When the Solution Has No Price

One problem faced by a society that is always working toward solutions to various problems is that certain solutions, however effective, may go unused because they cannot be commodified.

Consider obesity. True, billions of dollars have been made selling all sorts of diet and exercise and weight-loss products, but perhaps the best solution is the free one: eat a bit less and a bit better and take a good 30-minute walk every day. But it’s hard to make money pushing that idea.

In this interview with The Takeaway, the author and surgeon Atul Gawande offers another compelling example. Gawande’s new book, The Checklist Manifesto (see Levitt’s strong endorsement here) describes his effort to create a checklist for use in surgical settings that could cut down on errors.

The checklist, piloted in eight hospitals around the world, proved to be very successful. It was also essentially free. But, as Gawande explains in the Takeaway interview, widespread adoption has been far slower than he would like. Why?

If a pharmaceutical company came up with a drug or a device that offered the same improved outcomes as the checklist, Gawande notes, that drug or device would be worth billions of dollars, and would be marketed accordingly. The lowly checklist, meanwhile, has no such sponsor and therefore is far slower to spread.

Here’s hoping that the checklist, along with other cheap and simple solutions, can somehow keep worming their way into the marketplace, despite competition from much better-promoted (and often inferior) ideas.


I think of this sort of thing whenever I see credit card commercials.

There's no advocate for cash, so it's demonized


Shouldn't insurers want to champion a reduction in errors?


The solution has no price because the underlying problems are priced into the service provided. If current practices are providing a sufficient rate of return to the firm, there is little motivation to confront the inevitable protests that accompany imposition of "cost-cutting" measures. Those "cost-cutting" measures like reduced professional liability insurance premiums, legal fees, etc., place the burden of execution on the worker, but the rewards accrue to the shareholder. If the checklist could be tied to an incentive for the worker in such a way that they could receive a portion of the savings, I think that "price" would be eagerly paid by the firm.

And that was a great book, I'm trying to create a DO-CONFIRM list for some of the things I do.


Your advertisers state that "you get what you pay for..." and market so readers covet and purchase what they don't need and at inflated mark-ups. Your paper's other columnists adopt a "there's no free lunch" hubris about anything the public finds overpriced. Our culture has been inoculated against common sense by media.

Therefore, thanks for this article - a breath of fresh air. Dr. Gawande is a breathe of fresh air!


"...widespread adoption has been far slower than he would like. Why? "

Why? I think the answer is obvious: if it's 'free' then no one stands to make money off of it. This disincentivises a large number of people in our country, and certainly keeps any corporation from promoting it. Actually, now that I think of it, the fact that a good solution is free might actually increase the likelyhood of a corporation actively working against a solution should they have a different and maybe less effective solution.

The same is true with the "obesity epidemic".

Ian Kemmish

"But it's hard to make money pushing that idea"

Nonsense - as the endless stream of books like this shows, it's one of the easiest things in the world to make money pushing the idea of healthier diets and exercise.

Now, if the advice in any of these books were accurate, _and_ people decided to follow it - that's when it _would_ get hard to push it. But that's unlikely to ever actually happen because (whether your taste is for natural selection or conspiracy theories) the only books along those lines that ever get published are the ones that people buy, read, and ignore.


What's stunning is not slow rate of adoption -- it's that they weren't already doing this in the first place.

Operating without a checklist? That's medieval.


There are many many problems in the world that could be solved for "free" simply by convincing people to modify their own behaviors.

Of course that's much easier said than done, given that people do not always act in their own self-interest (as Malcolm Gladwell and others have shown), and often have difficulty figuring out where their own self-interest lies.


Re: "if it's free, then no one stands to make money off it. This disincentivises a large number of people ... "

Thus, churches should not exist - or, if they do, they should not be popular. Certainly, you shouldn't find them in every town in America.

That a good solution is free will keep *some* corporations from working for it; however, the economy is not only healthcare; there are corporations on the other side of the equation (see the Leapfrog Group for an example). There are, in fact, ways to promote this kind of solution; they're just not always used.

