’s checks, Gawande reiterates that Cook does not see the checklist as a replacement for his own experience and intuition. Rather, it is a failsafe that guides him away from risky investments. Gawande then highlights the work of psychologist Geoff Smart, who studied how venture capitalists made decisions. Smart discovered eight types of decision-makers, and suggested that most relied on instinct. His study revealed that capitalists who were more methodical and depended on checklists had a higher success rate. However, even when the study findings were made public, little changed: Capitalists who made decisions based on instinct stayed the course in spite of failure.
The final part of Chapter 8 centers on the famous, near-disastrous aviation incident branded the “miracle on the Hudson.” Gawande provides a detailed recounting of the incident: The plane in question left LaGuardia airport in New York City, but shortly after take-off, it made impact with a flock of geese, resulting in engine failure. Piloted by Chesley “Sully” Sullenberger, the plane averted disaster, as Sully and co-pilot Jeffrey Skiles landed in the Hudson River. Gawande examines how the press immediately anointed Sully a hero, which included a book deal and a subsequent movie. Sully was honored and received wide-spread recognition from the president at the time, George W. Bush, and the president-elect, Barack Obama. However, Sully was a somewhat reluctant hero and tried to focus on the efforts of his crew rather than his own decision-making. Gawande highlights how Sully and Skiles operated a plane with no working engines, how Skiles managed to run through specific checklists designed for such an emergency, and how the crew’s adherence to procedure resulted in successful teamwork. It was teamwork that saved the 155 passengers, not just the skill of a single pilot. Gawande shifts from this anecdote and revisits the absence of aviation-level checklists in the medical field. He cites the discipline of aviation as a major distinction between it and other professions, and calls his field to become more disciplined and regimented.
Chapter 9 Summary: “The Save”
Gawande mentions that as he prepared his own checklist, he was not convinced it would work. However, within a week of checklist use, a mistake was caught and more were subsequently caught. The checklist immediately made a difference. Gawande provides examples of how some mistakes were caught, revealing the checklists’ ability to improve communication between surgical team members. He then describes a situation in which he is convinced a checklist saved a patient’s life. Gawande had been performing laparoscopic surgery to remove a rare tumor on the adrenal gland of a 53-year-old patient named Mr. Hagerman. As Gawande was removing the tumor, he inadvertently cut into the vena cava, a disastrous error that resulted in immediate and voluminous blood loss. Because of the team’s checklist, in which blood loss was discussed prior to the surgery, the nurses were prepared to act. Because of this, the team was able to provide Mr. Hagerman with blood and likely saved his life. Gawande details how everyone in the operating room functioned as a team, and how each person responded efficiently and with urgency. Mr. Hagerman was saved, but did not come out of surgery unscathed: He lost partial sight in one eye. Gawande regrets his mistake and does not perform other adrenalectomies without thinking of Mr. Hagerman. However, he feels this regret keeps him vigilant, and Mr. Hagerman allows the story to be added to the book.
Chapters 8-9 Analysis
At the beginning of Chapter 8, Gawande ventures into a cultural examination. He states checklists are beneficial, even for experts, but questions if people will embrace them: “If someone discovered a new drug that could cut down surgical complications with anything remotely like the effectiveness of the checklist, we would have television ads with minor celebrities extolling its virtues” (158). He suggests people are drawn to new and shiny things. The checklist is not this. It is a mundane form of listing that does not have the same level of attractiveness as some new invention or discovery. Gawande also implicates the human ego in his explanation for why people resist checklists, despite being useful. He puts himself in the role of a surgeon who sees his job as that of a “master physician.” Speaking hypothetically, he says, “This is my patient. This is my operating room. And the way I carry out an operation is my business and my responsibility. So who do these people think they are, telling me what to do?” (159). Though Gawande is clearly exaggerating for effect, his point remains. He hopes that surgeons and other medical professionals will combat ego and recognize the utility and value of the checklist in saving lives. Begrudgingly accepting the checklist as part of the surgical process is not his goal; rather, he wants surgical personnel to understand why following a checklist matters. Understanding The Power of Discipline (in the form of checklists and open communication), especially as a team, is the goal.
As he often does, Gawande turns to real-life examples to show the value of checklists. He discusses the “miracle on the Hudson,” a famous airline incident in which a passenger plane was landed safely on the Hudson River in New York City. Chesley “Sully” Sullenberger tried to deflect praise to his crew, offering a contrast to Gawande’s hypothetical “master physician.” The plane’s 155 lives were saved because Sully and his crew did not falter under pressure. Instead, they relied on protocol—developed by checklist experts like Boorman—and exhibited The Effectiveness of Teamwork. They needed to perform individual tasks, but ego and pride were not involved at all. In complex environments and situations, who gets credit and who is deemed a “hero” doesn’t matter. This incident embodies the book’s three themes—The Applicability of Checklists, The Power of Discipline, and The Effectiveness of Teamwork—as it is compelling evidence to persuade those who would resist checklists.
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