Tag: Atul Gawande

The Science of High Performance

Research shows that knowing what you want to accomplish is more important than performance … at least at the start. But once you know where you’re going, you can accelerate progress by religiously implementing these steps.

1. Routines

The first tip comes from Tony Schwartz author of The Power of Full Engagement and Be Excellent at Anything. In his contribution to Maximize Your Potential, he recommends harnessing the power of a ritual.

A ritual is a highly precise behavior you do at a specific time so that it becomes automatic over time and no longer requires much conscious intention or energy.

Willpower and discipline are over-rated. Systems matter more.

In his book, Willpower: Rediscovering the Greatest Human Strength, Roy Baumeister contends that the most successful people don’t make better decisions because of their willpower. Rather, they develop routines and scripts. 

These routines become automatic and reduce the number of decisions we need to make (as well as reducing stress). Our brain doesn’t have unlimited resources so the more we can offload to routines and scripts the more we can put our limited energy to other things.

Developing these routines are key. In Michael Lewis’ profile of President Obama, he writes:

You also need to remove from your life the day-to-day problems that absorb most people for meaningful parts of their day. “You’ll see I wear only gray or blue suits,” (Obama) said. “I’m trying to pare down decisions. I don’t want to make decisions about what I’m eating or wearing. Because I have too many other decisions to make.” He mentioned research that shows the simple act of making decisions degrades one’s ability to make further decisions. It’s why shopping is so exhausting. “You need to focus your decision-making energy. You need to routinize yourself. You can’t be going through the day distracted by trivia.”

If we spend energy making too many little decisions, we’ll have less to make the more important decisions. Some companies are cluing into this.

“I think that the leadership at Google has an intuitive understanding of human nature and the way attention is a limited resource,” says David Rock author of Your Brain at Work. Google organizes their environment to make allow their employees to make fewer decisions.

The formula at Club Med is to include pretty much everything in the price, activities, food, even drinks, giving you fewer decisions to make. Now I know the research on decision making, and how making any conscious decision uses a measurable amount of glucose, but I wasn’t prepared for how relaxing it was not having to think anywhere near as much, even about simple things. It turned out to be a remarkably restful holiday.

When you work at google, you get to save your limited mental resources for the most important decisions. As Google’s CEO Eric Schmidt said, “Let’s face it: programmers want to program, they don’t want to do their laundry. So we make it easy for them to do both.”

…Other companies could do well to do the same, noticing what their employees end up wasting their attention on, and doing something about it. It’s sure making me rethink my own company’s benefits policies.

… as well as minimizing distractions and respecting attention, Google does other things to help its people be more productive, in particular being more productive at complex problem solving.

2. Focus

Your routines should be geared towards helping you focus.

In Your Brain at Work, David Rock writes:

One of the most effective distraction-management techniques is simple: switch off all communication devices during any thinking work. Your brain prefers to focus on things right in front of you. It takes less effort. If you are trying to focus on a subtle mental thread, allowing yourself to be distracted is like stopping pain to enjoy a mild pleasure: it’s too hard to resist! Blocking out external distractions altogether, especially if you get a lot of them, seems to be one of the best strategies for improving mental performance

Combining routine and focus is the sweet spot. Here are two examples you can put into practice today.

First, Mark McGuinness argues in Manage Your Day-to-Day that you should put your most important work first. It’s much easier to deal with less taxing things, like email, later.

The single most important change you can make in your working habits is to switch to creative work first, reactive work second. This means blocking off a large chunk of time every day for creative work on your own priorities, with the phone and e-mail off.

Another way to think of this is to pay yourself first: you are your own most valuable client. That’s what Warren Buffett and Charlie Munger do.

Another useful routine is to deal with email in batches, say from 10-11 and 3-4 each day. The rest of the day, turn the email client off so you’re not constantly interrupted with ‘new mail.’

Consider the wise counsel of Herbert Simon:

What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention, and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.

3. Practice

Experience doesn’t always make you better.

