« March 2008 |
Main
| May 2008 »
The logic of failure: why things go wrong and what we can do to make them right by Dietrich Dörner is an old and fascinating book. Almost 20 years has passed since it was first published in German. However, the wisdom contained in this book is timeless. I believe we need it more than ever in this unsettling time. Dörner is a distinguished psychologist specialized in cognitive anthropology. He observed many general behavioral tendencies when people were put into situations with “uncertainty, complexity, and lack of clarity.” Many decision makers, in the real as well as the simulated world, “acted without prior analysis of the situation, failed to anticipate side effects and long-term repercussions, assumed that the absence of immediately obvious negative effects meant that correct measures had been taken, let over involvement in ‘projects’ blind them to emerging needs and changes in the situation, and were prone to cynical reaction.”
Dörner pointed out that the daily demands were simple during the long history of human race. People were used to solve problems on an ad hoc basis and that was adequate. Only very recently, it became essential for us to understand and deal with complex systems. We are not yet prepared for such challenges. The good news is that many of the cognitive errors are predictable, as Dörner showed with many real life examples and computer simulations. Hopefully, we can train ourselves to become more aware of those negative tendencies and overcome them gradually in practice.
So what is a complex system? It is a system with many interrelated variables. Each variable could affect or be affected by many other variables in different ways: positive, negative, and maybe even with time delay. There might also be time-dependent components. The system could evolve on its own without our intervention. In some cases, we ourselves are even part of the complex system.
When facing complex systems like that, the information we have is often incomplete and vague and we are usually under the time pressure to do something. Many of us have difficulties in understanding the scope and the nature of the interconnectedness among variables. And the system development trend and pace are also hard to grasp. For example, many people don’t understand that one action could have multiple effects, intended as well as unintended. A solution to one problem could cause new and maybe even worse problems. We don’t have a good feel for the time and the implications of a dynamic system, especially when the nonlinear effect and the time delay are concerned.
Fundamentally our mistakes in dealing with complex system come from three sources, Dörner said. First, we don’t think about the problems we don’t have (yet). Second, we have a strong incentive to preserve the view that we are competent. Third, the inflow capability of our memory is small. We can only memorize a small chunk of information at a time. And our conscious thoughts are slow in processing large amount of data. Therefore we try to find shortcuts to economize time and effort. Sometimes these shortcuts work exceedingly well. And once in a while they are responsible for our cognitive failures. The Chernobyl atomic energy plant accident is an interesting example Dörner discussed in detail. The root cause was the violation of safety rules. Dörner pointed out that people involved in the accident were all experts. They have violated the same rules before without consequences. Many safety rules are designed with a margin. When people violate them, chances are they don’t get hurt the first few times. They were rewarded with gained efficiency by not going through those extra steps. Cognitively, they formed the shortcut and thought those rules were for other people, for the less experienced ones.
Dörner has a very simple system to organize complex actions. It should not be viewed as a linear flow from the first step to the last. At each step, as our understanding and our goals evolve, very likely we will discover that more work needs to be done in the prior or later steps.
· Formulation of goals. Goal setting is problem-setting. It’s not easy, as we have seen in Donald Schön’s reflection in action. It is an iterative process. In the beginning, we don’t always know exactly what we want. Perhaps we know what we don’t want. Or we have a general impression on what could be better than what we have now. Goals like that are not clear. As we gather more information about the system, we need to break down the general goal to multiple specific goals. For example, better organizational performance could include large revenue from sales, cost control, good product quality, etc. Some of those goals are not compatible with each other and we can’t realize all of them at once. In the above example, when the sales volume increases to a point, the training needs also increase if we want to ensure the product quality. But the trainings will cost money and have impact on cost control. In best cases, after we develop enough understanding, we could restructure the whole system to eliminate the negative links among the important variables. If a complex goal is not broken down to a set of clearly defined specific goals, many of us would pick a problem that we feel competent to solve, regardless of whether or not it should be solved at the moment. The project could take on a life of its own since we love challenges, especially the ones we feel are good matches to our capacity. We also tend to pick the most obvious problem at the moment to work on. It’s easy to ignore the potential future problems, especially those that start small but with exploding growth down the road. By focusing on the immediate actions and results, we don’t see our implicit goals, the ones we take for granted while we have them, such as health and family. Here, Dörner’s strategy is to make an effort to list all the features we want to retain before we set out to change the system.
· Formulation of models and gathering information. Our mental model of the external world guides us in gathering and interpreting information. People are known to screen out the data that don’t fit their mental models. One example is about the atmosphere ozone layer damage from chemical chlorofluorocarbons (CFCs). NASA scientists delayed the confirmation of this discovery by programming their computers to reject low ozone readings from satellite. Their mental model said it was impossible to have such low readings and there must be some instrument errors. It is essential that the new information provides feedback not only on the effectiveness of our decisions and actions but also on the accuracy of our mental model against the real world.
