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Comment by dctoedt | Hacker News Reader

In his book, The Checklist Manifesto, Gawande reports that at the end of a big checklist pilot project for the World Health Organization (IIRC), participating surgeons were surveyed.

• One of the survey questions was, in essence: Would the use of checklists improve your surgical practice? Most of the surgeons responded no. This was consistent with the resistance that Gawande encountered: I don't need no stinking checklist; I'm a good surgeon!

• But the more-telling survey question was this: Would you want another surgeon to use a checklist if operating on you or one of your family members? Something like 93% of the surgeons surveyed responded ... yes.

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I chalk this up more to management and not individual egos. Incentive structures configured by the vast majority of management in most organizations do not reward checklist development and more importantly checklist maintenance.

Bob: I'm developing and testing a checklist.

Management: Why is it taking sooo long!?!?? Why aren't you doing <<revenue/KPI-enhancing activity>>?

Versus:

Bob: I'm selling truckloads of surgeries.

Management: W000t! My manager will be ecstatic!

There is also a free rider problem with checklist development. Lots of workplaces love to somewhat or all-out pit employees against each other. Unless the entire team is creating and maintaining the checklist, the subset of the team creating/maintaining the checklist will always over time come out looking worse on KPI's that almost invariably never measure these kinds of activities.

The subset of the team that doesn't spend the time on creating/maintaining the checklist come out looking better on KPI's over time, and the checklists increase their relative standing against their checklist-creating peers.

Fix the incentive structures, and this problem fixes itself.

Just today, I was thinking the same thing, but about compile-time type checking. "You don't need it, because you're a good programmer? Great. But not everyone on your team is as wonderful as you. Do you want to be able to catch their errors at compile time?"

Wow. That's such a supreme indicator of overconfidence--the belief that I and I alone am so competent that I don't need safeguards.

I would not have hoped that a high percentage of surgeons have that trait. I wonder if I am guilty of it as well. Something to examine in the mirror in our future endeavors.

I like to use the term Dunning-Kruger instead of over-confidence or hubris to describe it. Everyone thinks they demonstrate above average skill. During the 2007-2009 financial crisis every single financial services firm justified their executive bonuses by claiming their personnel were above average. Very few car drivers consider themselves below average.

Before germ theory gained acceptance or was even understood, physicians and surgeons considered themselves above hand washing as a gentleman's hands are always clean. Ignaz Semmelweis discovered that washing hands and tools in chlorine solution reduced childbirth deaths. But he was unable to convince others.

In modern times doctors have answered a survey on the effect of pharmaceutical representatives visit. The overwhelming majority responded that they are not swayed by drug saleswomen, but that other docs are susceptible to choosing a prescription drug because of salesmanship instead of only efficacy & risk.

These are examples of illusory superiority[1], or the "Lake Wobegone effect".

[1]: https://en.wikipedia.org/wiki/Illusory_superiority

Dunning-Kruger is something more specific, that people with lower skill in an area overestimate their skill, because they are unable to distinguish competence in that area.

>I like to use the term Dunning-Kruger instead of over-confidence or hubris to describe it. Everyone thinks they demonstrate above average skill.

On HN, everyone thinks that everyone but themselves are affected by Dunning Kruger. In fact, calling out Dunning Kruger in others is a symptom of someone under the very same effect.

It's not the Dunning-Kruger effect because it's overconfidence expressed by highly trained, highly competent experts about their own performance compared to their peers. If anything it's "skilled and too aware of it" rather than "unskilled and unaware of it".

Good points. I feel like in the surgeon's case it's subtly but significantly different, though; these people aren't ignorant amateurs, they're highly trained professionals who do actual work on human bodies, with all the problem-solving skills and knowledge that implies. By all accounts they should be able to accurately assess their own abilities, as opposed to people affected by Dunning-Kruger. I think it's important to be mindful of hubris among the competent as well, perhaps more so because they are the ones actually doing the work in the end.

The effects you talk about definitely exist and I feel like a lot of those are arrogance, or possibly even our fundamental inability to observe without bias unless we take very careful precautions ahead of time. Perhaps doctors otherwise used to proper experimental control and thinking scientifically didn't apply the same precautions ahead of meeting with sales reps, because that appeared to be out of context of practicing medicine at the time, even though it is still part of the process. Apparently they are affected by bias without being aware of it. This is wholly conjecture on my part.

this is a very well written book and one I think of often...

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