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NancyLebovitz comments on Open Thread: May 2010, Part 2 - Less Wrong
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Gawande on checklists and medicine
Checklists are literally life-savers in ICUs-- there's just too much crucial which needs to be done, and too many interruptions, to avoid serious mistakes without offloading some of the work of memory onto an system.
However, checklists are low status.
I suggest that the problem starts earlier than rock-starism. Conventional schooling still tests on memory, and I think there's a leftover effect that one ought to be able to remember the basics, or be shown to be an inferior sort of person.
Sidetrack into science fiction: Varley's Eight Worlds stories have it that medicine has become so advanced and routinized that it's a low status occupation for people who want to work with their hands. When I read the stories, I wondered if he was getting a little indirect revenge on doctors. I do wonder what it could take for that to happen to medicine. Anyone have histories of de-professionalization in any field?
There's also a book: The Checklist Manifesto: How to Get Things Right:
Journalism, ongoing, according to some. Clay Shirky's book Here comes everybody makes an interesting link between this process and Ronald Coase's theory of the firm.
Surely not intrisically. Think of astronauts' checklists.
Suggestion: instead of "low status" as an explanation for why people do or don't do something, look for something closer to the specific domain. (Is it possible that doctors' practice is much influenced by media portrayal of how doctors behave? By expectations of their "customers"?)
Morendil:
Astronauts are soldiers. Unlike doctors, soldiers have a huge incentive not to let their beliefs depart too far from reality because of status or any other considerations, for the simple reason that it may easily cause them personally, and not just someone else, to get killed or maimed. Thus, military culture is extremely practice-oriented. Due to their universal usefulness, checklist-driven procedures are a large part of it, and having to participate in them is not considered demeaning, even for super-high-status soldiers like fighter pilots. Eventually, strict rule-driven procedures associated with the military often even develop a cool factor of their own (consider launch or takeoff scenes from war action movies).
Of course, soldiers who lack such incentives will, like WW1 generals, quickly develop usual human delusions driven by status dynamics. But astronauts are clearly not in that category.
So your narrative is "checklists fail to take root because they are low-status, except where their being a serious matter for the people who use them (not just bystanders) causes them to be accepted, and in one such case they gain high status for extraneous reasons".
Why, then, isn't the rising cost of malpractice insurance enough to drive acceptance of checklists? What does it take to overcome an initial low-status perception? How do we even explain such perception in the first place?
As I understand it, drastic, rare, and somewhat random punishment does little to change behavior. Reliable small punishments change behavior.
That analysis would be inconsistent with my understanding of how checklists have been adopted in, say, civilian aviation: extensive analysis of the rare disaster leading to the creation of new procedures.
Again, my point was to prompt an alternative explanation to the hypothesis "checklists are not used by surgeons because the practice is intrinsically low-status". Why (other than the OB-inherited obsession of the LW readership with "status") does this hypothesis seem favored at the outset?
How would we go about weighing this hypothesis against alternatives? For instance, "checklists are not used because surgeons in movies never use them", or "checklists are not used because surgeons are not trained to understand the difference between a checklist and a shopping list", or "checklists are not used because surgeons are reluctant to change their practices until it becomes widely accepted that the change has a proven beneficial impact"?
Morendil:
One relevant difference is that the medical profession is at liberty to self-regulate more than probably any other, which is itself an artifact of their status. Observe how e.g. truckers are rigorously regulated because it's perceived as dangerous if they drive tired and sleep-deprived, but patients are routinely treated by medical residents working under the regime of 100+ hour weeks and 36-hour shifts.
Even the recent initiatives for regulatory limits on the residents' work hours are presented as a measure that the medical profession has gracefully decided to undertake in its wisdom and benevolence -- not by any means as an external government imposition to eradicate harmful misbehavior, which is the way politicians normally talk about regulation. (Just remember how they speak when regulation of e.g. oil or finance industries is in order.)
The reason I attach high plausibility to such explanations is simply that status is the primary preoccupation of humans as soon as their barest physical subsistence needs are met. Whenever you see humans doing something without an immediate instrumental purpose, there is a very high chance that it's a status-oriented behavior, or at least behavior aimed at satisfying some urge that originally evolved as instrumental to human status games.
The alternatives you mentioned are by no means incompatible with status-based explanations, and some of them are in fact reducible to it. For example, the behavior of doctors in TV shows is a reflection of the whole complex of popular beliefs and attitudes from which the medical profession draws its extraordinary status -- and which in turn shapes these beliefs and attitudes to some extent. So, as I wrote in one of my other comments, if doctor TV shows started showing cool-looking checklist rituals prior to the characters' heroic exploits, these rituals would probably develop a prestigious image, like countdown procedures in action movies, which would likely facilitate their adoption in practice.
At the very least this seems to be privileging an extraversion hypothesis. You can only gain status by interacting in some way with other people, yet it is not uncommon for people to shun company and instead devote time to solitary occupations with scant status benefits.
Under your justification for favoring status explanations, the only reason anyone ever reads a book is to brag about it. This seems wrong, prima facie, as well as simplistic.