· Prediction and extrapolation. At this step, we turn to the dynamic nature of the complex system. We should especially pay attention to the underlying process and be aware of the system change in direction and pace.
· Planning of actions; decision making, and execution of actions. The action planning has three parts: the condition, the action, and the expected result. Often we envision the final result in very simple terms, and gradually correct our understanding and definition. Without the guidance of a clearly defined final goal, we tend to respond to the demand of the moment and follow our pre-established pattern of actions. Dörner’s solution is to set the so-called diversity efficiency as the intermediate goal. It is a state that “offers many possibilities for actions with high probability of success.” When stuck, Dörner has three strategies to move forward: analogous thinking, culling the unsuccessful strategies so far, and free experimentation.
· Review of effects of actions and revision of strategy. If the feedback comes with a big lag time, many of us would have a hard time making the connection between our actions and the results. We tend to over react and make the system oscillate.
In the world of the complex problems, no prescribed approach will always work. Depending on the context, it could be good to analyze the details and wait to see how the system develops, or to move quickly and just get a comprehensive and rough outline; to define our goals clearly, or just muddle through. Dörner emphasized the importance of developing common sense and operative intelligence, “the ability of using our own intellectual capabilities and skills”. He said, “dealing with problems in the most appropriate way is a hallmark of wisdom.”
The best way to gain this kind of wisdom is through exposure to various challenging problems. Hands-on experience in the real world is the best but it’s hard to come by. The second best is to use computer simulations of various cases to challenge people’s thinking and decision making. The feedback here is virtually immediate and the cost of error is small.
Better: A Surgeon’s Notes on Performance by Atul Gawande is another book about performance in medicine I came across recently. How doctors think dealt with the individual performance whereas Better looked at performance from both the individual level and the system level.
According to Gawande, diligence, moral clarity, and ingenuity are the fundamental requirements in medicine, or in any other practices that involve risks and consequences.
Diligence is “the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles.” It is “both central to performance and fiendishly hard”, as Gawande pointed out. He gave three examples to demonstrate his view: washing hands properly in the hospitals, WHO’s effort to eradicate polio, army medical teams’ effort to reduce casualties in the recent war. I found those three examples intriguing because the kind of diligence required is so different for each of them. Here is a brief summary of the three examples.
· Hand washing. It has been well established that proper hand washing could significantly reduce the rate of deadly infections in the hospitals. However, one hospital’s statistics show that doctors and nurses wash their hands properly less than one half as often as required. Why is it so hard to get doctors and nurses to comply? Patients come in because of the diseases they have. By washing hands properly, the doctors and nurses will not do further damage to the patients but this itself doesn’t cure the diseases.
· Army Casualty. The mortality is 10% in Iraq war, as compared to 42% in the Revolutionary War and 24% in Persian Gulf War. This is not because fewer soldiers got wounded or weapons became less damaging as time went by. Gawande claimed that the improvement was mostly from the performance of the army medical system, not from the advancement of any new medical technology and treatment. The military found out that the critical factor to reduce the mortality rate was to shorten the time it took for the wounded soldiers to get the medical attention. They set up a system to address the issue and diligently maintained the system. In Iraq war, they sent in Forward Surgical Teams right behind the troops on the battlefield with limited personnel and other resources. The wounded could be treated within an hour. The only thing the Forward Surgical Teams did was damage control. The wounded were transported to the next level of the medical care system, one level after another, if more treatment or more recovery time was needed. It took a lot of self-discipline for the doctors to only do what they were supposed to do at their particular level and not to try to take care of each individual soldier all the way through. And even with fatigue and the extreme demand on their time and energy, doctors managed to record each patient’s information, the treatments given and the results. This provided the necessary feedback for them to improve their performance.
· Polio eradication effort. One polio case was discovered somewhere in India. To shut down the transmission, a mop-up operation had to be taken to vaccinate at least 90 percent of the children under age 5 covered the region about 50,000 square miles, twice, one months apart. That means “employ thirty-seven thousand vaccinators and four thousand health care supervisors, rent two thousand vehicles, supply more than eighteen thousand insulated vaccine carriers, and have the workers go door to door to vaccinate 4.2 million children. In three days.” It’s amazing that this kind of goals can be achieved since WHO (World health Organization) only has information and expertise and doesn’t have resources or authority to do any of the above.
