A man dies in his sleep of unknown causes.
Why? An autopsy is performed. He died of a heart attack, and that is what is written on the coroner’s report. End of story, right? Not quite.
Why did he have a heart attack? What may have appeared to be an open-and-shut case of a heart attack was actually triggered by uncontrolled high blood pressure and diabetes.
Why were his medical conditions uncontrolled? He had not been taking his medicine regularly, so his health had been deteriorating.
Why hadn’t he been taking his medicine? He had been struggling to pay for it.
Why had he been struggling to pay? He didn’t have insurance and couldn’t afford the out-of-pocket costs.
The man died of a heart attack, but a post-mortem shows that the reasons for the heart attack were much more complicated. By only looking at the outcome, we tend to miss the underlying conditions that led to the final event. This prevents us from addressing the systemic failures that lead to heart attacks at a population-wide level.
What is a post-mortem?
Post-mortems are an incredibly important aspect of product development. The post-mortem looks at what went wrong during the process and unpacks it. There was an extensive post-mortem for the Challenger shuttle accident in 1986, which highlighted the fact that missing chart data steered the decision in the wrong direction prior to the launch.
We tend to only do post-mortems when something terrible happens. The Challenger Rodgers Commission and Columbia Accident Investigation Board analyzed the series of mistakes and process issues that led to both shuttle losses. After the 2012 election loss, the Republican Party did a post-mortem, informally called “The Autopsy”, while the Democratic Party did one after their 2016 loss, the more mundanely named, “Reviewing Election 2016 & Finding The Democratic Path Forward”.
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