In Talent Is Overrated, Geoff Colvin writes:

In field after field, when it comes to centrally important skills—stockbrokers recommending stocks, parole officers predicting recidivism, college admissions officials judging applicants—people with lots of experience were no better at their jobs than those with less experience.

Wait. What? That doesn’t make sense.

We typically operate in the OK Plateau.

The bestselling author of Moonwalking with Einstein and USA Memory Champion in 2005, Joshua Foer explains:

In the 1960s, psychologists identified three stages that we pass through in the acquisition of new skills. We start in the “cognitive phase,” during which we’re intellectualizing the task, discovering new strategies to perform better, and making lots of mistakes. We’re consciously focusing on what we’re doing. Then we enter the “associative stage,” when we’re making fewer errors, and gradually getting better. Finally, we arrive at the “autonomous stage,” when we turn on autopilot and move the skill to the back of our proverbial mental filing cabinet and stop paying conscious attention. … The OK Plateau is that point when we reach the autonomous stage and consciously or unconsciously stay to ourselves, “I am OK at how good I have gotten at this task,” and stop paying attention to our improvement. We all reach OK Plateaus in almost everything we do. We learn to drive when we’re teenagers, and at first we improve rapidly, but eventually we are no longer a threat to old ladies crossing the street, and we stop getting appreciably better.

If we want to perform better beyond some basic competence researchers say we must engage in deliberate practice. These are designed, mindful efforts, to master even the smallest detail of success. To get better you have to get out of the autonomous stage.

One way to stay out of the autonomous stage is deliberate practice. Expert musicians, for example, focus on the hardest parts not the easy ones that would allow them to sink into autopilot. The way to get better is to push your limits.

Unfortunately, deliberate practice isn’t something that most of us understand, let alone engage in on a daily basis. This helps explain why we can work at something for decades without really improving our performance.

Colvin continues:

Deliberate practice is characterized by several elements, each worth examining. It is activity designed specifically to improve performance, often with a teacher’s help; it can be repeated a lot; feedback on results is continuously available; it’s highly demanding mentally, whether the activity is purely intellectual, such as chess or business-related activities, or heavily physical, such as sports; and it isn’t much fun.

Consider a coach.

In his fascinating New Yorker article, Doctor Atul Gawande writes “In theory, people can do this themselves.”

But most people do not know where to start or how to proceed. Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short.

In other words, the coach provides objective feedback and structure.

Commenting on what it’s like to have a surgical coach, Gawande offers:

Osteen (Gawande’s coach) watched, silent and blank-faced the entire time, taking notes. My cheeks burned; I was mortified. I wished I’d never asked him along. I tried to be rational about the situation—the patient did fine. But I had let Osteen see my judgment fail; I’d let him see that I may not be who I want to be.

This is why it will never be easy to submit to coaching, especially for those who are well along in their career. I’m ostensibly an expert. I’d finished long ago with the days of being tested and observed. I am supposed to be past needing such things. Why should I expose myself to scrutiny and fault-finding?

It takes a special person to bring in a coach mid-career and subject themselves to “scrutiny and fault-finding.”

Maybe you’re thinking, I don’t need a coach because “I’m my own worst critic.” That may be the case, however, it is really hard, but not impossible, to be your own (objective) coach. You need structure and objective feedback.

(I don’t want to get into too much nuance, but you also have to think about feedback systems. Part of deliberate practice is immediate and constant feedback. This enables course correction. The time-to-feedback can derail deliberate practice if it’s too long.)

4. Exercise

In Brain Rules, John Medina explores the relationship between exercise and mental alertness:

Just about every mental test possible was tried. No matter how it was measured, the answer was consistently yes: A lifetime of exercise can result in a sometimes astonishing elevation in cognitive performance, compared with those who are sedentary. Exercisers outperform couch potatoes in tests that measure long-term memory, reasoning, attention, problem-solving, even so-called fluid-intelligence tasks. These tasks test the ability to reason quickly and think abstractly, improvising off previously learned material in order to solve a new problem. Essentially, exercise improves a whole host of abilities prized in the classroom and at work.