Among those three examples, the polio case probably is the most demanding and the most difficult one. And the hand washing seems to be the simplest one and it’s merely a compliance issue. The level of difficulty for the army casualty case is somewhere in between. Why is proper hand washing so difficult to accomplish while the other two, though more difficult, were planned and carried out successfully? Here is my take on this. Our attention is probably one of the most precious resources we have. Where we direct our attention is not a trivial decision. Certain details only contribute to our overall effectiveness but they don’t point to the result of any specific task. Outside the medical field, in our own personal and professional life, examples are everywhere. For instance, our physical health. How many of us diligently apply what we know and really make sure we have a healthy lifestyle? What about learning something generally useful but might not be applied immediately? Or what about keeping a good work record? My daughter Chloe had a play date with one of her classmates last Saturday. I got to spend a couple of hours chatting with the other girl’s parents Joe and Katie, both are patent lawyers. I complained to them that patents are pretty much useless for me if my goal was to find interesting technical ideas. They laughed. Joe pulled out one of the patents he was working on. He pointed it out that I simply didn’t know how to read a patent. Then he patiently and enthusiastically showed me the overall structure of a patent. As he explained, I gradually understood that the abstract and the claim sections are there for lawyers and I should only pay attention to the first drawing and the technical detail summary section. Thanks, Joe. How come I never took the time to learn how to read a patent properly before? When it was Joe’s turn to complain, he said that engineers in general don’t know how to write and how to communicate and on top of that they don’t know how to keep good work record, the kind that other people can use to repeat the procedure and get the same results. I felt very embarrassed. I am guilty of being sloppy in keeping record myself. One example is the comments I should have put in when I do computer programming. I know it’s important and I should be more disciplined to do so but I often don’t. The comments won’t contribute directly to the results of the program and it takes away my time and attention. Most of us work in an ad hoc fashion and only focus on the immediate result of the task at hand. To pay attention to the details involved in things like hand washing in the hospitals, adopting a healthy lifestyle, or keeping good work record is to go against our fundamental human tendency. This is very hard. We have to expand our visions and look at things systematically. It takes strong discipline and conscious mental effort. Sometimes, it almost seems to be easier to accomplish the polio mop-up operation since the difficult details in planning and coordination have a direct link to the purpose of the operation. The army medical system’s success probably is for the same reason. Better yet, it had a feedback loop built in. To improve the performance in the cases like hand washing, I think the real challenge is to create a connection between the details we need to pay attention to and the specific results we genuinely care about and preferably with a good feedback loop. It’s a challenge and it could be a constant struggle.
This led me to another interesting point in the book. Apgar score. Both of my kids had Apgar scores recorded right after their births. I never knew what they were for. Before Virginia Apgar, an anesthesiologist, came up with the score named after herself, many newborn babies were declared still born and left to die when they were “malformed or too small or just blue and not breathing well.” “The score turned an intangible and impressionistic clinical concept—the condition of new babies—into numbers that people could collect and compare.” And the performance can be easily monitored and improved upon because of the metrics. However, Gawande pointed out the tyranny to a particular score. The revealing example is the popularity of Cesarean section in childbirth nowadays. It is a surgical procedure that is easy to learn. And it’s relatively safe and reliable, especially if only the well-being of the babies is concerned. Since Apgar score doesn’t measure mothers’ blood loss, recovery time, and pains, Cesarean section became the dominant procedure in childbirth while many other harder to learn ingenious maneuvers and devices for dealing with various difficulties were fading away even though they might be better for the mothers.
Gawande provided so many great examples in the book. Each one of them could be a trigger for deep reflection. I will leave them for the interested readers to discover for themselves. Personally, I also love his examples of different modes of malpractice compensation and health insurance. Both of those examples make me wonder why a fair and efficient system can not be scaled up easily.
Reading Patricia Ryan Madson’s book improv wisdom is like taking a walk in a traditional Chinese garden. You can make a stop anywhere and there’s always something intriguing for you to look at. This little book of merely 159 pages is so full of gems. It is one of the books that have changed my outlook toward life.
Madson has been a drama teacher for many years. For her, “a successful life involves both planning and improvising.” She sees the similarities between improvisation and life. She believes that the principles and techniques of improvisation could help us expanding our vision of life, and with that we could be more open to possibilities, and do more of the things that matter to us. Life is rarely scripted. Would you agree? It is “something we make up as we go along.” We are all improvisers here and there and from time to time. I like the way Madson introduces the improvisation. She says, “improvisation has nothing to do with wit, glibness, or comic ability. A good improviser is someone who is awake, not entirely self-focused, and moved by a desire to do something useful and give something back and who acts upon this impulse.”
Here are some of Madson’s ideas that I particularly like.
