As a postscript to “Structures and Emergence,” I offer a recent story in the New Yorker about intensive care, checklists, executives and practitioners, and a stubborn practical expert visionary. (The story is also about nearly intractable institutional and professional dysfunction, but neither of those qualifies as news or deserves more than a sad acknowledgement followed by the next several steps in the long trek onward and upward.) It’s not the first time I’ve been inspired by Atul Gawande, the article’s author. Gawande gave me the idea for an APGAR for class meetings, and I see from a random spam trackback (a kind of shuffle-playback for the blog?) that my first Gawande reference came way back in December, 2004, when he wrote about the “focus, aggressiveness, and inventiveness” that characterize the pursuit and achievement of excellence, even more than skill or knowledge.

Once again Gawande’s exploring the idea of excellence, and again the exploration is by way of a story about a perceptive, inventive, doggedly committed professional who’s able to realize a vision, glimpse by glimpse. To use current jargon, the “outcomes” seem easily described: more patients live and leave the ICU. The real lessons are deeper, however. They concern the space between innovation and standards, between experimentation and automaticity, and how expertise, or more particularly a culture of expertise, can lead to a sometimes fatal detachment from the necessary routines of effective practice.

A physician named Peter Pronovost (not unlike Virginia Apgar) has established a basic checklist of ICU procedures designed to minimize infection, to manage pain effectively, to limit complications linked to mechanical ventilation, and in general to remind nurses and doctors of what should happen routinely to give patients the best chance of surviving whatever disease or trauma had brought them to the ICU in the first place. His physician colleagues resisted the checklists at first. Some of the arguments bordered on the absurd: “spend time with patients, not on paperwork,” though the paperwork was short, focused, and designed to keep patients healthy, not satisfy bureaucracy. However, by concentrating on a single metric, infection rates, Pronovost was able to sell the idea. (I am reminded that a tactical gain can be the legs that push a strategic imperative over the goal line.) The results were interesting:

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.

Thus checklists need not be a reductive substitute for complexity, but can instead serve as vital first step in complexity management that actually frees up time and attention for the more idiosyncratic or urgent needs. In their explicit articulation of “minimum, expected steps in complex processes,” checklists also turn information into knowledge by expecting (even compelling) a certain kind of attention. A checklist is not just a list, after all. It’s a script; it anticipates a performance.

It seems to me that our students often deal with complexity by reducing it rather than managing it. Who can blame them when much of the schooling they experience obviously and maddeningly does exactly the same thing? It also seems to me that all of us in school tend to confuse lists with checklists. This is a subtler distinction, and I may not be making it well, but to keep the implicit stage analogy going, it has something to do with the difference between repeating lines and acting them out.

For me, the most provocative bits of Gawande’s essay come at the end in a restatement of his mighty theme:

We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.

There they are, beautifully pulling against a tensile center: expert audacity and the virtues of regimentation. The tension is beautifully recursive, for to manage this tension expertly, one must establish and manage–perform?–another instance of it. Like a rosined bow pulling across a violin string.

The essay’s subtitle, presumably invented by an editor, asks a haunting question that effectively concludes the piece: “If something so simple can transform intensive care, what else can it do?”