Posts Tagged 'Atul Gawande'

Thoughts on how we can make a “worthy difference”

There are some things that people do that matter far more than others. In this post from March 2013 surgeon Atul Gawande offers his thoughts on what those things are.

8 ways you can become a positive deviant

In Better: A Surgeon’s Notes on Performance, physician Atul Gawande describes a talk he gave to medical students addressing the topic, “How do I really matter?” He decided to offer “five suggestions for how one might make a worthy difference, for how one might become, in other words, a positive deviant.”

(In another post I defined positive deviants as individuals who with the same resources available to their peers achieved more favorable outcomes. They do so through identifiable behaviors that distinguish their performance from that of others.)

In his talk Gawande suggested: 

Ask an unscripted question. “You don’t have to come up with a deeper important question, just one that lets you make a human connection,” he wrote.

Don’t complain. “[N]othing in medicine is more dispiriting than hearing doctors complain.”

Count something. “It doesn’t really matter what you count… The only requirement is that whatever you count should be interesting to you.”

Write something.

Change. “[M]ake yourself an early adopter,” Gawande recommended. “Look for the opportunity to change…. Be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure.”

Gawande’s suggestions lead me to think more deeply about the behaviors of school leaders whom I have viewed as Positive Deviants. 

 I concluded that they possessed one or more of the following habits:

1. Writing to gain clarity and to communicate;

2. “Counting” things to improve their performance (most things that count can be measured, even if only in rudimentary ways);

3. Reading widely in search of new ideas, perspectives, and inspiration;

4. Continuously seeking more effective and efficient ways to do things; 

5. Engaging the support of others when challenged by stretching goals or demanding circumstances;

6. Persisting over many months and even years to achieve important goals because the values represented by those goals were so important;

7. Seeing things in unique ways that were in opposition to accepted wisdom or common practice; and

8. Assuming that important problems can be solved, and that working alone or in collaboration with others they would contribute to their solutions.

What behaviors would you add to this list?

How checklists can improve teaching and leadership

Even under the best of circumstances good teaching is an incredibly complex task which can appear almost effortless to the casual observer.

The intellectual, emotional, interpersonal, and even physical demands of teaching cannot, however, be underestimated.

Therefore, a “fundamental” of leadership is that teachers and principals use whatever tools are at hand to manage those demands. 

Checklists are just such a tool that when effectively used enable teachers to focus their cognitive abilities on the unexpected moment-to-moment changes in the classroom that make teaching an improvisational art.

That is why I’m bringing back an essay from April 2013 on the subject of checklists that also happens to be my most-viewed post.

The power and uses of checklists for teachers and administrators

Checklists are a simple but powerful way to improve individual and group performance. They are declarations of standards that ensure that important tasks are completed.

By routinizing certain procedures, checklists ensure that higher-order mental processes are available for complex, non-routine events, which is why they are regularly used by surgeons and airplane pilots, as well as by those engaged in other demanding occupations.

Physician Atul Gawande makes the case for checklists in his book, The Checklist Manifesto: How to Get Things Right. (An earlier post elaborates on the educational implications of this book and others by Gawande.)

While good checklists are precise, Gawande notes, “They do not try to spell out everything – a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps – the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical.”

Checklists, Gawande adds, “… can help experts remember how to manage a complex process… They can make priorities clear and prompt people to function better as a team.” 

To illustrate the ways in which checklists can improve group functioning, Gawande explains how they can level hierarchy and distribute power in ways that can save patients’ lives when they require surgical team members to introduce themselves before surgery and to state their roles and unique perspectives regarding the procedure. 

Checklists have a number of important applications in school settings:

• Checklists could be used by teachers in preparing lessons, like this checklist for project-based learning.

• Checklists could be used by principals and teacher leaders in preparing for faculty or team meetings based on the ingredients of successful faculty meetings that I offered in this post.

• Checklists could be used to increase influence using the elements contained in the SUCCESS acronym as a guide (see my previous post).

• Checklists could be used in developing both long-range and short-term professional learning plans for schools and school systems. Here are a few things that might be included on such checklists:

___ Focuses on priority areas of student learning based on various sources of evidence, including but not limited to standardized tests;

___ Addresses core tasks of teaching such as the development of engaging student work and using assessments to promote learning;

___ Engages all teachers in learning, not just volunteers;

___ Occurs virtually every day as a routine part of teachers’ collaborative work on high-functioning teams—PLCs, grade level, department, or other structures;

___ Assesses effects of professional learning based on changes in instructional practices and improvements in student learning. 

