Surgeon and science writer Atul Gawande’s previous books, Complications (on the role of intuition, the unknown, and other hard to quantify things in the practice of medicine) and Better (on the pursuit of excellence and why we often don’t reach it, focused on by not exclusive to medicine), are two of my favorite nonfiction books. I’ve read them both several times over and highly recommend them. Better in particular has wide-reaching implications and requires no independent interest in medicine.

The Checklist Manifesto, about why checklists are a good idea which can be used in many endeavors, makes an extremely convincing and well-documented case in favor of checklists. But unlike his previous books, which used specific cases to make larger points, this really is a book about checklists.

It would have been of far more general interest if it had been a book about the tension between set routines and individualism, and used checklists as an example of that. Instead, it’s the other way around. By the end of the book I had read the word checklist so often that it reminded me of my experience reading the book about Toni Bentley's ass.

Worth checking out from the library, but not something you’re likely to want to re-read.

Complications: A Surgeon's Notes on an Imperfect Science

Better: A Surgeon's Notes on Performance

The Checklist Manifesto: How to Get Things Right
rachelmanija: (Book Fix)
( Jan. 7th, 2009 05:11 pm)
The Borders at the Promenade had a 40% going out of business sale. People were rushing about with armfuls of books in a manner which made one think of predatory or carrion-eating life forms, like vultures and sharks.

I ran into an old friend and forced him to buy one of my very favorite books from last year (now out in paperback), Atul Gawande's Better, ostensibly an account of how excellence in medicine is achieved or not, but also a fascinating psychological and sociological analysis of how individuals and groups achieve success or failure. Unlike most works that supposedly provoke thought, this one actually does. I found it very inspirational, and also an extremely engaging read. Highly recommended.

For myself, I scavenged the manga shelves, sadly largely picked-over by the time I arrived, and got myself some volumes I'd been missing in series I'm already reading or have finished reading: Angel Sanctuary, Sand Chronicles, Afterschool Nightmare, Fullmetal Alchemist, and Hikaru no Go.

I also bought the first two volumes of High School Debut, which I have not yet read.

Remaining book purchases:

Sick Girl, by Amy Silverstein. Memoir of a woman who gets a heart transplant at the age of 24; this does not solve her health problems, but rather leaves her chronically and severely ill. Recced by [livejournal.com profile] branna. I read this last night. A defiantly non-inspirational illness memoir, well-written, informative, and refreshing in its lack of "I am so glad that I have a chronic illness because it taught me so much about life and brought me closer to my family."

Breathe My Name, by R. A. Nelson. A YA novel, apparently about a girl adopted after her mother went insane. I liked Nelson's previous novel Teach Me, which had somewhat cliched subject matter but a great voice.

The Caliph's House: a Year in Casablanca, by Tahir Shah. Travel nonfiction. A British family moves to Casablanca, into a house reputed to be inhabited by jinns.

Eating India: an odyssey into the food and culture of the land of spices, by Chitrita Banerji. Food/travel/history nonfiction. Looks both informative and fun.

Early India: From the origins to AD 1300, by Romila Thapar. Looks informative and not fun. But hopefully a good resource.

The Last Mughal: the fall of a dynasty, Delhi 1857, by William Dalrymple. I've read a lot about this period but not from this angle (focused on the last Mughal Emperor.) I like Dalrymple's writing style, especially in his other book, City of Djinns, that alternated a memoir of his life in modern Delhi with a history of the city.

Babur Nama. The journal of the Mughal emperor Babur, beginning when he inherited a kingdom at the age of twelve in 1494 and continuing through his rule in India. Random flip-throughs revealed poisoning attempts, a resolve to try wine for the first time, battles, and other fun stuff.
rachelmanija: (Book Fix)
( Jan. 7th, 2009 05:11 pm)
The Borders at the Promenade had a 40% going out of business sale. People were rushing about with armfuls of books in a manner which made one think of predatory or carrion-eating life forms, like vultures and sharks.

