Prior installments:
How We 'Managed' To Screw It Up,
Getting Off The Grid
Off The Grid
Abstractions
Going Organic
Interview With A Management-ist
eXtreme tAylorism
Changed By It
"I'm working to reinvent our company's operational practices. As I understand things, technology is a key enabler for making processes more efficient. At the same time to really improve things new processes should be developed which take advantage of increased communication and automation now available. I'm looking for a good forum which talks about "use this to do that", "this tool allows you to do this better", and possibly discuss streamlined processes."
Parse the language in this posting. Notice what isn't there!
What isn't there? People are missing, replaced, as F. W. Taylor long-ago predicted, by "the system." Who performs these 'operational practices?' Who does this disembodied 'communicating?'
What IS there? 'New processes,' 'technology,' 'efficiency,' and 'automation,' enablers for an unmentioned community of ... ... (wait for it) ... PEOPLE?
Isn't this where we've learned to go? What we've learned to do? To chase ephemeral efficiency with as-of-yet unimagined technology? And what do we imagine that technology to be? Something featuring software, no doubt. Something that comfortably integrates within the existing network. Platform independent. Licensed or open source. Upgradeable. A good, solid, tangible cause capable of making our aspirations real.
Notice one other word imbedded within this posting. Notice the 'should' innocuously standing there, just as if it weren't controlling the traffic flow for the whole danged inquiry. Also notice the tenaciously passive voice, which never specifies any who except for the author's innocent 'I'. He will be reinventing 'our' company's operational practices. 'I'm' looking for a good forum. I find no evidence of either 'us' or 'we' in the entire posting. Where did we go? Why no us?
Am I being too harsh? Reading too much into this posting? Perhaps, but then again, perhaps not. We construct our world with language, and the world this language creates doesn't seem to include space for the object of the whole inquiry, speaking in what Bateson called 'the dormative,' language that induces sleep rather than action. It focuses upon derivatives rather than the underlying source. What IS that source?
In his remarkable book How Doctor's Think, Jerome Groopman, MD recounts how injecting technology into the practice of medicine brings unintended social consequences, typically because some manager somewhere focused upon derivatives rather than the actual practice. Easing the effort to invoice insurance carriers inhibits the doctor's ability to reliably diagnose. Simplifying diagnosis by documenting decisions using pre-formatted decision trees disables diagnosing. The cognitive confusion inherent in any social interaction becomes more complicated by streamlining apparently trivial tasks.
I could be arguing in favor of more whole system thinking, except what passes for the whole system in the management-ist's language excludes most of the system's holistic nature. Certainly, we can create notional models of any system, but can include in those models only those elements we characterize as causative; germane. The result is a curiously satisfying reduction, wholly comprised of derivatives sensitive to underlying, unseen, unaccounted for, uncountable components. Groopman labels the most commonly overlooked element 'context,' and claims that little any doctor actually does holds meaning out of context. Like the old thought experiment that proposed dissecting a cat to find the purr, decomposition discards the context, typically the social context.
Before the author of this post will be able to really reinvent 'our company's operational practices,' he will need to reinvent his way of describing reinvention. Were he to actually reinvent, his initiating notions of what characterizes reinvention must certainly crumble. Otherwise, he will merely reinvent more (perhaps even more) of the same.
That was a characteristically long-winded preface to what I intended to address in this posting: enablers. The manager is commonly represented as enabler, the cause of performance and efficiency, the 'driver' of results, the 're-inventor of operational practices'. In a social context, enablers are those individuals who assume the burden of someone else's addiction-induced dysfunction. In an organizational context, managers are expected to both make and take this heat, sometimes innocently (and sometimes not so innocently) encouraging the very dysfunction they intend to eradicate. Most commonly, this dysfunction centers around individual agency or the lack of it. We want to hold people accountable for their performance, but insist upon them agreeing to be irresponsible to achieve that.