The acronym CREATE could be used to help planners remember those ingredients: Core tasks of teaching, Results for students, Every day, All teachers, Team-based learning, Evidence-based decision making. 

What additional uses do you see for checklists in educational settings?

Our failure to conceive the idea of…

IMG_1365I appreciate letters to the editors and blog comments that enable me to see a problem and its solutions in fresh ways.

My previous post described physician Atul Gawande’s New Yorker perspective regarding the uneven pace of medical innovation and my thoughts about the implications of his views for education.

A couple of weeks later this letter written by Daniel Mark Fogel of the University of Vermont appeared in the magazine:

Gawande begins with an example of an innovation that spread rapidly after 1846: William Morton’s use of gas to render patients insensible to pain. This advance has been pondered elsewhere, however, as a discovery that surgeons were agonizingly slow to adopt. In 1800, the English chemist and inventor Humphry Davy, in his book “Researches,” described the anesthetic properties of nitrous oxide, remarking, “As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage in surgical operations.” This discovery caught the attention of Samuel Taylor Coleridge, to whom Davy’s publisher sent “Researches.” Richard Holmes, who tells the story in some detail in his book “The Age of Wonder: How the Romantic Generation Discovered the Beauty and Terror of Science,” relates that Coleridge wrote to Davy, pressing him to pursue the matter with Coleridge’s friend Sir Anthony Carlisle, a leading London surgeon. Yet nearly half a century of excruciating pain for surgical patients was to pass before the date when Gawande takes up the story. Holmes suggests that the best explanation for the failure to adopt anesthesia is that surgeons—who prided themselves on the speed with which they operated and on their psychological mastery of pain—were simply unable to conceive of the idea of painless surgery.

“The failure to conceive the idea of…”—that is exactly it!

The failure to “conceive the idea” that:

• Virtually all students can learn important things given high-quality teaching and sufficient time

• Learning for both adults and young people is as much about effort as it about “smarts.”

• It is possible to design schools in which everyone in the school community experiences engagement, success, and satisfaction virtually every day.

• Together we are better than we are alone—teaching and school leadership are not independent activities but part of a larger, interdependent whole.

What ideas would you add to this list?

Why the spread of new teaching practices cannot be “teacher proofed”

IMG_1365

Education should be more like medicine, educators are often told. High-quality research is disseminated to physicians who unfailingly apply it to improve healthcare.

It is a simple and appealing idea, but it is one that often breaks down in examination rooms as physicians’ biases and habits meet patients’ unwillingness or inability to comply with treatment plans.

Like new teaching approaches, however, medical innovations spread at different speeds, a phenomenon explored by Atul Gawande in “Slow Ideas” in the July 29, 2013 issue of the New Yorker. Here are two examples:

Before surgical anesthesia was discovered in the mid-1800s, “… attendants pinned patients down as they screamed and thrashed, until they fainted from the agony,” Gawande writes. Within a year of its invention anesthesia spread around the world, although, as Gawande notes, “… there were forces of resistance…. Some people criticized anesthesia as a ‘needless luxury’; clergyman deplored its use to reduce pain during childbirth as a frustration of the Almighty’s designs.”

Another major innovation in medical-practice came along a decade or two later, this time the elimination of germs to prevent infection, a leading cause of death at that time. In this case, however, it took a generation for the recommendations to become routine.

Reasons for the uneven spread of innovation

Gawande suggests likely causes for the varied speed of implementation—the source of some problems were invisible (for instance, germs), and new practices may have been contrary to physicians’ beliefs and/or were more technically complex to apply.

“This has been the pattern of many important but stalled ideas,” Gawande writes. “They attack problems that are big but, to most people, invisible; and making them work can be tedious, if not outright painful.”

Gawande notes the power of institutional culture and the failures of traditional approaches to change—seeking to persuade through “rational evidence,” making demands accompanied by threats, or offering incentives. “[N]either penalties nor incentives achieve what we’re really after: a system and a culture where X is what people do, day in and day out, even when no one is watching.”

