Atul Gawande’s “The Checklist Manifesto”: Book Review, Notes + Analysis

Poor Ash’s Almanack > Book Reviews > Effective Thinking (cognitive load reduction)

Overall Rating: ★★★★★★ (6/7) (solid for its category)

Learning Potential / Utility: ★★★★★★ (6/7)

Readability: ★★★★★★★ (7/7)

Challenge Level: 2/5 (Easy) | ~195 pages ex-notes (220 official)

Blurb/Description: Surgeon and bestselling author Atul Gawande discovers and implements an unlikely tool for dramatically reducing procedural errors: a simple checklist.

procedural errors: a simple checklist.

Summary: A lot of investors extol the virtues of The Checklist Manifesto, but I think most of them either misread or misapply the book.  I actually think it’s a fantastic book, although in my experience, checklists are less directly-applicable to investing than investors (or Gawande) would believe.  Why?  It’s a function of the categorization of errors that Gawande discusses himself: most investing errors are errors of judgment rather than technical mistakes (i.e., forgetting to apply correct knowledge) – and thus not a good candidate for being resolved by checklists.  So I derived a lot more value, personally, from Jerome Groopman’s How Doctors Think (which addresses the cognitive biases that can result in misdiagnoses).

That said, there are some limited applications in my line of work where checklists can help, and as a practical, understandable, applicable example of structural problem solving / human-centered design, I think The Checklist Manifesto shines.  Just be careful to read it carefully: Gawande does a great job of explaining not only the power of checklists but also their limitations and the conceptual as well as practical issues with using them.  Unfortunately, most investors (including the ones Gawande discusses) seem to use them the wrong way.

By Amar Karodkar [CC BY-SA 4.0)
Highlights: This is an extremely readable, digestible book; Gawande does a great job of spanning empirics and storytelling, as well as providing his own expertise in medicine without getting in the way of letting others (in the areas of AEC – architecture, engineering, construction – and obviously flying / aviation) tell their own stories.  

Gawande also doesn’t pitch checklists as a “silver bullet” even though a lot of readers take it that way: he clearly and carefully delineates the types of errors they can help prevent, and the practical considerations in building, maintaining, and using them.  I particularly enjoyed the very practical sections where he discussed the initial challenges in applying a checklist in his own OR, and the process he and his team took to apply one effectively.

Lowlights: There really aren’t many flaws in this book.  I would criticize the section on investing at the end, which is not only rushed but also inconsistent with the rest of the book: the investors Gawande discusses don’t use checklists at all in the way he advocates using them throughout the book (you can clearly see the difference, for example, between the implications of the pseudonymous Cook substituting checklists for judgment, and Gawande’s own discussion of how they’re used in his OR.)  

Moreover, I think Gawande overreaches in drawing conclusions of success and error avoidance from a small data set; a checklist obviously didn’t prevent Pabrai from running into Horsehead Holdings (ZINC) – nor would checklists have possibly prevented any of the errors that I’ve made over the course of my investing career, because they’ve all been errors of judgment rather than technical failures on simple problems like transposing digits in a spreadsheet.

Nonetheless, Gawande can’t be held responsible for investors’ general misunderstanding of his book, and given how solid the rest of the book is, I don’t fault him for the one brief “eh” bit at the end.

Mental Model / ART Thinking Points:  Path-dependency / dependent events, nonlinearitylocal vs. global optimization,   empathymemoryculturemargin of safetyproduct vs. packagingselection biasincentivesstructural problem solvinghumans vs. econs, mistakes, dose-dependency,activation energy, marginal utility, one to many,

You should buy a copy of The Checklist Manifesto if: you want a quick, practical book that exemplifies the mentality of structural problem solving, whether or not checklists are appropriate for your specific line of work.

Reading Tips: there’s no need to skim this book because it’s so brief.  In fact, in a twist frequent readers will find unusual, I’d advocate reading it very carefully / word-for-word: Gawande makes very clear, well-articulated points, but also doesn’t flog them to death, so I think it’s easy to skim this book and come away with the wrong conclusions.