· Substitute “yes and” for “yes but”. For those of us trained in science and engineering, the ability to plan and to make critical judgment is so important. It is very hard not to think about the opposite and the alternatives. The “yes and” idea was shocking for me. Instead of finding faults and being argumentative, can I imagine trying once just to agree, accept, notice what is right, not what is wrong, assume what is presented to me is a good enough idea to start with, and then work hard to add to the idea in a positive direction? Could I just give whatever idea I hear or I think of at the moment a chance to develop and not to filter it out immediately with my experiences and beliefs? “Yes but” is perhaps one of the most familiar phrases we hear every day. Maybe unconsciously we don’t want to give up control, either toward others or toward our own future. We want to be so certain about the outcome before we act or support an idea. When was the last time you heard yourself saying “yes but”? Maybe you were excited about the possibility of doing something, then your mind immediately turned against you, “yes, but here are a few conditions that make it impractical.” The “yes and” mindset nudges us in the direction of building on someone’s ideas or dreams, including our own, even though the success is not guaranteed. However, as Madson points out, saying “yes” without “and” is a form of aggression. From this, I finally understood a criticism I got a few times since my early 20s. That is I asked too many questions. The point is not about the questions I asked. It is the sin I committed by saying “yes” but not “and”. I kept asking probe questions to get the other person to talk but I didn’t volunteer my own ideas, interests, or hobbies.
· Attention instead of preparation. Madson insisted that attention is far more important than preparation. We already have what it takes to start doing whatever we want to do or need to do. “All our past experiences prepared us for this moment.” If we trust ourselves and pay close attention to what is happening moment by moment, not to be distracted by what has happened or what might happen, we will find that we do have the ideas, words, and talents whenever we really need them. Sometimes planning and preparation could become a form of procrastination. I believe this idea works just as well for people contemplating mid-career changes as for people working with small kids. I can testify the later. I used to read one book after another to compile a list of activities for my once in a while bored kids. Often when I most needed the ideas, the list was not handy. I ended up listening to their whining and fighting screams till my hair standing up. Now I force myself to use Madson’s attention to this moment idea. My kids must enjoy being with me a lot more, judging from the excuses they try to make up to stay at home with me. Madson points out that our attention determines our experience. When we are self-conscious, we might experience fear and tension. The best way to get out of that is to redirect our focus outward, noticing the details around us and doing what needs to be done in the context. Paying attention also means doing one thing at time. For example, when we are with people, instead of thinking about what to say next, we listen totally and we try to remember their names and faces.
· Action. Emotions are not the best guide for action. To make sure we stay on course, Madson suggests us to ask “What is my purpose now?” not “what do I feel like doing?” We all have a unique gift and she asks “What would not get done if I were not here?” As long as we know our purpose, Madson tells us to just show up and act now. Sometimes our physical presence is the most important first step. We can start anywhere with something that is the most obvious to us. We don’t need to strive for perfection or originality. Just being average is good enough. What seems to be apparent to us might be useful or even a revelation to others. Action is a way of discovery. Often after we start doing something, we have a more realistic perspective and we can evaluate ideas better at that point. Madson also mentions that, in a group setting, when something needs to be done and we have the ability to do it, it’s better just to do it and not to think about and argue whose job it is.
· Adversity. Life is not always smooth and pleasant. However, it is the struggle and balancing in the face of instability that makes us feel more alive. How do we develop higher tolerance against life’s inherent instability? How do we “work skillfully, kindly, respectively with difficult people?” What about mistakes we make? Madson encourages us to see the reality as it is and not to dwell on what is not. In challenging situations, she recommends that we write down pure facts and details without judgment and emotions and then go from there. As for mistakes, Madson asks us to collect them. A mistakes is sometimes simply an unexpected outcome. We should just “notice it, acknowledge it, and use it.” Instead of asking “How on earth did I do that?” Why not focus on what comes next? We can ask “What can I make of this?” The goal in dealing with adversities and mistakes is always resilience and perseverance.
· Interdependence. In improvising, Madson says, “Safety lies in knowing your partner will go along with whatever idea you present.” To help us notice and appreciate interdependence, Madson encourages us to ask “what had I received from others during my life?”, “What had I given back to them?”, and “What trouble or bother had I cause them?” She wants us to nurture gratitude and practice giving thanks with details. The support and encouragement we give each other are some of the most precious gifts if we view them as so. Madson asks us “doing things in a kind way and doing kind things”. Why not “offer a pleasing face”, “encouraging eyes”, and smile? Why not share controls and try to make our partners look good?
Madson listed and elaborated on 13 maxims for improvisation. “Say yes”, “Don’t prepare”, “Just show up”, “Start anywhere”, “Be average”, “Pay attention”, “Face the facts”, “Stay on course”, “Wake up to the gifts”, “Make mistakes, please”, “Act now”, “Take care of each other”, “Enjoy the ride” There are many “try this” sections for each of the maxims. I especially appreciate two of the interesting games and one exercise I picked up in “try this” sections. The first game is to invent a proverb together. A member of the group starts the sentence with one word. The next person adds one more word that seems logical at the moment. Then next and next till the sentence is finished. Look at what you’ve got. Another game is to gather a group of friends and randomly pick a daily object. Go around the room and ask each person the question “What is the use of this object?” For the great exercise, try for a day or a week, pick a person, say, your spouse or your colleague, and find something right about everything he/she says or does.