“In the era of the iPhone, Facebook, and Twitter,” he writes, “we’ve become enamored of ideas that spread as effortlessly as ether. We went 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. People and institutions can feel messy and anachronistic. They introduce, as the engineers put it, uncontrolled variability.”

Gawande adds: “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, the great scholar of how new ideas are communicated and spread. 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.”

Implications for school administrators and teacher leaders:

  • There are no “teacher proof” ways to spread new ideas and practices, technologically or otherwise.
  • That’s because the spread of new ideas is intensely interpersonal with all the complexities and demands of human nature and group dynamics. “Messy” is an apt term to describe such processes.
  • The diffusion of new ideas and practices is enabled by a culture of continuous improvement. It is also a means by which such cultures are shaped.
  • The spread of innovation happens over time through the social influence provided by countless individual and small group conversations. “Training” and other forms of “presentations” may help initiate those conversations, but they are never a substitute for them.

My next post will offer another perspective on Gawande’s ideas stimulated by a letter to the editor of a subsequent issue of the New Yorker.

The power and uses of checklists for teachers and administrators

IMG_1365

Checklists are a simple but powerful way to improve individual and group performance. They are declarations of standards that ensure that important tasks are completed.

By routinizing certain procedures, checklists ensure that higher-order mental processes are available for complex, non-routine events, which is why they are regularly used by surgeons and airplane pilots, as well as by those engaged in other demanding occupations.

Physician Atul Gawande makes the case for checklists in his book, The Checklist Manifesto: How to Get Things Right. (An earlier post elaborates on the educational implications of this book and others by Gawande.)

While good checklists are precise, Gawande notes, “They do not try to spell out everything – a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps – the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical.”

Checklists, Gawande adds, “… can help experts remember how to manage a complex process… They can make priorities clear and prompt people to function better as a team.”

To illustrate ways in which checklists can improve group functioning, Gawande explains how they can level hierarchy and distribute power in ways that can save patients’ lives when they require surgical team members to introduce themselves before surgery and to state their roles and unique perspectives regarding the procedure.

Checklists have a number of important applications in school settings:

• Checklists could be used by teachers in preparing lessons, like this checklist for project-based learning.

• Checklists could be used by principals and teacher leaders in preparing for faculty or team meetings based on the ingredients of successful faculty meetings that I offered in this post.

• Checklists could be used to increase influence using the elements contained in the SUCCESS acronym as a guide (see my previous post).

• Checklists could be used in developing both long-range and short-term professional learning plans for schools and school systems. Here are a few things that might be included on such a checklist:

___ Focuses on priority areas of student learning based on various sources of evidence, including but not limited to standardized tests;

___ Addresses core tasks of teaching such as the development of engaging student work and using assessments to promote learning;

___ Engages all teachers in learning, not just volunteers;

___ Occurs virtually every day as a routine part of teachers’ collaborative work on high-functioning teams—PLCs, grade level, department, or other structures;

___ Assesses effects of professional learning based on changes in instructional practices and improvements in student learning.

The acronym CREATE could be used to help planners remember those ingredients: Core tasks of teaching, Results for students, Every day, All teachers, Team-based learning, Evidence-based decision making.

What additional uses do you see for checklists in educational settings?

8 ways you can become a Positive Deviant

IMG_1365

In Better: A Surgeon’s Notes on Performance, physician Atul Gawande describes a talk he made to medical students addressing the topic, “How do I really matter?” He decided to offer “five suggestions for how one might make a worthy difference, for how one might become, in other words, a positive deviant.”

(In yesterday’s post I defined positive deviants as individuals who with the same resources available to their peers achieved more favorable outcomes. They do so through identifiable behaviors that distinguish their performance from that of others.)

In his talk Gawande suggested:

Ask an unscripted question. “You don’t have to come up with a deeper important question, just one that lets you make a human connection,” he wrote.

Don’t complain. “[N]othing in medicine is more dispiriting than hearing doctors complain.”

Count something. “It doesn’t really matter what you count… The only requirement is that whatever you count should be interesting to you.”

Write something.

Change. “[M]ake yourself an early adopter,” Gawande recommended. “Look for the opportunity to change…. Be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure.”

Gawande’s suggestions lead me to think more deeply about the behaviors of school leaders whom I have viewed as Positive Deviants.