Morendil:
Note that I also mentioned "satisfying some urge that originally evolved as instrumental to human status games" in my above statement. Today's world is full of super-stimuli that powerfully resonate with ancestral urges even though they don't actually lead towards the goals that these urges had originally evolved to promote, and are often even antithetical to these goals. Just like candy bars cheat the heuristic urges that evolved to identify nutritious and healthy food in the ancestral environment, it is reasonable to expect that solitary occupations with scant (or even negative) status benefits cheat the heuristic urges that originally evolved as useful in status games, or for furthering some other goal that they no longer achieve reliably in the modern environment.
You will probably agree that super-stimulation of status-seeking urges explains at least some non-beneficial solitary activities with high plausibility, for example when people neglect their real-life responsibilities by getting caught up in the thrill of virtual leadership and accomplishment provided by video-games. Of course, this by no means applies to all such activities; it is likely that the enjoyment found in some of them is rooted in urges that evolved for different reasons.
To address your above example, unless we assume some supernatural component of the human mind, I see no possible explanation of human book-reading except as a super-stimulus for some ancestral urges (whether status-related or not), unless of course it's done not for enjoyment, but purely to acquire information necessary for other goals. While it's far from being a complete explanation of human book-reading, it seems plausible to me that people sometimes enjoy books in part because it enhances their status signaling abilities in matters of erudition and taste. Also, it seems to me that stories super-stimulate the human urges for gossip, which are likely a device with an original status-related purpose, and all sorts of complex information may super-stimulate curiosity, whose evolution has likely been only partly status-based. These are of course just rough outlines of the complete truth, which we don't yet know.
On the other hand, to get back to the original topic, when it comes to issues where actual power and prestige in human societies is at stake, in any case I've ever given much thought, the prominent role of widespread status-related beliefs and behaviors seems to me strikingly obvious and without any rival explanations that would be even remotely as plausible. The ability to account for such explanations by evolutionary theories additionally enhances their plausibility, as well as the fact that many deep and accurate insights into human nature by classical writers and philosophers can be faithfully retold in the more explicit modern language of status dynamics.
There's nothing "super" about a book: no corresponding "normal" stimulus that elicits a natural response, such that a book is an exaggerated version of it.
Book-reading is explained straightforwardly enough as satisfying curiosity, a trait we share with many species (think cats).
If reading a book sometimes trumps the quest for status, then the latter cannot be THE primary preoccupation of people beyond bare physical subsistence. You will at least need to retreat to "an important" preoccupation.
Now, if you were to explore this topic without jumping to conclusions, perhaps you'd recognize this one example as the start of a list, and would in an unbiased manner draw up a somewhat realistic list of the activities typical humans engage in, and sort them into "activities having a high status component" and "activities not primarily status-related". Then we might form a better picture of "how important".
I just want to throw in a note that I don't think human motivation is adequately explained by status alone -- I would expand the list to SASS: Status, Affiliation, Safety, and Stimulation. (Where, as some folks here have pointed out, "Safety" might be more accurately described as stability, certainty, or control, rather than being purely about physical safety.)
Book-reading, in particular, is more likely to meet Safety/Stimulation needs than Status or Affiliation ones.... though you could maybe get those latter two from a book club or an academic setting.
In the spirit of Morendil's question: what other professions should be shunning useful but low-status tools (particularly checklists) for the same reason as doctors, according to the status model? I don't know enough about (a) lawyers, (b) politicians, (c) businesspeople, (d) salespeople, or (e) other high status professions to judge either what your model would predict or what they do.
It's worth noting that engineering is (moderately-)high-status but involves risk of personal cost in case of error, making the fact that it shows widespread adherence to restrictive professional standards explicable under the status theory.
Now that's an interesting question! Off the top of my head, some occupations where I'd expect that status considerations interfere with the adoption of effective procedures would be:
Judges -- ultra-high status, near-zero discipline for incompetence.
Teaching, at all levels -- unrealistically high status (assuming you subscribe to the cynical theories about education being mostly a wasteful signaling effort), fairly weak control for competence, lacking even clear benchmarks of success.
Research in dubious areas -- similarly, high status coupled with weak incentives for producing sound work instead of junk science.
For example, there are research areas where statistical methods are used to reach "scientific" conclusions by researchers with august academic titles who are however completely stumped by the finer points of statistical inference. In some such areas, hiring a math B.A. to perform a list of routine checks for gross errors in statistics and logic would probably prevent the publication of more junk science than their entire peer review system. Yet I think status considerations would probably conspire against such a solution in many instances.