Pairs Well With:

Jerome Groopman’s “How Doctors Think” (HDT review + notes) – a careful and cogent analysis of how doctors deal with, or don’t deal with, cognitive biases that can lead to misdiagnosis.

Daniel Schacter’s The Seven Sins of Memory” (7SOM review + notes) – a memorable book about the ways in which the human memory consistently fails us.

Don Norman’s The Design of Everyday Things (DOET review + notes) – a much broader, deeper look at the concept of human-centered design and structural problem solving.

Cass Sunstein + Richard Thaler’s Nudge (NDGE review + notes) – another example of structural problem solving and setting up conditions for success.

Reread Value: 3/5 (Medium)

More Detailed Notes (SPOILERS BELOW):

IMPORTANT: the below commentary DOES NOT SUBSTITUTE for READING THE BOOK.  Full stop. This commentary is NOT a comprehensive summary of the lessons of the book, or intended to be comprehensive.  It was primarily created for my own personal reference.

Much of the below will be utterly incomprehensible if you have not read the book, or if you do not have the book on hand to reference.  Even if it was comprehensive, you would be depriving yourself of the vast majority of the learning opportunity by only reading the “Cliff Notes.”  Do so at your own peril.

I provide these notes and analysis for five use cases.  First, they may help you decide which books you should put on your shelf, based on a quick review of some of the ideas discussed.  

Second, as I discuss in the memory mental model, time-delayed re-encoding strengthens memory, and notes can also serve as a “cue” to enhance recall.  However, taking notes is a time consuming process that many busy students and professionals opt out of, so hopefully these notes can serve as a starting point to which you can append your own thoughts, marginalia, insights, etc.

Third, perhaps most importantly of all, I contextualize authors’ points with points from other books that either serve to strengthen, or weaken, the arguments made.  I also point out how specific examples tie in to specific mental models, which you are encouraged to read, thereby enriching your understanding and accelerating your learning.  Combining two and three, I recommend that you read these notes while the book’s still fresh in your mind – after a few days, perhaps.

Fourth, they will hopefully serve as a “discovery mechanism” for further related reading.

Fifth and finally, they will hopefully serve as an index for you to return to at a future point in time, to identify sections of the book worth rereading to help you better address current challenges and opportunities in your life – or to reinterpret and reimagine elements of the book in a light you didn’t see previously because you weren’t familiar with all the other models or books discussed in the third use case.

Pages 8 – 12: one of the core premises of The Checklist Manifesto is that there are two primary drivers of errors: lack of knowledge (ignorance) or incorrect application of correct knowledge (mistakes).  As an analogy, the first category would be not knowing how to solve a trigonometry problem because you don’t know trigonometry.

The second category would be knowing how to solve a trigonometry problem, but forgetting SOHCAHTOA and solving for sine when you should be solving for cosine.  In the context of medicine, Gawande highlights a lot of statistics on how frequent these second-category errors are.  However, they can be difficult to address due to the hangups associated with them.

Page 18: in discussing the heroic (and miraculous) rescue of a little girl whose core body temperature had dropped to 66 degrees F (~19 degrees C), Gawande points out one of the core drivers of mistakes in medicine:

to save this one child, scores of people had to carry out thousands of steps correctly… the degree of difficulty in any one of these steps is substantial.  Then you must add the difficulties of orchestrating them in the right sequence.”

A good example of  path-dependency. Later, on page 24, Gawande cites an Israeli study which found that the average ICU patient required 178 meaningful actions by doctors/nurses daily… so a three-day stay means more than 500 points at which something could go wrong.  See also Megan McArdle on medical errors in “ The Up Side of Down ( UpD review + notes).

The mental model at work here is exponential growth / nonlinearity: while it might seem surprising to readers that error rates in medicine are so high, if ten percent of given procedures have a major error, that doesn’t mean that doctors are screwing up 10% of the time, necessarily.  Each individual procedure might be (and likely is) composed of numerous steps at which something could go wrong, and as I like to say, “any geometric series that includes a zero multiplies to zero.”