5. Rest

Taking time to rest won’t make you a slacker. While the corporate culture of “back-to-back” meetings from 9-5 may seem “cool” it is actually crazy. Rest is a critical component of creating and sustaining excellence.

Michael Mauboussin: Two Tips to Improve The Quality of Your Decisions

Michael Mauboussin, chief investment strategist at Legg Mason and our first interview on the podcast, offers two simple techniques to improve the quality of your decision making: a decision journal and a checklist.

1. Create a decision journal and starting using it. 

Many years ago when I first met Danny Kahneman, and Kahneman is one of the preeminent psychologists in the world who won a Nobel Prize for economics in 2002, even though he’s never taught an economics class.

When I pose him the question, what is a single thing an investor can do to improve his or her performance, he said almost without hesitation, go down to a local drugstore and buy a very cheap notebook and start keeping track of your decisions. And the specific idea is whenever you’re making a consequential decision, something going in or out of the portfolio, just take a moment to think, write down what you expect to happen, why you expect it to happen and then actually, and this is optional, but probably a great idea, is write down how you feel about the situation, both physically and even emotionally. Just, how do you feel? I feel tired. I feel good, or this stock is really draining me. Whatever you think.

The key to doing this is that it prevents something called hindsight bias, which is no matter what happens in the world. We tend to look back on our decision-making process, and we tilt it in a way that looks more favorable to us, right? So we have a bias to explain what has happened.

When you’ve got a decision-making journal, it gives you accurate and honest feedback of what you were thinking at that time. And so there can be situations, by the way, you buy a stock and it goes up, but it goes up for reasons very different than what you thought was going to happen. And having that feedback in a way to almost check yourself periodically is extremely valuable. So that’s, I think, a very inexpensive; it’s actually not super time consuming, but a very, very valuable way of giving yourself essential feedback because our minds won’t do it normally.

2. Use a checklist. 

Mauboussin: So the best work on this I’ve seen is by Atul Gawande, who is a surgeon in Boston who wrote a book a couple of years ago called The Checklist Manifesto, and one of the points he makes in there is that when you go from field to field, wherever checklists have been used correctly and with fidelity, they’ve been extremely effective in proving outcomes. So we all know none of us would step on an airplane today without the pilot having gone through the checklist. It’s been a big move into medicine, especially for example, in surgery where checklists have really made substantial inroads in reducing infections, for example, and hence mortality, and other areas like construction elsewhere.

So the question is, how do you become more systematic in applying what you know? And I’ll just mention one other thing on this. There are two; Gawande talks about two kinds of checklists. By the way, this branch is right out of aviation. One is called a do-confirm checklist, a do-confirm, and that just basically says, Hey, just do your normal analysis the way you’ve always done it and been trained to do that, but stop periodically just to confirm that you’ve covered all the bases. So as an analyst that might say, hey, I’m going to do a really thorough evaluation work. I might look very carefully at return on capital trends. I might study the competitive strategy position. You are just going to do all that stuff, but you’re going to stop every now and then, just to check to make sure you’ve done everything.

The second one is called, the second kind of checklist, is called a read-do checklist. This is when you get into a difficult situation, for example you’re a pilot and one of your engines goes out, the redo will guide how you should approach that problem. So you don’t have to think about it so much, you just sort of go through it systematically. And so for an investor that might be hey, what happens when a company misses a quarter? What happens when they have a negative announcement or an executive departure? Sometimes that means sell the stock. Sometimes that means buy more. Sometimes it means do nothing, and a read-do checklist can help guide some of that thinking as well. So it’s really a way to be structured and consistent in your analysis.

Smart People Are Reading These Books

Ok, so you’ve seen the nine books Bill Gates is reading this summer. Gates has some pretty smart friends and they were kind enough to share what they were reading this summer too.


Vinod Khosla is one of the co-founders of Sun Microsystems,and founder of the firm Khosla Ventures, which focuses on venture investments in various technology sectors, most notably clean technology.

