Posts Tagged 'Gawande'

Checklist Manifesto

Just today it seems that they might have finally discovered some wreckage from the missing Malaysian Airlines, Flight 370. Over close to two weeks on every news outlet, every page, every website, people are talking about this flight. There has been an incredible amount of  ink  spilled on the reaction or lack of reaction by authorities, or on possible motives or explanations for its disappearance, but there has been comparatively little on the passengers, their families, or their communities. Why are we so focused on the  idea of a missing aircraft  to the exclusion of an actual missing aircraft? What about the people they left behind, the people waiting for them, and the people themselves who are missing?

This seems pretty straight forward; we are all self-interested. We are more concerned how this or something like this might impact us than what it means to people we do not know on the other side of the world. This got me thinking about Atul Gawande‘s 2009 The Checklist Manifesto .   Gawande points out that, while airplane pilots use checklists to ensure optimal outcomes, surgeons do not. While the surgeon might think that their education is beyond needing a remedial checklist, that is not the biggest difference. The biggest difference is if the surgeon fails the patient dies while if the airplane pilot fails he goes down with the ship. It is easy to distance yourself when you do not have as much invested in the outcomes. The book’s main point is simple: no matter how expert you may be, well-designed check lists can improve outcomes.

This idea got me thinking about Shmini, this week’s Torah Portion. There we read:

And Aaron’s sons, Nadav and Avihu, each took his pan, put fire in them, and placed incense upon it, and they brought before the Lord foreign fire, which God had not commanded them. And fire went forth from before the Lord and consumed them, and they died before the Lord. Then Moshe said to Aaron, “This is what the Lord spoke, [when God said], ‘I will be sanctified through those near to Me, and before all the people I will be glorified.’ “And Aaron was silent. And Moses called Mishael and Elzaphan, the sons of Uzziel the uncle of Aaron, and said to them: ‘Draw near, carry your brethren from before the sanctuary out of the camp.’  So they drew near, and carried them in their tunics out of the camp, as Moshe had said. And Moshe said to Aaron, and to Eleazar and to Ithamar, his sons: ‘Let not the hair of your heads go loose, neither rend your clothes, that ye die not, and that God be not wroth with all the congregation; but let your brethren, the whole house of Israel, bewail the burning which the Lord has kindled. And you shall not go out from the door of the tent of meeting, lest you die; for the anointing oil of the Lord is upon you.’ And they did according to the word of Moses. ( Leviticus 10:1-7)

Similar to our silence around the missing passengers from the Malaysian Airlines, Flight 370, I have always felt Aron’s silence to be painful. How could a father stay quiet when faced with the death of his two sons? But I think it is also interesting to think about the role of the priest.  In Gawande’s terms is the priest more like a surgeon  or more like an airplane pilot?  You might think with their special status and their role in ancient society that they are like doctors, but Moshe treats him like an airplane pilot. In response to tragedy he does not join him in morning, but rather gives him checklist of what he and his sons need  to get done. The priest serves the entire nation and needs to understand that he is responsible for the patient on the table ( AKA the nation of Israel). But at the same time they need to know that they are flying the plane and are at risk. I think this has interesting implications for today’s Jewish communal professionals. We too need to understand our role. We cannot pretend to be removed surgeons operating the community at arm’s length. If we understand that we are flying the plane, we need to have our own checklist manifesto to ensure that we achieve optimal outcomes for our entire community.

And most importantly, may the friends and family of the pilots and passengers of  Malaysian Airlines, Flight 370 find a voice for their sorrow and comfort from their mourning.

– Thank you to Alon Meltzer for inspiring this post.

Slow Choices

Recently I read a wonderful article by Atul Gawande, author of  The Checklist Manifesto, in the New Yorker. In this piece Slow Ideas, he discusses how in the medical field some ideas spread quickly while other ones languish. One might assume with our highly networked digital world good ideas would spread seamlessly and evenly throughout the field. Evidently being informed about the best ideas is not enough to get people to change their habits. In his article he gives a lot of medical examples to prove this, but seeing that I am a Rabbi I will spare you all of the examples. One of the most telling factors that led to change in medical habits was the perception of causality. Where doctors could see the impact of anesthesia sedating the patient right away, they did not directly see the consequences of washing their hands. In the case of anesthesia the surgical experience changed right ways. They did not perceive a direct causal link between the infections caused by germs and their lack of sterile surgical practices. It is not that doctors were lazy or ill-willed, they just were slow to wash their hands because they did not see its impact.

I got to thinking about this article in the context of Re’eh, this week’s Torah portion. There we read:

See, I set before you this day a blessing and a curse: the blessing, if you shall hearken to the commandments of the Lord your God, which I command you this day;and the curse, if you shall not hearken to the commandments of the Lord your God, but turn aside, out of the way which I command you this day, to go after other gods, which you have not known. ( Deuteronomy 11: 26-28)

The Torah is asking us to see the impact of all of our choices. Sight is central to the human conception of causality. Before us are always choices to be made between blessings or curses. At the same time we are empowered to make choices we are held responsible for the consequences of these choices. The Torah does not leave open the possibility of a pareve , neutral, choice. We are being asked to have the vision to realize the consequences of all of our choices.

There in his article Atul Gawande wrote:

The key message to teach surgeons, it turned out, was not how to stop germs but how to think like a laboratory scientist. Young physicians from America and elsewhere who went to Germany to study with its surgical luminaries became fervent converts to their thinking and their standards. They returned as apostles not only for the use of antiseptic practice (to kill germs) but also for the much more exacting demands of aseptic practice (to prevent germs), such as wearing sterile gloves, gowns, hats, and masks. Proselytizing through their own students and colleagues, they finally spread the ideas worldwide. ( Slow Ideas)

I do not think this conception is limited to surgeons. If more of us saw our lives in the context  of a laboratory we would be seeking out evidence to evaluate all of the choices we make every day. But do not worry I am not about to hand in my Tallit for a lab coat. Gawande is pointing out that often it is not what we know, but who we know that makes the biggest impact. As he writes, ” We yearn for frictionless, technological solutions. But people talking to people is still the way that norms and standards change.” It is the people that we see that influence our habits.  What Gawande calls apostles, we call hassidim. While Gawande is focused on medical practices, the Torah is asking us to think about in regard to all of our practices. We need to develop communities of vision that empower us to see the positive impact each of us can have on the world and stay focused.


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