Dr. Checklist admits that “No one really ever has control.”

Atul Gawande’s latest book Being Mortal concludes, in the words of one reviewer, that “sometimes the only sure way to gain control is first to relinquish it, whether to a bad disease, a dying patient or the constraints of a finite life span.”  Let go.  That sounds familiar.

Dr. Gawande’s most recent best-seller The Checklist Manifesto presented the case for using checklists to control and improve the quality of medical care, as well as other complicated procedures.  The emergency management manuals of municipalities in New Jersey, and I assume elsewhere throughout the country, contain detailed outlines of procedures to be employed in various emergencies–who does what, where, when and how, including who makes which decisions.  Accompanying these procedures are checklists to use during an actual emergency asking whether each of these required steps has been done and done correctly.  In a crisis such checklists help emergency personnel focus on the job and filter out the distractions caused by many things happening at once or by emotion.  We did “table top” exercises at least once a year to test how these procedures worked, and field exercises every year or two.  After almost every exercise, whether on paper or on scene, we would encounter problems we had not anticipated.  The procedures and the checklists would get updated to account for what we’d learned.  Then we’d have a real emergency and run into something we still had not anticipated.

The U.S. Marines have a saying for how to deal with the unexpected: Adapt. Improvise.  Overcome.  To adapt is to let go of expecting a certain order in events.  To improvise is to imagine what is going on in new ways and to imagine new ways of how to handle what is going on.  Given that this comes from the Marines, many people would probably interpret “overcome” as referring to physical force applied to an “enemy.”  In practice, in battle, what needs to be overcome first is oneself—not only one’s fears and expectations, but perhaps even more one’s false beliefs about one’s limited abilities to control the outcome.

In the end, checklists cannot anticipate every contingency.  In the end, even the most perfectly executed procedure may fail.  All we can do is to keep adapting, improvising, and overcoming, each step working by letting go of what we think is going on, what we think is the only way to work on the problem, and of the fallacy that can control all that is happening.

It was a good thing that this post was relatively short.  The first time I clicked to save it on the website, everything disappeared and a message came on the screen: You are not on the internet.


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