Slow Ideas: Dr. Atul Gawande’s Still Trying to Make Us Better.

I loved the book Better: A Surgeon’s Notes on Performance. It was written a few years ago by Atul Gawande, a surgeon and professor at Harvard Medical School. It’s brilliant. From simple practices like making and following checklists to more complex concepts such as ingenuity and perseverance, Dr. Gawande took lessons from the greatest medical advances and applied them to everything from running a business to educating our children. And now he’s at is again, writing in the July 29th edition of the New Yorker magazine about the important concept of Slow Ideas: Some innovations spread fast. How do you speed the ones that don’t?”  

In the article, Gawande explains that “In our era of electronic communications, we’ve come to expect that important innovations will spread quickly. Plenty do… But there’s an equally long list of vital innovations that have failed to catch on.”

Many of our clients are worried about innovation. Are they innovating enough? Too much? How do you know when an idea is good? How long should you invest in it? What’s the best way to build an innovation culture in the organization? Should some organizations avoid innovation? Our clients are thinking a lot about innovation because they know that good business is built on good ideas.

But, in a world that has come to view a slow idea as synonymous with a “bad” idea, how do we avoid losing out on incredible and necessary innovations?


It seems like a no-brainer – if an idea is good, and people know it is good, won’t it just spread quickly? According to Dr. Gawande, it’s not that simple. Take two examples:

1)      The discovery of anesthesia. With the innovation of anesthesia patients were suddenly able to experience instant relief from pain. This idea spread very fast. In weeks every capital around Europe was using it and in just seven years every hospital in America was too.

2)      The discovery of Lister antiseptic. Antiseptic was an innovation that allowed for the prevention of infection. But infection is something you can’t see. Antiseptic was based on carbolic acid so it burned your hands – you had to feel pain in order to use it. So while the long term consequences of not using it were terrible, the short term pain was a deterrent.

The relief of pain during surgery was an instant gratification. Both patients and doctors benefitted. Surgeries could take longer with more attention to detail, doctors could operate in relative calm, and outcomes were much better. But the use of antiseptic was more of a delayed gratification. It was painful to endure, and its impact was not visible. The concept was abstract, with short term drawbacks and benefits that only existed in the future. Antiseptic is a perfect example of how some very good ideas are also slow ideas.


Back in my life as a corporate trainer I used to have to conduct annual diversity training courses for employees. I liked the material, and I believed in what I was teaching, but I could tell that people left believing basically the same things they believed when they arrived in the class. I began to use the courses to teach people about how we come to believe things, and how we change what we believe. I was a huge fan of Project Implicit (a Harvard University study promoted by Malcolm Gladwell in his book Blink) that shows the myriad ways in which our subconscious mind directs how we feel and act in situations where we may feel uncomfortable – such as around people of a different race, religion, sexual orientation, and so on. The study confirmed that while “training” in diversity did not change subconscious reactions; there was something that did – exposure. When participants were exposed for long periods of time to positive representations of people of a different, race, religion, sexual orientation, etc. the subconscious mind began to shift more positive. In other words, if we want to change our mind, we have to change our exposure. And changing our prejudices won’t happen fast—it’s a slow idea.

In his recent appearance on the Colbert Report, Stephen Colbert tackles this critical social issue with Dr. Gawande [Watch the clip]

Colbert: I want an app on my phone – I can just hit it and it tells me what a good idea is and I adopt it with no thought.

Dr. Gawande: We have so overvalued apps or incentives to get people to do the right thing… What you see over and over again is that the most powerful force for changing people’s norms and standards is not whether you pay them, not whether you penalize them, but whether you talk to them. People talking to people… do you trust and know someone who is doing this? Then you change.

Colbert: This is how gay marriage spread. This was a slow idea. But eventually so many people got to know gay people they said, “Well I am against gay rights, but not Brian and Alan – they seem like good guys.” And that’s how they crept into our hearts.

Exactly. In one of my diversity training classes I remember one young woman [we will call her Karen] raised her hand and told a similar story: “I believed that being gay was evil,” she confessed. “I thought it was going against God’s law, and I could never be friends with someone who was gay. But when I was hired here I became best friends with Sally [not her real name] in my department. She trained me and helped me succeed. She and I went to lunch together every day. We hung out on weekends, went shopping together and over six months she became a really important person in my life. Then she told me she was gay. I said, ‘I am sorry but I can’t be your friend anymore.’ I thought that was the only choice I had. I had to follow my beliefs. But over a few weeks I realized that my heart was broken. I missed her friendship so much. And I also realized that my beliefs had changed. I knew Sally wasn’t evil. And I knew she didn’t choose to be gay. My friendship with her changed the way I believe. No training class ever could do that. I had to know and spend time with her to change.”