The Score Takes Care of Itself by Bill Walsh, Steve Jamison and Craig Walsh
The Lean Startup by Eric Ries
The Checklist Manifesto by Atul Gwande
The Creative Destruction of Medicine by Eric Topol
The Power of Habit by Charles Duhigg
The Viral Storm by Nathan Wolfe
Willpower by Roy Baumeister & John Tierney

Here’s a list of books recommended by Vaclav Smil, who does interdisciplinary research in the fields of energy, environmental and population change, food production and nutrition, technical innovation, risk assessment, and public policy.

First belles-lettres, memoirs, narratives and stories:
This spring I re-read again Burton’s great twovolume classic of a pilgrimage to Mecca, one of the greatest, and the most informed travelogues ever written.
Another enjoyable re-read was Beerbohm’s playful Zuleika story.

New, and highly recommended, first-time readings have included von Rezzori (The Snows of Yesteryear and Memoirs of an Anti-Semite) and Crace, and Jean Renoir’s memories of his father.
Decades ago I was impressed by Caro’s first volume of Lyndon Johnson biography: this year came out a no-less readable latest instalment: The Passage of Power.

On the science/engineering side I have been reading (in preparation for my next book) many works on old and new materials:
Allwood and Cullen (Sustainable Materials with Both Eyes Open) and Berge (The Ecology of Building Materials) stand out and should be much more widely read.
I have also appreciated Eisler’s sobering history of fuel cells falling short of their repeatedly exaggerated promise.
And among the books on global economy I must recommend Nolan’s look at China and the world.

Nathan Myhrvold, was Microsoft’s Chief Technology Officer, and now follows a wide variety of interests.

A Universe from Nothing, Lawrence Krauss
Knocking on Heaven’s Door: How Physics and Scientific Thinking Illuminate the Universe and the Modern World, Lisa Randall
The Quest: Energy, Security, and the Remaking of the Modern World, Daniel Yergin
The Honest Truth About Dishonesty: How We Lie to Everyone—Especially Ourselves, Dan Ariely

Here’s a list of books recommended by Arne Duncan, the United States Secretary of Education and CEO of Chicago Public Schools.

How Will You Measure Your Life? by Clayton Christensen
Creating Innovators by Tony Wagner

Here’s a list of books recommended by Steven Pinker, a Harvard College Professor and Johnstone Family Professor in the Department of Psychology at Harvard University. He conducts research on language and cognition, and his most recent book is “The Better Angels of Our Nature: Why Violence Has Declined.”

Peter Diamandis, Abundance – Diamandis is even more optimistic than I am, and this book will remind readers of the opportunities we have to stave off disease, hunger, and privation.

Henry Hitching, The Language Wars – a stylish history of style and usage, for those of you who have ever wondered who decides what’s correct and incorrect in the English language.

Rebecca Goldstein, 36 Arguments for the Existence of God: A Work of Fiction – an exploration of the tension between faith and reason, played out in the romantic and academic fortunes of an atheist bestselling professor.

Here’s a list of books recommended by David Christian. David is a member of the Australian Academy of the Humanities who originated the “Big History” online course, which surveys the past on the largest possible scales.

Steven Pinker, The Better Angels of Our Nature: Why Violence has Declined. A famous Harvard psychologist and linguist does something historians should have done years ago: look for serious data about changing levels of violence in human societies. And his findings are stunning and in many ways unexpected. He finds that in the last two centuries, almost all forms of violence have declined drastically. Murder rates have plummeted in most parts of the world, domestic violence has declined sharply, but even the number of military casualties has declined, partly because the huge casualties of modern warfare were dwarfed by the even larger increases in total population. This is a very optimistic book about the gains of modernity.