Imagine a manager commanding a subordinate to do something that the subordinate knows he cannot do. Will he say yes? He knows his no will encourage a raft of 'get with the program' innuendo, insistences that he explain exactly why he can't, and 'help' getting over his cluelessness. Very probably all of these will occur if he says 'No!" while being managed by a management-ist, because his personal perspective is gumming up the system, and the organization is all about the system. Isn't it?
The under-apprecated technology we seek might well be what the eggheads at MIT are calling Social Technology. Social Technology is not before-the-fact causative, it involves no software, except the software imbedded in every individual at birth, though our sensitivity to it can be disabled by some of the socialization received thereafter. It includes two of Aristotle's Causations explicitly omitted from reductionist science and its progeny, scientific management; management-ism. Omitted as metaphysical: not countable, not reducible, not manageable. Omitting these two causations leaves only the most primitive two, those commonly labeled Material causation and Efficient causation.
Material Causation ascribes cause to the nature of material. The fireplace is rigid because it is constructed of brick. Efficient causation ascribes cause to some previous act. We're late because the last meeting ran long. Science, scientific management, even management-ism limit their domain of inquiry to these two dimensions, when their domain of existence includes and is subtly influenced by Aristotle's un-reducible and uncountable metaphysical causations: Formal Causation and Final Causation.
Formal Causation ascribes cause to form. An example of formal causation are the differences we experience when communicating face-to-face and via email. The form of communication subtly influences, affects, 'causes' difference. Asking exactly how or why these changes occur assumes a material or efficient causation at work, and while these questions might well elicit any number of interesting responses, none will be satisfying in the way that a material or efficient causation might provide.
Final Causation ascribes cause to some imagined future state, as if our aspiration caused the result. A common example of final causation at work is found in scheduling assumptions: the flight departs at four because we want to arrive at five. What caused the flight to depart at four? Our aspiration to arrive at five. Certainly a raft of material, efficient, and formal causations were also involved in arriving at five, but without the aspiration, none of them would mean anything. The root cause is our anticipation of future events.
When a management-ist searches for the root cause, he limits his search to material and efficient effects, though these will inevitably provide only the most primitive parts of the explanation. This is fine if identifying the material or efficient causes provides some leverage for useful action. Omitting formal and final causations limits possibility for change, and holds the source of what are commonly referred to as unintended consequences. These might be better described as unimagined consequences resulting from unseen and unconsidered contexts. Because science education focuses upon understanding the material world and cataloguing efficient causations (aka Best Practices and Procedures), it focuses the practitioner's attention away from powerful, causative points of leverage. Without acknowledging the influence of the metaphysical, any practitioner can degrade into focusing upon the purely physical, firmly believing that an efficient cause must be provided to enable performance. Hence, the enabling management-ist.
Who gets disabled in this context? Those who become addicted to the material and efficient world-view. The management-ist, all-powerful though he might seem, is just as addicted as those who firmly believe that he causes their performance. This aspiration might well be the final cause of this disabling enabling. Mention the metaphysical to a dedicated management-ist and watch his eyes roll.
Who manages the management-ist? Next time.
For the last fifteen years, I've been facilitating curious workshops. These never told anyone what they should do, and I've developed a strong aversion to anyone who presumes to know what I should do and when I should do it. Nothing I do involves procedures. Nothing seems suited to steps or checklists. This is an improvement over the years following my graduation from university, when I performed a lot of quantitative analysis on what was in retrospect subjective experiences. I attempted to routinize a lot of work which never as a result exhibited routine. For I was infected with the notion that I should measure and, more dangerously, that only if I measured could I properly manage. The people I was charged with managing were wiser than I was, however, and while some of them chased the measurable manageable metric god, none of us ever caught him. And we succeeded at an acceptable rate, anyway.
Jerry Weinberg's Problem Solving Leadership Workshop, which I helped facilitate for seven years, attracted many upwardly mobile middle management types. Some were team leaders tapped to move into management. Others were managers being groomed for executive futures. Some were executives trying to improve their effectiveness. Most came with little understanding of what this experience would bring. Many were frustrated that no one would tell them exactly what they would learn, being used to workshops that provided succinct lists of learning objectives and descriptions of what would be learned.
