Yet his latest article in the New Yorker, "How Do Good Ideas Spread?" focuses on the limits of the relatively simple checklist approach:
Gawande's piece focuses on what makes changing medical practices so difficult. He contrasts the rapid adoption of anesthesia with the incredible resistance of the medical establishment to Joseph Lister's theory of antisepsis (essentially, that doctors should wash their hands).
"So what were the key differences? First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn’t be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons’ hands. You can imagine why Lister’s crusade might have been a tough sell.
This has been the pattern of many important but stalled ideas. They attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful."
He goes on to describe his efforts to improve medical care for childbirth in rural India. At first, the challenge seems insurmountable. The hospitals lack resources, and the doctors and nurses, while dedicated, are stretched beyond belief. Numerous educational campaigns had failed.
"In the era of the iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions to the major difficulties of the world—hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions.What finally seems to work? Sustained 1:1 interaction.
But technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers. Mass media can introduce a new idea to people. But, Rogers showed, people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process."
Many startups use technology to change behavior. But sometimes, the best technology is simply sitting down with your user. It's long and messy, but it works.
“Why did you listen to her?” I asked. “She had only a fraction of your experience.”
All the nurse could think to say was “She was nice.”
“She was nice?”
“She smiled a lot.”
“That was it?”
“It wasn’t like talking to someone who was trying to find mistakes,” she said. “It was like talking to a friend.”