Anders Aslund’s trilogy: How Capitalism was Built, Russia’s Capitalist Revolution: Why Market Reform Succeeded and Democracy Failed, and How Ukrine became a Market Economy and Democracy, Peterson Institute. A fascinating, if somewhat partisan, trilogy of books on the transition from a command economy to a market economy in easter Europe after the fall of communism. Aslund’s basic conclusion is that the transition to market economies has been pretty successful in 18 out of 21 post-Communist countries; in all these countries more than 50% of GDP now comes from the private sector, and, surprisingly, growth rates in the last decade have been highest in the former Soviet countries. (The three still in an economic time warp are Belarus, Turkmenistan and Uzbekisan.) But democratisation has been far less successful. It has largely succeeded in Eastern Europe and the Baltic republics, but most of the countries that belonged to the Soviet Union still have relatively to strongly authoritarian political systems, in which parliaments exist, but have little impact on government. Corruption levels and lack of respect for the rule of law remain high in most of the former Soviet countries. He also argues strongly that ‘shock therapy’ and rapid reform were essential because slower reforms merely allowed former elites to regain power over significant parts of the economy and skim off huge ‘rents’.

Brian Cox, Jeff Forshaw, The Quantum Universe: And Why Anything that can Happen, Does and Why Does E=mc2? (And Why Should We Care?). I loved both these books, but I must confess, as a non-scientist, that I didn’t understand the argument in full. Great to give you a sense of the thinking of modern physicists, but occasionally, despite the very clear explanations of the authors, I had to let the argument flow over me and enjoy it rather than understand it! Still worth it. Each time I have a go at quantum physics or relativity I’m convinced I’ve understood them a bit better, but please don’t make me sit an exam on them!

Sam Kean, The Disappearing Spoon: And Other Trues Tales of Madness, Love, and the History of the World from the Periodic Table of the Elements. A wonderful and entertaining book on the periodic table of elements. It’s not just on the periodic table, that wonderful document that helps us see the similarities and difference between different ‘species’ of elements. It’s also on the discoverers of the elements (some wonderful tales here) and on the elements themselves. Elements that were used as poisons, from cadmium to mercury to thallium, the most deadly of all. Or silver, a wonderful disinfectant, which the astronomer Tychoe Brahe used to have a special nose made when his own was cut off in a duel. The title comes from a spoon made from Gallium, which has such a low melting point that the spoon will disappear as you start stirring your tea.

Jan Zalasiewicz, The Earth after Us: What Legacy will Humans Leave in the Rocks? asks what traces we will leave behind us in 100 million times. As one of the pioneers of the idea that we now live in a new era, the Anthropocene, in which humans have become the most powerful force for change in the biosphere, he believes that we will indeed leave traces behind. But they won’t be easy to decipher for alien palaeontologists in the distant future. One of the strangest might be the absence of a layer of limestone as our oceans get too acidic to allow its deposition.

Here’s a book recommended by Charles Kenny, a fellow at the Center for Global Development and the New America Foundation. He’s also the author of “Getting Better: Why Global Development is Succeeding, and How We Can Improve the World Even More.”

The book I’ve just finished is a couple of years old – so out in paperback and perfect for the beach. It’s A Splendid Exchange by William Bernstein – a history of trade from pretty much the beginning to now. That makes It a global history, but one focused on some of the most colorful of the world’s explorers and some of its most interesting technology. It particularly interesting to see how much truly globe-spanning trade has turned from an activity designed to bring a few luxuries to the very rich into a vital part of preserving the quality of life of everyone planet-wide.

Here’s a list of books recommended by Atul Gawande, a surgeon and public health researcher who practices general and endocrine surgery at Brigham and Women’s Hospital in Boston. He’s also the author of “The Checklist Manifesto.”

My fun books for summer:
The Swerve – Stephen Greenblatt
The Green Eagle Score and The Black Ice Score – Richard Stark
Alien vs. Predator – Michael Robbins
The Kings of Cool – Don Winslow

Michael Kinsley is a columnist for Bloomberg View and for many years was the Editor of The New Republic and a columnist for the Washington Post.