Jerry invited participants to create their own learning objectives, instead. A pre-work assignment that just baffled many.
The workshop served as a kind of introduction to self more than providing a set of general instructions. Each participant was encouraged to write in a personal journal, and us facilitators called frequent journal breaks for people to jot down their reflections. No one was ever required to share their personal reflections, and aside from an opening ritual where small groups distilled and reported their learning objectives and a closing ritual where each team reported on whether they'd achieved their objectives, personal learning stayed quite personal. No one knew what anyone else was really learning.
I attended my first PSL in the late 80s, when I was a driven middle manager. I was what I've since labeled 'zoned in' on my career, my work life, my company, my projects. I was monoral, single-minded, a driver. My wife at the time complained a lot about my schedule, my obsession with work, claiming that I'd changed since I went to university and took a management job. I couldn't see it. I claimed that while I was no longer the songwriter I once had been, I was "just playing a different-shaped guitar now."
PSL involved a series of simulations, experiential games intended to help people "catch themselves being themselves." I stumbled into myself on the first night, in the middle of a black box simulation. The me I encountered in that game differed so greatly from the persona I'd been inhabiting that I took sick, what I now recognize as soul sick, and missed much of the balance of the workshop. I was deeply changed by that experience.
I had no way to know this at the time, but many who attended PSL over the following years experienced similar results. Many encountered an unfinished or neglected side of themselves and found their resulting selves less willing and able to engage as they had previously unselfconsciously engaged. They woke up and were changed by the experience. Some left the companies that had sent them. Others struggled upon return to find a place for something that had not seemed germane before attending the workshop. Many stayed connected and started a now life-long conversation considering who they are and what they are doing in this world. I'm still connected to many people I first met attending and later facilitating PSL. My present wife, Amy, was a student at PSL when we first met.
What does this have to do with management-ism? Management-ism requires the subjugation of self, the often pre-conscious denial of who I am and what I am doing. To encounter self in a revelatory way, after not being aware of self's absence, unsets more than our carefully constructed house of cards. It changes the game.
As I said, I met Amy at a PSL, where she was 'just another student' when I first noticed her, the shortest member of her learning team, standing on a chair, painstakingly positioning the top tier of cards on a planned eight-foot house of cards. Her team had won the first round of competition, where the challenge was to build a four-foot house of cards, and had taken their proprietary technology and moved from the lobby where other teams could copy to an adjacent dining room for round two. As I approached their construction, yardstick in hand, her team members asked for a measurement. Taking my yardstick, they found that they were building their eight-foot house of cards in a seven-foot, ten-inch room. No way to succeed.
What Amy and her team did then was instructive. They became political. "Would it be good enough to show that we could have succeeded? Can we use Amy's foot in lieu of a standard one?" And they began to build faster. They continued building for a few minutes after time was called on that round in a kind of Wiley Coyote attempt to keep running after losing their ground.
On reflection, Amy realized that she'd stumbled upon a dandy metaphor for her life. Her work assignment was like trying to build an eight foot house of cards in a seven foot ten inch room. So was her marriage. So was her career. She was changed by her unanticipated experience of self.
Management-ists tell stories about how self-less they are, about how they sacrifice for their company, their team, their goals, their customer, just as if their selflessness contributed to creating more value, more results, more satisfaction, as if what matters to them doesn't really matter at all. They can encourage selfless cultures, where their curious affliction gets rewarded as the norm and any semblance of self experienced as evidence of less than full commitment.
F W Taylor deliberately omitted self from his efficient procedures, measuring only what he measured, not the inevitably self-infused organization. The workers complained a lot at the time, reasoning that since Midvale Steel was not competing in the small margin railroad rail market but the huge margin government armaments market, there was plenty of space for a variety of self in the fabrication. Nor did the calculated efficiencies prevent the company, or the bulk of it, from being acquired by the Pittsburgh steel combine and turned away from its DNA. We wonder now what that self-lessness really achieved.