I ran into an old friend and forced him to buy one of my very favorite books from last year (now out in paperback), Atul Gawande's Better, ostensibly an account of how excellence in medicine is achieved or not, but also a fascinating psychological and sociological analysis of how individuals and groups achieve success or failure. Unlike most works that supposedly provoke thought, this one actually does. I found it very inspirational, and also an extremely engaging read. Highly recommended.

For myself, I scavenged the manga shelves, sadly largely picked-over by the time I arrived, and got myself some volumes I'd been missing in series I'm already reading or have finished reading: Angel Sanctuary, Sand Chronicles, Afterschool Nightmare, Fullmetal Alchemist, and Hikaru no Go.

I also bought the first two volumes of High School Debut, which I have not yet read.

Remaining book purchases:

Sick Girl, by Amy Silverstein. Memoir of a woman who gets a heart transplant at the age of 24; this does not solve her health problems, but rather leaves her chronically and severely ill. Recced by [livejournal.com profile] branna. I read this last night. A defiantly non-inspirational illness memoir, well-written, informative, and refreshing in its lack of "I am so glad that I have a chronic illness because it taught me so much about life and brought me closer to my family."

Breathe My Name, by R. A. Nelson. A YA novel, apparently about a girl adopted after her mother went insane. I liked Nelson's previous novel Teach Me, which had somewhat cliched subject matter but a great voice.

The Caliph's House: a Year in Casablanca, by Tahir Shah. Travel nonfiction. A British family moves to Casablanca, into a house reputed to be inhabited by jinns.

Eating India: an odyssey into the food and culture of the land of spices, by Chitrita Banerji. Food/travel/history nonfiction. Looks both informative and fun.

Early India: From the origins to AD 1300, by Romila Thapar. Looks informative and not fun. But hopefully a good resource.

The Last Mughal: the fall of a dynasty, Delhi 1857, by William Dalrymple. I've read a lot about this period but not from this angle (focused on the last Mughal Emperor.) I like Dalrymple's writing style, especially in his other book, City of Djinns, that alternated a memoir of his life in modern Delhi with a history of the city.

Babur Nama. The journal of the Mughal emperor Babur, beginning when he inherited a kingdom at the age of twelve in 1494 and continuing through his rule in India. Random flip-throughs revealed poisoning attempts, a resolve to try wine for the first time, battles, and other fun stuff.
Complications is a medical memoir/set of essays and case studies, very much in the tradition of Oliver Sacks' The Man Who Mistook His Wife for a Hat, only less technical and about surgery rather than neurology. Specifically, it's about the human element in medicine: how errors occur and how to prevent them, how and why doctors learn, succeed, and fail, and areas of medicine about which very little is understood. It's fascinating.

One of the essays which I thought has particularly broad resonance was on how anesthesiology, unlike any other branch of medicine, was subject to a complete overhaul designed to eliminate errors in practice. For instance, anesthesiology machines used to be designed completely differently depending on what company built them, so that dials on one machine turned clockwise to increase dosage, while on others, they turned clockwise to decrease dosage. Anesthesiologists were supposed to just make sure they knew how to use each machine, and remember which one they were using. And mostly they did. But every now and then they spaced out, and every now and then someone died as a result. (Imagine if some cars had the gas pedal on the left and the brake on the right, and on some they were reversed, and you were just supposed to check which kind of car you were driving and always remember and never absent-mindedly forget that you were in your friend's left-braking car, and hit the wrong pedal.) Now all anesthesiology machines are designed to the same specs, so that you always turn the dials in the same direction if you want to increase dosage, and in the opposite to decrease it.