Sidenote: one way to promote this kind of innovation is through regulatory methods (that's often the way to equally apply a cost-inducing requirement across an industry).

Kevin H

I think with things like this, you need to first focus on the upcoming generation. It is a lot easier to sell this idea to medschools, the incentive is for their doctors to be the most efficient, best doctors they can be. While there will certainly be some institutional inertia there as well, getting the checklist idea embeded into medical training itself is the best way to have doctors stick with it long term.

Eric M. Jones

The overpopulation problem could be solved by the widescale promotion of self-help books and special procedures and study guides for getting pregnant and having babies.

It will just be too much trouble.

Olivier Glinec

I'm pleased to inform you that the surgical checklist is compulsory in every hospital in France since january the first.
the use of this list is supposed to halve post surgery problems.

Daniel Deboer

You bring up a great point: a lot of things with huge net benefits are hard to make money off of.

But hard doesn't mean impossible, and I can see a lot of room for growth in the "walk 30 minutes and eat less" market, especially if the whole thing was mixed with a good dose of social networking.

If someone could come up with a way to put the individual in touch with the group easily and cheaply, there's a goldmine there.


Because errors cause death, and no one in the medical industry is paid to keep us alive and healthy. They're just paid to do stuff, or to pay providers when we get sick.

In an industry like retail, this would be called "supply chain re-engineering" or "logistics", and you could make buckets as a consultant.


The idea to "eat a bit less and a bit better and take a good 30-minute walk every day" is obviously free. However, actually eating less and walking 30 minutes every day is not free. There are real costs for food and opportunity costs for walking 30 minutes.

The same is true of a checklist. The idea and draft of the checklist may be free, but using it has some opportunity cost. It appears the studies show that the opportunity costs are well worth it in terms of improved patient outcomes, but that doesn't mean that there is no upfront cost to using the checklist.


Well, this is part of the big argument for substantial government involvement in health care because it is subject to so much market failure. If the hospital were a corporate factory, the VP of Ops would have an incentive to save costs and improve quality so she'd love a solution that were free.

Daniel R. Wagner MD

It probably won't be very long until a smart trial lawyer figures out that his injured client got that way because the hospital did NOT use a checklist that had been shown in other places to prevent the injury suffered by the client. Malpractice defense lawyers will argue that the checklists are not the standard of care, but I doubt that the jury will buy it. It will only take one or two successful suits and the risk management folks, and probably the Joint Commission, will be all over hospitals to adopt checklists.

John Carlton-Foss

Indeed, my thinking about adoption of innovations has recently taken a further turn toward emphasis on the importance of the principles and actions of sales and marketing. This would appear perhaps to provide another example.

There are lots of examples of how innovative technologies have not been adopted by doctors. Part of the issue is the degree of conservativeness in the profession, stemming from a concern that practitioners have for doing well by the patient, and causing no harm. In the extreme, this takes the form of the requirement for FDA approval.

On the other side of the discussion, it would seem that something like this could possibly go viral if a number of conditions were satisfied. I would be very interested to know if people out there have good ideas about what those conditions might be within the medical community.


Making the checklist spread is easy. Patients should be permitted to hire a Professional Guardian to monitor the care they receive during surgery and that Guardian should be permitted to require and monitor compliance with best practices such as "the checklist".

I had to laugh at this comment from twicker:

"Re: "if it's free, then no one stands to make money off it. This disincentivises a large number of people ... "

Thus, churches should not exist - or, if they do, they should not be popular. Certainly, you shouldn't find them in every town in America."

When did churches become free? They demand hours of your time every week under threat of eternal damnation and every time you show up they expect you to contribute money with yet another threat of eternal damnation if you don't give at a "sacrificial level".

Wonks Anonymous

Back in about 1960 we discovered a simple but not necessarily zero cost way to improve health. It was called "quit smoking".

Since then the evil government has intervened with massive public relations campaigns to promote the idea while taxing and regulating the noble corporations that worked so hard to promote smoking and their own profits.

This was not rocket science, we simply taxed a public nuisance and promoted a public good.

It has pretty much worked. Maybe we could try it again with our national food habits?