Page 22: on the difference between theory and practice, and local vs. global optimization:

“One of the most common diagnos[is categories in medical computer systems is] “Other.”  On a hectic day, when you’re running two hours behind and the people in the waiting room are getting irate, you may not take the time to record the precise diagnostic codes in the database.”   

Gawande later stresses the need for checklists to be practical.  

Page 33: The failure of Boeing’s Model 299 in 1935 was caused by the dramatically increased complexity of the airplane relative to previous aircraft; the investigation blamed the crash on “pilot error.”  This led to the creation of the airplane checklist (which is an interesting story), but this reminded me a bit of Don Norman’s The Design of Everyday Things ( DOET review + notes).  Anyway, here and elsewhere, aviation is the best example of the potential power of checklists.

Page 35: As I’ll discuss more later, I think some people, particularly investors, tend to read this book in a very lazy way (in some senses, I did too the first time).  Gawande specifically calls out here that just 1,000 trauma patients in the state of Pennsylvania had 32,261 unique combinations of diagnoses – obviously you can’t substitute mechanics for judgment.  Mentally bookmark this; we’ll come back to it later.

Page 36: Gawande highlights the “fallibility of human memory and attention” – see memory and Daniel Schacter’s The Seven Sins of Memory ( 7SOM review + notes) for an extensive discussion of this topic.

Page 38: note that, while it gets less airtime, equally important to the idea of a checklist itself is the idea of creating a culture where you’re allowed to call out superiors for mistakes.

Pages 39-40: checklists “helped with memory recall and clearly set out the minimum necessary steps in a process” and led to meaningful tangible improvements.  

But when “genius” doctor Peter Provonost tried to get buy-in from other hospitals for adopting a checklist, it was slow… Gawande here and elsewhere implies a lot of this was due to a combination of ego and the perceived silliness of checklists (later in the book, Gawande himself later notes that he felt “hokey” introducing himself to team members, even though this was an important step in the process.)

Pages 49 – 50: I think way more people throw around the word “checklist’ than have actually deeply read and considered Gawande’s book.  Gawande breaks down problems into various categories, and as referenced on Page 35 (and elsewhere, later), it’s not really possible or practical to checklist-ize everything.  The idea is just to use it to provide a margin of safety for the key failure points that are easy to forget.

Here, Gawande also references “forcing functions” – an example of structural problem-solving (or, if you prefer, “human-centered design”) of the type discussed in The Design of Everyday Things. Norman discusses forcing functions on pages 141 – 145 of DoET.

Page 55: amusing anecdote about how engineer Joe Salvia decided not to become a doctor because of o-chem –

“why do I have to memorize them if I know where the book is?  […] that seemed ridiculous to me.  Plus I wasn’t good at memorizing.  So I quit.”  

And yet so much of education is sadly like this.

Pages 76 – 78: interesting discussion on how Wal-Mart managed (literally) to help during Hurricane Katrina.

Page 80: on Van Halen using brown M&Ms as a proxy for whether or not the stage was set up safely and correctly…  product vs. packaging

Pages 81 – 85: as a foodie, I appreciated this

Page 87: nice psychology…

Page 91: here, Gawande provides statistics on complications rates for surgery (5 – 15%), which seems astonishingly high but isn’t really when you think about the geometric series.  See also dependent events and Megan McArdle on medical errors in The Up Side of Down (UpD review + notes).

Page 91: selection bias and incentives… one challenge with pay-for-performance is it incentivizes doctors to solve easier problems (healthier patients) rather than harder ones (sicker patients)

Page 92: on the importance of human-centered design / structural problem solving, including empathy and  product vs. packaging: Gawande, walking through the basement of the World Health Organization, notices

“pallet after pallet of two-hundred-page guideline books [from third-party expert groups…] on malaria prevention, HIV/AIDS treatment, and influenza management, all shrink-wrapped against the gathering dust.  […] At the bedsides of patients in Bangkok and Brazzaville, Boston and Brisbane, little had changed.”  

Good content delivered in an unusable format isn’t helpful.

Pages 95 – 97: the soap study is interesting in more ways than one.  They found a leverage point (soap) to change behavior to achieve a positive outcome, but again there’s an example of human-centered design and empathy.  Per CDC doctor Stephen Luby,

“Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not.”