I concluded that they possessed one or more of the following habits:

1. Writing to gain clarity and to communicate;

2. “Counting” things to improve their performance (most things that count can be measured, even if only in rudimentary ways);

3. Reading widely in search of new ideas, perspectives, and inspiration;

4. Continuously seeking more effective and efficient ways to do things;

5. Engaging the support of others when challenged by stretching goals or demanding circumstances;

6. Persisting over many months and even years to achieve important goals because the values represented by those goals were so important;

7. Seeing things in unique ways that were in opposition to accepted wisdom or common practice; and

8. Assuming that important problems can be solved, and that working alone or in collaboration with others they would contribute to their solutions.

What behaviors would you add to this list?

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Improve performance

Photo/Dennis Sparks

I have learned important things about leadership from surgeon Atul Gawande’s books: Complications: A Surgeon’s Notes on an Imperfect Science, Better: A Surgeon’s Notes on Performance, and The Checklist Manifesto: How to Get Things Right. His books illustrate how doctors—and those engaged in other complex endeavors, including educators—are challenged as they apply an imperfect science to their decision-making, struggle to work collaboratively with colleagues, and treat “patients” who are not always cooperative with their “doctor’s” best efforts.

“We look for medicine to be an orderly field of knowledge and procedure,” Gawande observes in Complications. “But it is not. It is an imperfect science. . . . There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing.” Gawandi describes “quick learning” surgical teams as being lead by surgeons who “. . . convened the team before each case to discuss it in detail and afterward to debrief. He made sure results were tracked carefully.” These doctors became partners with their teams rather than standing outside and above it. Gawande also noted that when surgeons were learning new skills things sometimes got worse before they got better, a medical variation of the “implementation dip,” a phenomena which is well known among those who seek to improve teaching and learning.

In Better Gawande discusses what it takes to be good at something—diligence, doing the right thing, and ingenuity. He includes a discussion of one my favorite approaches to improvement, positive deviance inquiry, as it is used to minimize hospital infections. Gawande suggests ways doctors can become positive deviants—don’t complain (“nothing is more dispiriting in medicine that hearing doctors complain”), count something (“if you count something you find interesting, you will learn something interesting”), write something (“it need only add some small observation about your world”), and change (“be willing to recognize the inadequacies in what you do and to seek out solutions”), practices that I also belief would improve the practice of school leadership. “[F]ind something to try, something to change,” he concludes. “Count how often you succeed and how often you fail. Write about it. Ask people what they think. See if you can keep the conversation going.”

Gawande’s The Checklist Manifesto explains how clear goals, measuring progress, decentralized decision-making with accountability, teamwork, clear communication, and the use of checklists contribute to improved performance. His primary teaching tool are compelling stories from public health, surgery, building construction, Hurricane Katrina, and the January 2009 crash of US Airways 1549 into the Hudson River. He views “the miracle on the Hudson” as less about the heroic acts of individuals that the power of teamwork, training, and protocols: “The crew of US Airway Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize were one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation. . . .”

EL columnist Thomas Hoerr links Gawande’s ideas to school leadership in his essay, “Checking for Checklists.” Hoerr notes that in Complications Gawande “. . . wrote about how important it is for a surgeon to have a great deal of experience doing a particular operation. You want to be operated on by someone who has done this specific surgery many times. Gawande talks not just about repeated experience— which is important—but also about the analysis and reflection that accompany it. The merit of experience is not just in having the experience, but in learning from it.” Hoerr acknowledges that as leaders “. . . it’s clear that we spend much more time planning than reviewing. We spend hours making plans, acquiring new information, and learning new skills. We spend far less time gathering data on our performance and learning from our experiences.”

About The Checklist Manifesto Hoerr writes, “This August when my faculty and I plan for the coming year, one of our tasks will be to consider what checklists we might create. How might checklists address the necessary steps for eliciting student engagement, differentiated instruction, or principal renewal? I can envision checklists that ensure that we have reviewed all aspects of a student’s progress, that teachers have incorporated all of our talking points in their presentations to parents, and that I have spoken to all the relevant stakeholders before I initiate action. Then we need to evaluate the effectiveness of the checklists during and at the end of the school year. We might decide that a checklist isn’t applicable to some situations, but even so, the reflection and dialogue will be beneficial.”

Take a moment now to . . .

• select one of the terms in bold from above that is most relevant to your work and make a commitment to engage in that practice or use that technique.


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