Seeing past the checklist

  | January 3, 2017

When someone as thoughtful and wise as Edgar Schein tells you that a question changed his life, you pay attention. Ed is one of my heroes, the author of numerous books about human dynamics, leadership, and organizational behavior, from the classic "Organizational Culture and Leadership" to the more recent "Helping."
During a recent visit, he told me about a summer day on outer Cape Cod. His granddaughter had been injured. The closest hospital was in Hyannis, over an hour and a half away through seasonal traffic on Route 6. It was a stressful, tiring trip for both Ed and the girl's father — to and from the hospital, loaded with worry about the child's condition.
Ed told me he related this story to Ellen Langer, Ph.D., a Harvard-based social psychology professor and the author of "Mindfulness." Her response was to ask, “What else was going on?"
“What do you mean?" replied Ed. “We were worried sick and exhausted by the long drive."
She repeated, “What else was going on?"
That's when Ed realized that the trip to the hospital had actually been remarkably calm. The little girl was in good spirits the entire way, entertaining the adults with her chatter, and the family had enjoyed their time together.
The point is that we tend to focus on the uncomfortable or stressful parts of our day, forgetting how much good is happening most of the time.
“This story," Ed said, "has changed my way of looking at things."
Ellen told Ed two more stories, both related to medicine. The first was about a geriatrician who often treated older people with aches and pains. It reflected Ellen's special concern for the elderly, who often suffer from learned helplessness. The doctor, while empathetic about his patients' problems, would also ask them, “What are you doing when it doesn't hurt?"
This enabled the patients to identify the activities associated with parts of the day when they weren't in pain. They could then “practice" those activities and feel less discomfort during more of the day.
Ellen's second story was about a surgeon who, like most, habitually followed the pre-surgical checklist before operating on patients. This is the procedure you use to make sure you are operating on the correct patient, that you are performing the correct procedure, that you are about to cut into the correct side of the body, and so on.
This surgeon, though, realized that a checklist can become overly routinized and mechanical, losing its meaning and effectiveness. So in addition to following the protocol, he would ask his team, “What's different today?" The question would cause the doctors, nurses, and surgical technician to return their focus to the specific man or woman about to go under the knife — and adopt a more attentive attitude toward the developments in the operating room.
At Beth Israel Deaconess Medical Center, we employed a slightly different technique: to pause after the pre-surgical checklist for a "moment of reverence," while the circulating nurse reminded us to consider that the patient before us was someone's mother, father, sister, or brother, and to behave in accordance with that person's needs.
In medicine, as in other fields, we tend to rely on checklists to ensure quality and safety. But several years ago, Captain Chesley (“Sully") Sullenberger — the US Airways pilot famous for his dramatic emergency landing on the Hudson River — told a group at MIT that "a checklist alone is not sufficient. What makes it effective are the attitude, behavior, and teamwork that go along with the use of it."
The surgeon cited by Ellen had developed a social process that enhanced the protocol of the pre-surgical checklist. He had introduced a mindfulness for his entire team that made the checklist more effective every time it was employed.
In a 1999 JAMA essay, family physician and researcher Ronald M. Epstein, M.D., described the concept of "mindful practice." The goal, Epstein wrote, is “to become more aware of one's own mental processes"— listening attentively, recognizing biases and judgments, becoming more flexible.
Mindful practitioners, he wrote, "attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks. This critical self-reflection enables physicians to listen attentively to patients' distress, recognize their own errors, refine their technical skills, make evidence-based decisions, and clarify their values so that they can act with compassion, technical competence, presence, and insight."
In other words, they notice what else is going on — as Ed Schein learned to do after that harrowing drive.
I love that a person of Ed's stature and reputation is constantly on the lookout for revelations about the human condition, and for ways to be more mindful in his own life. His modesty about what he doesn't know is also a worthy example. This trio of stories meant a lot to Ed, and they also could mean a lot to all of us.
Paul F. Levy is the former CEO of Beth Israel Deaconess Medical Center from 2002-2011. He is the author of “Goal Play! Leadership Lessons from the Soccer Field.

Seeing past the checklist