Also, a nice reminder to wash your hands!

Page 98: Gawande cites a study at Columbus Children’s Hospital finding that one-third of their appendectomy patients didn’t receive appropriate antibiotics during the correct window prior to surgery.  He notes, on  humans vs. econs and mistakes, that:

“[doctors and nurses] assume we get this kind of simple task right 100% of the time.  But in fact we don’t.  With all the flurry of things that go on[…]”

Pages 101 – 102: again, I don’t think most people read this book very carefully/correctly.  Gawande notes that surgery has four big killers; for three of them:

“science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t.  These misses are simple failures – perfect for a classic checklist.”  

For more complex, unexpected problems, though:

“no one checklist could anticipate all the pitfalls a team must guard against.  So they had determined that the most promising thing to do was just to have people stop and talk through the case together.”

A good example of  dose-dependency.

Page 103: made me laugh.  But also, Gawande noting one of the causes of disaster is a culture of “that’s not my problem”

Pages 107 – 108: here’s the reference to the process feeling “hokey” – but it worked.  Apparently, you work better with people whose names you know, and having everyone speak up lowered the activation energy for speaking again.

Page 113: what happens with a checklist that’s too clunky: you don’t use it

Pages 116 – 119: really interesting

Page 120: good checklists are not supposed to turn people’s brains off rather than turn them on,” as Gawande puts it.  

And yet most investors who discuss checklists seem to use them this exact way: as a substitute for, rather than a complement to, judgment.  

Gawande goes on to note that good checklists are simple and straightforward.  On Page 123, he emphasizes the importance of focusing on “killer items” (areas where things could go really wrong) rather than every little thing.  Good example of marginal utility / 80-20.

Elsewhere, he provides a tangible example: in his own operating room, while he considered using a checklist to ensure fire safety, it was distracting and fires aren’t enough of a statistical risk to make it worthwhile.  

Page 121: as important as the checklist is the process and organizational culture around the checklist.  

Page 128: Gawande again emphasizes that checklists are “not comprehensive how-to guides”

Page 133: back to the concept of human-centered design: Gawande cites a statistic from a study that found that it took doctors seventeen years, on average, to adopt certain new breakthrough treatments.  Why?  Gawande’s take is that:

“more often [than not], the necessary knowledge has not been translated into a simple, usable, and systematic form.”  

700,000 medical journal articles are published per year, and obviously nobody could keep up with all of them (even just in your own specialty).  Cue the Shawn Achor quip about six people, including the author’s mom, reading journal articles… one to many is here as well.

Pages 138 – 139: here’s the discussion of fires I mentioned

Page 145: going back to the earlier notes about path-dependency and  nonlinearity, here’s how prevalent errors are in surgery: Gawande’s team found one of six critical surgery safety steps was missed two-thirds of the time.

Page 147: I can’t remember why now, but at the time, there was something here

Page 155: in an example of careful science, Gawande makes sure that the power of the checklist isn’t just a result of the observer effect / Hawthorne Effect

Page 164: the section on investing is the only weak link in the book, but it’s not long enough to be worth skipping

Page 172: not really sure that a “checklist-driven approach” is the core issue here so much as a growth mindset.

Page 174: Sully!

Page 177: a good reiteration of what good checklists are and what bad checklists are (the checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with.”)  In other words, cognitive load reduction so you can, as Gawande puts it, “focus on the hard stuff.”

Also, don’t forget to FLY THE AIRPLANE.

Page 183: “We are built for novelty and excitement, not for careful attention to detail.”  I need to read more about novelty/sensation-seeking.  Also an important note at the bottom of the pages about the need to refine and update checklists… you can’t set them in stone and forget them.  Cross-reference Feynman and the disease of bad ideas i culture –  The Pleasure of Finding Things Out – PFTO review + notes –  pages 184-185.

Page 191: margin of safety


First Read: 2014 – 2015

Last Read: February 2018

Number of Times Read: 2


Review Date: February 2018

Notes Date: February 2018