Keeping Score

May 7, 2009

If you count something interesting, you will learn something interesting"

  • Atul Gawande

Last year I read two excellent books by Atul Gawande:

I recommend them both.

One idea that has stuck with me from these is the power of simple tests or checklists.

An example he gives in “Better” is the Apgar Score, created by Dr Virginia Apgar in the early 1950s as a quick and easy way to assess the health or otherwise of a new born baby.

It is almost certainly the first test you passed in your life!

Prior to this many babies which were the wrong size (too small) the wrong colour (blue) or not breathing, perhaps as a result of a difficult birth, would die because it was assumed that nothing could be done to save them. At the time, remember, over 3% of babies died during child birth.

The concept of the test was more or less dismissed when she first suggested it because it was thought to be too simplistic to be useful, but today is used all around the world, and has had a massive impact.

Here is a quote from the book:

The score turned an intangible and impressionistic clinical concept - the condition of new babies - into numbers that people could collect and compare. Using it required more careful observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores - and therefore better outcomes - for the newborns they delivered.

He was recently interviewed by Charlie Rose:

Here is an extract from that interview, where he talks about the same idea, this time in the context of general surgery: specifically a checklist used by surgeons at key points during a procedure, and the massive difference it has had to the outcomes where it has been used:

We introduced a 90-second checklist that happens right before [the patient goes] to sleep, and then right before an incision, and right before [the patient] leaves the room, kind of like before takeoff, after takeoff and on landing.

It checks 19 things that if we missed them, we will harm you. But it turns out we miss one of those steps about two-thirds of the time, and using the checklist in every hospital we put it in - we put it in eight hospitals that range from rural Tanzania to Seattle, Washington — and each hospital it went into reduced complications by double digits, on average by about a third.

Something that was easy and made such a big impact would be popular, right? Actually no:

Q: And how is the medical profession responding to this?"

A: Well, there are two kinds of reactions. We surveyed the teams afterwards, asked them what did you think. And about 80 percent said, you know, in the end, it wasn’t as bad as I thought. It was swift. I thought it improved care. But there was a solid 20 percent who said, this is a waste of my time. I don’t think it improves anything. But then we asked them one more thing. We said, if you were having surgery, would you want the checklist? And 94 percent said they would want it.

It makes me wonder what other things we dismiss as being too simple to be useful. Or, what things we oppose for ourselves but which we would think others should do. “Do as I say not as I do” perhaps, or is it “I’m an expert, so I don’t need it”?

I’m sure this same idea could be applied to a wide range of different things.

For example, imagine a simple test that you could do at the end of each day which measures the impact of your actions on your own health:

  1. Did you eat well?
  2. Did you exercise?
  3. Did you get enough sleep?
  4. Did you spend time with family and friends?

How would you score?

Would you want to know?

Maybe you would even share your results with others, in order to be able to compare?

And then, having created a false sense of competition, wouldn’t you be incented to do better?

Clearly keeping score can be pretty powerful, as long as you choose the right score to keep.