Karen’s story confirms Dr. Gawande’s theory of how slow ideas spread – through social learning. People talking to people they trust who represent the change in question. It’s not that diversity training isn’t important – it is – but the real way diverse cultures are created is through integration and relationship-building.


Dr. Gawande posits the strategy of mentorship as a powerful way to change beliefs and behaviors. This is the method they are using to lower the death rate of newborns with the BetterBirth Project. Mentorship works because it relies on a trusted relationship between the teacher and the student. It’s built on people talking to people, and people working side-by-side.

But critics argue that such one-on-one teaching “isn’t scalable.” Gawande argues “sure it is” – it just requires “broad mobilization, substantial expense, and perhaps the development of a new profession.” The creation of anesthesiology meant doubling the number of doctors in every operation. It was done, and quickly, because the benefits were so tangible. Not having a patient screaming on the operating table was clearly a great idea. But with Lister antiseptic things moved more slowly. Still, with broad mobilization and vast expense, the idea was eventually adopted on a grand scale and we all enjoy the benefits today. So, it’s not that the concept of mentorship is not scalable – it’s just that scaling it causes pain and expense in the short term for huge benefits in the long term. In other words, it’s a Slow Idea.

(For all those organizational development and human resources experts out there who have been proposing such training methods for years only to be shot down – hang in there – you’re not wrong!)


In the New Yorker article, Dr. Gawande explains that: “The most common approach to changing behavior is to say to people, ‘Please do X.’ Please warm the newborn. Please wash your hands. Please follow through on the twenty-seven other childbirth practices that you’re not doing. This is what we say in the classroom, in instructional videos, and in public-service campaigns, and it works, but only up to a point.”

Offering penalties for not doing X and incentives for doing X are other common organizational solutions that often miss the mark. Several psychological studies confirm the use of penalties to promote or deter behavior more often than not results in people quitting, or “checking out” of the process. Whereas the use of incentives often turns out to be much more complex than anticipated – with numerous methods to choose from, the risk of unintentionally incentivizing additional unwanted behaviors or overemphasis of the incentivized behavior to the detriment of another much needed behaviors, and so on.

Gawande continues,

“To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way.”

Psychologists tell us:

Change always involves uncertainty.

Uncertainty always involves risk.

That means that change, even good change, is always a risk.

And we are hard-wired to avoid risk…


If every change requires risk, and overcoming risk requires effort, then people must make a decision to apply effort and endure risk in order to adopt change – this is fundamentally a social process. This is not the quick fix solution that most organizational leaders are seeking when it comes to creating a culture that encourages innovation and rapidly adopts change. “In the era of iPhone, Facebook, and Twitter, we’ve become enamored of ideas that spread as effortlessly as ether. We want frictionless, “turnkey” solutions… We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, and the engineers put is, uncontrolled variability… But people talking to people is still the way that norms and standards change,” says Gawande.


Evolutionaries are transformational change agents. Understanding the social learning component of transformational change is essential for any Evolutionary to be successful in bringing slow ideas to life. And today’s Evolutionary Leaders have their work cut out for them. There are many slow ideas that must gain traction in the coming decades:

  • Global warming and climate change
  • Poverty and hunger
  • Damaged health from too much sugar in our modern diet
  • The shrinking middle class
  • Trillions of dollars in student debt
  • Health care for our Baby Boomer generation

The list goes on and on. The solutions to the world’s biggest problems are not simple or fast. We need solutions that are innovative, scalable, and holistic. They won’t be cheap. There will be no instant gratification. We will endure pain and risk in the short term for long term benefits. People will need to change what they believe and how they behave. In short, we will need Evolutionary Leaders who are masters in evangelizing, strengthening, and guiding Slow Ideas.

About Carmen Voillequé

CEO of Best Practices Media.
Co-Founder of Strategic Arts and Sciences.

Voillequé is a senior consultant and partner with Strategic Arts and Sciences and the CEO of Best Practice Media. Her background features deep experience in education, curriculum development, and management training. Voillequé works with a wide range of client groups including government agencies, financial institutions, and health care companies. Last year Voillequé completed a scope of work that allowed all of the public and private agencies who serve the needs of children in Oregon to plan and work together to maximize resources. She is also a sought after speaker and strategic planner with a reputation for tackling tough issues.