Changing behavior to spread innovations: “she was nice”

“Why do some innovations spread so swiftly and others so slowly?” asks Atul Gawande in The New Yorker. He begins by discussing the different paths in the 19th century of surgical anesthesia and antiseptics.

Anesthesia spread “like contagion.” It took only a few months from the time news of the innovation was published in a Boston medical journal until it had been used around the world. On the other hand, antiseptics to prevent infection in surgery took more than two decades to spread.

What made the difference? It wasn’t technical complexity, Gawande said. Both procedures were complex and took technical knowledge. He offers a few ideas:

  • Anesthesia dealt with a visible and immediate problem (pain) while antiseptics dealt with an invisible problem (germs) that wouldn’t lead to infection until well after the surgery.
  • Anesthesia offered benefits for doctors (a sedate patient), while antiseptics caused problems for doctors. Carbolic acid, the most commonly used antiseptic, was unpleasant to work with and burned their hands. No wonder they were reluctant.

The surgical norm didn’t change until some pioneering Germans began to change the identity of a surgeon from a warrior to a scientist with a white lab coat.

Gawande offers another example: an effort in the 1980s in Bangladesh to teach people how to rehydrate a person suffering from cholera. A simple solution of sugar, salt and water can keep someone with severe diarrhea and dehydration alive.

Teams of trainers went door to door, village to village, to teach a mostly illiterate population seven easy-to-remember messages about what to do (such as how to recognize signs of the illness) and how to do it. They even came up with simple ways to measure the correct proportions of salt, sugar and water using people’s hands and fingers, instead of a cup or spoon that might be the wrong size.

Trainers found it was more effective to have mothers make the solution themselves with the trainer helping. They retained the information better.

After doing a pilot test with positive results, the project went nationwide. Trainers went to more than 75 thousand villages and showed 12 million families how to save their children. And it worked. “Child deaths from diarrhea plummeted more than eighty per cent between 1980 and 2005,” Gawande said.

Gawande is currently involved in an ambitious effort to change the way babies are delivered in poor, rural India. The nurses who deliver most of the babies are well trained and very competent. But they don’t make use of some simple things that would help more babies survive, such as taking the mother’s blood pressure and temperature, using clean gloves and soap, and bundling the baby next to the mother after birth to keep it warm.

The experiment, called the BetterBirth Project, is training child care workers to mentor nurses and doctors in rural hospitals in better practices. Workers say the training effort works, but it takes a while. The key is personal connections, time spent at the hospital with staff, getting to know them and patiently helping them make changes, step by step.

Gawande followed one trainer and nurse for a few visits. The nurse had to learn and practice new methods and incorporate them into her routine. As she changed, she saw more babies live who might have died. That helped convince her the changes were worth it.

Gawande is convinced that the personal relationship of the trainer to the nurse was critical. “Why did you listen to her?” he asked the nurse. “She had only a fraction of your experience.”

The nurse admitted that at first she didn’t listen to the trainer. But that changed and she even started to look forward to the visit. The reason?

“All the nurse could think to say was ‘She was nice.’

‘She was nice?’

‘She smiled a lot.’

‘That was it?’

‘It wasn’t like talking to someone who was trying to find mistakes,’ she said. ‘It was like talking to a friend.’ ”

And that, Gawande concludes, was the answer.

Many thanks to my friend and colleague Kathy Kramer,, who sent me this article.