Another new standard has to do with another type of medical error, that of operating on the wrong side of the body. In the past, this happened every now and then, with disastrous results (like the wrong leg getting amputated) and the response was to fire the offending surgeon. But, as Gawande points out, humans are bilaterally symmetrical, and so this sort of error is inevitable, and periodically firing surgeons will not prevent it. Now the standard of care is for surgeons to initial the correct body part while the patient is still awake and able to correct them if they're wrong, and that particular error has dropped off to almost never in hospitals where that's a practice.

Both of these cases involve competing plans on how to prevent error. Plan A is to have individuals make a new check to see whether they're doing the right thing every single time they do it, and to punish them if they ever do it wrong. Plan B is to design a system where the system itself is set up with the correct method already in place, so that individuals don't have to make a check every time they do the action, but merely follow the same procedure each time. Plan A is more theoretically ideal-- it allows for more individual autonomy-- but Plan B works better. Plan A requires humans to be perfect. Plan B assumes and auto-corrects for human imperfection.

An issue that I noticed way back when I was disaster relief worker, but that has come back into the news recently, and which involves a conflict between A and B plans, is official policy on pets in disaster zones. (For the purposes of this post, I'm ignoring issues of poverty and access to the means of evacuation, but addressing issues involving people are either able to evacuate themselves into shelters, or are being picked up by rescue vehicles.) The standard practice is a form of Plan A. Pets are typically not allowed for in evacuation plans. They are not allowed on to evacuating vehicles. They are not allowed into shelters. They are not collected and transported into disaster pet shelters. Pet owners are assumed to behave like perfectly rational and self-interested individuals, and to abandon their pets.

There are a number of reasons for this policy, which include the possibility of diseases or parasites spreading from animals to people, the possibility of people getting bitten, liability resulting from that, lack of room, lack of resources, and so forth. However, there is a very big problem with the policy: people frequently refuse to leave their pets. Often enough, they would rather stay and risk death with their pets than without them.

The current state of affairs is that Plan A remains in effect, although it causes the unnecessary deaths of both humans and animals, and the makers of Plan A tear their hair out at the additional deaths and hold-outs and refusals to evacuate (causing many more rescue vehicles and teams to be dispatched), and beg people to just be sensible and leave their pets. Well, some percentage of people are just not going to do that, ever. So, do we leave them to die? Do we expend excessive amounts of resources to pluck them from roof-tops because they refused to leave at the first warning, because they weren't allowed to take their pets with them? Or do we recognize that Plan A has a problem?

In this case, there needs to be a Plan B that acknowledges that a lot of people are not willing to leave their pets, and works with it. It should be standard in cases of disaster to evacuate pets, either with their owners to shelters that, by the new standard, should have kennels attached, or to pet shelters that will keep the pets until they can be reunited with their owners. Yes, this does expend more resources, but it would be ultimately both more humane and more efficient.

Though I said I wasn't going to address the issue of poverty, this ties into that. We can lecture people all we want for not saving up 72 hours worth of easily portable food and water for their entire family, or for not having cars, or for not leaving their pets behind. That will not, however, prevent people from being too poor or too busy or too loving, and doing exactly the things that we tell them not to, but know they will. Or we can acknowledge that people will behave in the manner of people-- inefficient, imperfect, poor, ill, unlucky, carless, careless, inattentive for that one crucial moment, and subject to human emotions-- and make our plans accordingly.
Complications is a medical memoir/set of essays and case studies, very much in the tradition of Oliver Sacks' The Man Who Mistook His Wife for a Hat, only less technical and about surgery rather than neurology. Specifically, it's about the human element in medicine: how errors occur and how to prevent them, how and why doctors learn, succeed, and fail, and areas of medicine about which very little is understood. It's fascinating.