I disagree somewhat that judges face near-zero discipline for incompetence. Except for judges on the highest court in a jurisdiction, most judges frequently face the prospect that the opinions they author may be reversed. It is true that frequent reversals will almost never lead to the sanction of the judge losing his or her job (due to lifetime appointments or ineffectiveness of elections at removing incumbent judges except for the most serious and publicized faults). But the resulting hit to status for frequent reversals can be quite serious; and because judges are so high status, as you note, they tend to be very concerned with maintaining that status. The handful of judges I've known personally have been quite concerned with their reversal rate and they particularly don't want to be reversed in a way that is embarrassing to them because it suggests laziness, incompetence, poor reasoning, cutting corners, or the like. (On the other hand, reversal for disagreements that can be characterized as “political” is probably not seen as quite so status-lowering.) At any rate, the law does provide checklist-like procedures or guidelines in many instances, and most judges do follow them, at least in part because failure to do so could lead to reversal.
Expanding on your example of judges- this fits in with general problems for people in the legal professions. For example, there have now been for many years pretty decent understanding about problems with the standard line-up system for criminal suspects. There are also easy fixes for those problems. Yet very few places have implemented them. Similarly, there have been serious problems with police and judges acting against people who try to videotape their interactions with police. Discussing this in too much detail may however run into the standard mind-killing subject.
Morendil:
My understanding is that the present (U.S.) system of malpractice lawsuits and insurance doesn't leave much incentive for extraordinary caution by individual doctors. Once you've paid your malpractice insurance, which you have to do in any case, you're OK as long as your screwups aren't particularly extreme by the usual standards. Moreover, members of the profession hold their ranks together very tightly, and will give up on you only in cases of extremely reckless misbehavior. They know that unlike their public image, they are in fact mere humans, and any one of them might find himself in the same trouble due to some stupid screwup tomorrow. And to establish a malpractice claim, you need not only be smart enough to figure out that they've done something bad to you, but also get expert testimony from distinguished members of the profession to agree with you.
I am not very knowledgeable about this topic, though, so please take this as my impression based on anecdotal data and incomplete exposure to the relevant literature. It would be interesting if someone more knowledgeable is available to comment.
I'd say that in a sense, it's a collective action problem. The pre-flight checks done by fighter pilots (and even to some extent by ordinary pilots) are perceived as cool-looking rituals, and not a status-lowering activity at all, because these procedures have come to be associated with the jobs of high-status individuals. Similarly, if there was a cool-looking checklist procedure done by those doctors on TV shows, presented as something that is only a necessary overture for acts of brilliance and heroism, and automatically associated with doctors in the popular mind, it would come to be perceived as a cool high-status thing. But as it is, in the present state of affairs, it comes off as a status-lowering imposition on people whose jobs are supposed to be one hundred percent about brilliance and heroism.
Also, there is the problem of the doctor-nurse status disparity. Pilots, despite having much higher status, don't look down on their mechanics much; after all, they have to literally trust them with their lives. (And it's similar for other military examples too.) Not so for doctors; it is probably a humiliating experience for them to be effectively supervised and rebuked for errors by nurses. (Again, I'm not an insider in the profession, so this is just my best guess based on the available information.)
The above cited article answers that question almost directly: the idea that typical doctors are doing such a lousy job that they would benefit from a simple checklist to avoid forgetting trivial routine things contradicts the very source of their high status, namely the public perception of them as individuals of extraordinary character and intellectual abilities, completely unlike us ordinary folks who screw things up all the time by stupidly forgetting some simple detail. The author, as I noted earlier, feels the need to disclaim such implications to avoid sounding too radical and offensive. Medicine has been a subject of magical thinking in every human culture, and ours is no exception.
The people who decide malpractice suits are likely to be more sympathetic to pleas of having used one's judgment and experience but making a mistake, over having used a rigid set of rules from which one did not deviate even as the patient took a turn for the worse.
Yes, there is a powerful irrational status-driven reaction against the idea that something so rudimentary as checklists could improve the work of people who are a subject of high status reverence and magical thinking. Note how even in this article, the author feels the need for pious disclaimers, denying emphatically in the part you quoted that this finding presents any evidence against the heroic qualities of character and intellect that the general public ascribes to doctors.
Of course, the fact that this method dramatically inverts the status hierarchy by letting nurses effectively supervise doctors doesn't help either. In our culture, when it comes to immense status differences between people who work closely together, relations between doctors and nurses are probably comparable only to those between commissioned officers and ordinary soldiers. I don't think such a wide chasm separates even household servants from their employers.
This reminds me of the historical case of Ignaz Semmelweis, who figured out in mid-19th century, before Pasteur and the germ theory of disease, that doctors could avoid killing lots of their patients simply by washing their hands in disinfectant before operations. The reaction of the medical establishment was unsurprising by the usual rules of human status dynamics -- his ideas were scornfully rejected as silly and arrogant pseudoscience. What effrontery to suggest that the august medical profession has been massively killing people by failing to implement such a simple measure! Poor Semmelweis, scorned, ostracized, and depressed, turned to alcoholism and eventually died in an insane asylum. Hand-washing yesterday, checklists today.
I'm pretty sure it's more complicated than that. My impression is that experienced nurses can generate some clout, and that (if I can believe Heinlein) experienced sergeants can have influence over new lieutenants. This is informal, and dependent both on the ability of the subordinate to be firm without seeming to upset the hierarchy and the receptiveness of the person who's theoretically in charge.
Does anyone have actual information?