The Twilight of Expertise (part 13: ICU doctors)

The other shoe drops. A year ago Atul Gawande wrote in The New Yorker about the Apgar score, a low-tech measurement of newborn viability that led to vast improvements in obstetrics. That’s the “how to improve?” side of things. Now Gawande has written about something equally simple and powerful on the “here’s how to improve” side of medicine: the use of checklists to improve ICU treatment. The first article was called “The Score”; this one is called “The Checklist”.

Checklists are the idea of Peter Pronovost, an ICU doctor at Johns Hopkins Hospital. His first checklist, in 2001, was designed to prevent infections on tubes inserted into patients. Nurses made sure that doctors followed the checklist. It’s like the Ten Commandments: the top and bottom getting together to improve the behavior of people in the middle. Checklists involved the empowerment of nurses (bottom) by hospital administrators (top) to improve the performance of doctors (middle). No coincidence, I’m sure, that the Apgar score also involved female empowerment: Virginia Apgar was one of the first powerful women in medicine.

Pronovost told Gawande:

The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.

Not to mention a sick person’s perspective. I completely agree. Several years ago I heard an industrial designer give a talk to an interface design group. He said that new high-tech products go through three stages: (a) used only by gadgeteers and professional engineers (e.g., the first home computers); (b) used by experts (e.g., billing software for lawyers); and (c) mass market (e.g., cell phones). The discipline of engineering, he said, was good at designing for the first two stages but not the third.

The similarities suggest a common explanation. I think one reason goes back to Veblen: It is low status to do useful work. It may also have to do with male dominance of medical research and engineering. When balancing status versus usefulness, men may weigh status more highly.

More innovation in the delivery of medicine: house calls. No kidding. More about Peter Pronovost.

2 Replies to “The Twilight of Expertise (part 13: ICU doctors)”

  1. Interesting insight about the three stages of industrial design. Apple seems to be proof of this idea. They dominate personal audio players (and have a good shot at dominating cellphones) despite being late entrants into both sectors.

    Before I had an iPod, I had an iRiver audio player — great technology with an interface that made you want to slam it into the wall every time you used it. And I still have a cellphone that Verizon insists be loaded with its confusing, ugly interface, one that only allows it to store 50 txt messages (despite 90% of the phone’s memory being empty.)

  2. Interesting perspective. I used to work in user interface and don’t see the problem being so much that design for an end user is female or low status, but that may be because I worked for companies that highly valued the usability of their products.

    The engineers and scientists who create the products have highly specialized knowledge in a very narrow field; they create the products in a way that makes sense to them and the way they view and interact with the world. Part of the problem is that there are very few people who understand both the way the end users are going to interact with the product and the way the engineers see the product. The process requires usability testing directly with the kind of people who will use the product; it requires people who carefully watch those interactions and can improve the design; and it requires people who can translate the design vision to the engineers in a way that they can understand it.

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