One of the essays which I thought has particularly broad resonance was on how anesthesiology, unlike any other branch of medicine, was subject to a complete overhaul designed to eliminate errors in practice. For instance, anesthesiology machines used to be designed completely differently depending on what company built them, so that dials on one machine turned clockwise to increase dosage, while on others, they turned clockwise to decrease dosage. Anesthesiologists were supposed to just make sure they knew how to use each machine, and remember which one they were using. And mostly they did. But every now and then they spaced out, and every now and then someone died as a result. (Imagine if some cars had the gas pedal on the left and the brake on the right, and on some they were reversed, and you were just supposed to check which kind of car you were driving and always remember and never absent-mindedly forget that you were in your friend's left-braking car, and hit the wrong pedal.) Now all anesthesiology machines are designed to the same specs, so that you always turn the dials in the same direction if you want to increase dosage, and in the opposite to decrease it.

Another new standard has to do with another type of medical error, that of operating on the wrong side of the body. In the past, this happened every now and then, with disastrous results (like the wrong leg getting amputated) and the response was to fire the offending surgeon. But, as Gawande points out, humans are bilaterally symmetrical, and so this sort of error is inevitable, and periodically firing surgeons will not prevent it. Now the standard of care is for surgeons to initial the correct body part while the patient is still awake and able to correct them if they're wrong, and that particular error has dropped off to almost never in hospitals where that's a practice.

Both of these cases involve competing plans on how to prevent error. Plan A is to have individuals make a new check to see whether they're doing the right thing every single time they do it, and to punish them if they ever do it wrong. Plan B is to design a system where the system itself is set up with the correct method already in place, so that individuals don't have to make a check every time they do the action, but merely follow the same procedure each time. Plan A is more theoretically ideal-- it allows for more individual autonomy-- but Plan B works better. Plan A requires humans to be perfect. Plan B assumes and auto-corrects for human imperfection.

An issue that I noticed way back when I was disaster relief worker, but that has come back into the news recently, and which involves a conflict between A and B plans, is official policy on pets in disaster zones. (For the purposes of this post, I'm ignoring issues of poverty and access to the means of evacuation, but addressing issues involving people are either able to evacuate themselves into shelters, or are being picked up by rescue vehicles.) The standard practice is a form of Plan A. Pets are typically not allowed for in evacuation plans. They are not allowed on to evacuating vehicles. They are not allowed into shelters. They are not collected and transported into disaster pet shelters. Pet owners are assumed to behave like perfectly rational and self-interested individuals, and to abandon their pets.

There are a number of reasons for this policy, which include the possibility of diseases or parasites spreading from animals to people, the possibility of people getting bitten, liability resulting from that, lack of room, lack of resources, and so forth. However, there is a very big problem with the policy: people frequently refuse to leave their pets. Often enough, they would rather stay and risk death with their pets than without them.

The current state of affairs is that Plan A remains in effect, although it causes the unnecessary deaths of both humans and animals, and the makers of Plan A tear their hair out at the additional deaths and hold-outs and refusals to evacuate (causing many more rescue vehicles and teams to be dispatched), and beg people to just be sensible and leave their pets. Well, some percentage of people are just not going to do that, ever. So, do we leave them to die? Do we expend excessive amounts of resources to pluck them from roof-tops because they refused to leave at the first warning, because they weren't allowed to take their pets with them? Or do we recognize that Plan A has a problem?

In this case, there needs to be a Plan B that acknowledges that a lot of people are not willing to leave their pets, and works with it. It should be standard in cases of disaster to evacuate pets, either with their owners to shelters that, by the new standard, should have kennels attached, or to pet shelters that will keep the pets until they can be reunited with their owners. Yes, this does expend more resources, but it would be ultimately both more humane and more efficient.

Though I said I wasn't going to address the issue of poverty, this ties into that. We can lecture people all we want for not saving up 72 hours worth of easily portable food and water for their entire family, or for not having cars, or for not leaving their pets behind. That will not, however, prevent people from being too poor or too busy or too loving, and doing exactly the things that we tell them not to, but know they will. Or we can acknowledge that people will behave in the manner of people-- inefficient, imperfect, poor, ill, unlucky, carless, careless, inattentive for that one crucial moment, and subject to human emotions-- and make our plans accordingly.
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