Sunday, March 14, 2010

Preferring Process Is Tough

In Complications, Atul Gawande writes about how we should prefer process over results, becase,
Good decision can have bad results (sometimes people must take terrible chances), and bad decisions can have good results.
In other words, you should evaluate your decisions on the basis of the knowledge that you had when you made the decision. Be process-oriented as opposed to results-oriented.

This is a noble maxim, but it's important to recognize just how hard it is. For example, elsewhere in the book, Gawande describes the case of a patient whose treatment went awry:
In a lab test done the day before, the patient's clotting had seemed slow, which wasn't serious, but an ICU physician had decided to correct it with vitamin K. A frequent side effect of vitamin K is blood clots. I was furious. Giving the vitamin was completely unnecessary--just fixing a number on a lab test. Both the chief resident and I lit into the physician. We all but accused him of killing the patient.
So they blame the resident for administering vitamin K, which was apparently a bad decision. But when autopsy shows that the vitamin K-induced blood clots were in fact not the cause of death, Gawande writes that,
In the days afterward, I apologized to the physician I'd reamed out over the vitamin.
It is good to admit it when you have erred, but I don't see why Gawande would apologize here. Either the resident administering vitamin K was a bad decision at the time it was made or it wasn't--the specific cause of death, the "result," shouldn't change anything.

I don't mean to pick on Gawande. What this example shows is that even people who write about preferring process over results have a tough time applying it. It is really quite an unnatural thing to do.


Gawande's three books are all interesting, but Better is the most data-deluged (a good thing) and focused. Checklist Manifesto should have cut the fluff and focused more on the interesting explanation that checklists have yet to be adopted despite yielding huge results because they are low status.