There is only one novel that makes the cut for any of the other distinguished recommenders. That is Zuleika Dobson (1911), by Max Beerbohm, a parody of life at Oxford. I would only give it a B+ (although there is a very funny portrayal of an American Rhodes Scholar). Those who are willing to leave the heavy stuff to Bill and are looking for something shorter and more amusing might consider:

The Dog of the South, by Charles Portis. A first-person account of one man’s attempt to reclaim his wife by following her trail of credit-card charges.”It was cool up there and the landscape was not like the friendly earth I knew. This was the cool dry place that we hear so much about, the place where we are supposed to store things.”

Memento Mori, by Muriel Spark. A group of old people in London keep getting a mysterious phone call from someone saying, “Remember you must die.”

Scoop (or anything else) by Evelyn Waugh. This great novel of journalism has absolutely nothing to say about the profession’s current trials.

Finally, I second Bill’s recommendation of Behind the Beautiful Forevers by Katherine Boo, an unbelievably rich account of the life of the unbelievably poor people who live on a mountain of trash next to Mumbai’s glamorous new international airport.

Source: The Gates Notes, various pages.

Top Athletes And Singers Have Coaches. Should You?

Getting better at something you’re decent at, isn’t as easy as it sounds. Consider driving. A skill you likely learned as a teenager. Within a few hundred hours under the wheel, you went from a petrified know nothing to a competent and predictable driver.

Let’s say you’re mid-30s now and you want to get better at driving. How would you do it?

The easiest way is to hire a back seat driver — someone to tell you that you’re taking the turns too sharply, or not coming to a complete stop. Basically, their job would be to point out all the little things you do that keep you from getting better.

Isn’t not hard to find this person. The hard part is putting your pride and reputation on the line.

We can’t do this for everything but we can do it for some things. The things that matter the most.

With that in mind, here is a wonderful essay by Atul Gawande in the New Yorker on whether we need a personal coach.

…I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?

…Élite performers, researchers say, must engage in “deliberate practice”—sustained, mindful efforts to develop the full range of abilities that success requires. You have to work at what you’re not good at. In theory, people can do this themselves. But most people do not know where to start or how to proceed. Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short.

…Osteen watched, silent and blank-faced the entire time, taking notes. My cheeks burned; I was mortified. I wished I’d never asked him along. I tried to be rational about the situation—the patient did fine. But I had let Osteen see my judgment fail; I’d let him see that I may not be who I want to be.

This is why it will never be easy to submit to coaching, especially for those who are well along in their career. I’m ostensibly an expert. I’d finished long ago with the days of being tested and observed. I am supposed to be past needing such things. Why should I expose myself to scrutiny and fault-finding?

If you’re interested in learning more about effective coaching, check out Barbara Lourie Sand’s book “Teaching Genius,” which describes the methods of the legendary Juilliard violin instructor Dorothy DeLay. DeLay trained an amazing roster of late-twentieth-century virtuosos, including Itzhak Perlman, Nigel Kennedy, Midori, and Sarah Chang.

Atul Gawande: Error in Medicine: What Have We Learned?

Over the past decade, it has become increasingly apparent that error in medicine is neither rare nor intractable. Traditionally, medicine has down- played error as a negligible factor in complications from medical intervention. But, as data on the magnitude of error aceumulate—and as the public learns more about them—medical leaders are taking the issue seriously. In particular, the recent publication of the Institute of Medicine report has resulted in an enormous increase in attention from the public, the government, and medical leadership.

Several books have been defining markers in this journey and highlight the issues that have emerged. Of particular note is Human Error in Medicine, edited by Marilyn Sue Bogner (2), published in 1994 (unfortunately, currently out of print) and written for those interested in error in medicine. Many of the thought leaders in the medical error field contributed chapters, and the contributions regarding human factors are especially strong. The book is a concise and clear introduction to the new paradigm of systems thinking in medical error.


Dr. Atul Gawande, is the New York Times bestselling author of Better: A Surgeon’s Notes on Performance , Complications: A Surgeon’s Notes on an Imperfect Science, and The Checklist Manifesto: How to Get Things Right .