“Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.”
— Atul Gawande
We fail for two reasons. The first is ignorance and the second is ineptitude. In The Checklist Manifesto: How to Get Things Right, Atul Gawande explains:
In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed, is “necessary fallibility” — some things we want to do are simply beyond our capacity. We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is—and will remain—outside our understanding and control.
There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snowstorms, save people from heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre point out, we have just two reasons that we may nonetheless fail.
The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.
For most of history, we've failed because of ignorance. We had only a partial understanding of how things worked.
In Taking the Medicine, Druin Burch writes:
Doctors, for most of human history, have killed their patients far more often than they have saved them. Their drugs and their advice have been poisonous. They have been sincere, well-meaning and murderous.
We used to know very little about the illnesses that befell us and even less about how to treat them. But, for the most part, that's changed. Over the last several decades our knowledge has improved. This advance means that ineptitude plays a more central role in failure than ever before.
Heart attacks are a great example. “Even as recently as the 1950s,” Gawande writes, “we had little idea of how to prevent or treat them.” Back then, and some would argue even today, we knew very little about what caused heart attacks. Worse, even if we had been aware of the causes, we probably wouldn't have known what to do about it. Sure we'd give people morphine for pain and put people on bed rest, to the point where people couldn't even get out of bed to use the bathroom. We didn't want to stress a damaged heart. When knowledge doesn't exist, we do what we've always done. We pray and cross our fingers.
Fast-forward to today and Gawande says “we have at least a dozen effective ways to reduce your likelihood of having a heart attack—for instance, controlling your blood pressure, prescribing a statin to lower cholesterol and inflammation, limiting blood sugar levels, encouraging exercise regularly, helping with smoking cessation, and, if there are early signs of heart disease, getting you to a cardiologist for still further recommendations.”
If you should have a heart attack, we have a whole panel of effective therapies that can not only save your life but also limit the damage to your heart: we have clot-busting drugs that can reopen your blocked coronary arteries; we have cardiac catheters that can balloon them open; we have open heart surgery techniques that let us bypass the obstructed vessels; and we’ve learned that in some instances all we really have to do is send you to bed with some oxygen, an aspirin, a statin, and blood pressure medications—in a couple days you’ll generally be ready to go home and gradually back to your usual life.
Today we know more about heart attacks but, according to Gawande, the odds a hospital deals with them correctly and in time are less than 50%. We know what we should do and we still don't do it.
So if we know so much, why do we fail? The problem today is ineptitude. Or, maybe, simply “eptitude” — applying knowledge correctly and consistently.
The modern world has dumped a lot of complexity on us and we're struggling to keep our heads above water. Not only is the complexity of knowledge increasing but so is the velocity. The world is getting more complex. This challenge is not limited to medicine. It applies to nearly everything.
Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result so has our struggle to deliver on them. You see it in the frequent mistakes authorities make when hurricanes or tornadoes or other disasters hit. You see it in the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screw ups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge.
Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. What do you mean half of heart attack patients don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors? It is not for nothing that the philosophers gave these failures so unmerciful a name—ineptitude. Those on the receiving end use other words, like negligence or even heartlessness.
Those of us who make mistakes where knowledge is known feel like these judgments ignore how difficult today's jobs are. Failure wasn't intentional and the situation is not as black and white.
Today there is more to know, more to manage, more to keep track of. More systems to learn and unlearn as new ones come online. More emails. More calls. More distractions. On top of that, there is more to get right and more to learn. And this, of course, creates more opportunity for mistakes.
Our typical response, rather than recognising the inherent complexity of the system by which judgments are made, is to increase training and experience. Doctors, for example, go to school for many years. Engineers too. Accountants the same. And countless others. All of these professions have certifications, continuous training, some method of apprenticeship. You need to practice to achieve mastery.
In the medical field, training is longer and more intense than ever. Yet preventable failures remain.
So here we are today, the start of the twenty-first century. We have more knowledge than ever. We put that knowledge into the hands of people who are the most highly trained, hardest working, and skilled people we can find. Doing so has created impressive outcomes. As a society, we've done some amazing things.
Yet despite this, avoidable failures are common and persistent. Organisations make poor mistakes even when knowledge exists that would lead them to make different decisions. People do the same. The know-how has somehow become unmanageable. Perhaps, the velocity and complexity of information has exceeded our individual ability to deal with it. We are becoming inept.
Gawande's solution to deal with ineptitude is a checklist. The Checklist Manifesto: How to Get Things Right is fascinating and eye-opening in its entirety.