But our training and the context within which we manage seems now to insist upon us acquiring the bug. Those who suffer from it might never suspect their infection. Those who recover from it usually stumble upon or over themselves, then work to incorporate their discovery into something quite distinct from the game they were originally certified in and the one they were convinced they just had to play. Those who've not yet made this discovery remain confident, certain that they are playing the right game right. This unchangeable certainty is clear evidence that something essential's missing from the mix.
([Note: I am the Management-ist depicted here. I am also the one interviewing (or, in proper management-ist lingo, 'being interviewed by') the management-ist. I have been on both sides of this conference table.]
The chill will crawl up the back of your neck.
The surroundings are comfortable enough: a well-appointed office, a conference room decorated with fine art. The welcome will be genuinely warm. The conversation always starts with small talk—studied small talk, as if I'd been instructed to 'start from the heart' and engage with the 'person' first. Whether this takes the form of sports, the weather, the travel from there to here, or the nearly universal quick apology for being a few minutes late for the meeting, the first five minutes of the interview will be beside the point.
Study the scenery. What books are displayed? (These are clues to the form and texture of belief.) What clutter prevails? Am I wearing one of those absolutely unfunctional Polo dress shirts with a logo in lieu of a pocket? Tassled loafers or tasseled Top Siders? The tassel: the management-ist's curious decoration of choice!
Listen to the language. I will pass more than your maximum annual dose of unconditional superlatives. I will say 'best' when the context screams 'better', I will use 'accountability' as a synonym for 'responsibility', I will revere 'predictability' as if it were 'reliability.' Listen closely, you will not understand very much of what I say. I speak in deep code. Buzz words punctuated with references. I will not speak for myself, but quote noted authorities, just as if knowing who said what makes what I say meaningful. Mostly, my story will be garbled. Ask for clarification and expect to receive a puzzled frown.
Sometime within the conversation, I will disclose another's shortcoming. 'They' will have done something 'stupid.' 'They' won't have 'gotten it.' 'They' will be characterized as some form of clueless, a condition linguistically elevated to character flaw. You will sense that 'they' managed to fake it until this recent unmasking of the deeper truth. 'They' are the cause. Defend 'them' at your own peril.
If your mind wanders, reflect on how it is that such a smart and experienced individual could be surrounded by such blunder. If I confide that 'my people' are well-intended, but not very experienced, return a year later, and I will repeat the same story. Then wonder: How could that year have not resulted in someone acquiring experience?
Whatever the topic, notice the interview wandering back toward me, the management-ist. I am the final arbiter of experience. More interestingly, I have assumed the role of final arbiter of everyone else's experience, too, second-guessing whatever fails to make a priori sense or contradicts my personal convictions. I feel powerful, but I am stuck in a story I seem to star in, yet hold little culpability for creating.
Jung claimed that this sort of absent presence occurs when a secondary temperament component (Thinking/Feeling) overrides the two primary temperament modes (Intervert/Extravert-iNtuition/Sensing). Typically, where acquired knowledge is more valued than how one naturally relates to others and how one naturally prefers to acquire information. In other words, where one more highly prizes what they have acquired over what they are naturally endowed with. Perhaps this is the delusion of our age, our very culture writ large. We move to cities to escape where we're from. We take degrees to distinguish ourselves from others so we can get a high-paying job. We assume professional (literally, what we profess) roles, then fuss about not being able to talk about what theory doesn't really work. We believe ourselves to be what we know, not who we are.
Fine, I'd rather have a knowledgeable manager than an ignorant one. But the fine distinguishing line is not between knowing and not knowing, but between knowing and being. The management-ist is defined by what they know, rather than more properly informed by it. A management-ist without a litany of oft-quoted external references (whether from Heroclitus or Tom Peters) is to their mind, no manager at all.
Some worship before the alter of continuous improvement. Others, six sigma. Whatever their belief, you will notice explanations that do not and could not ground themselves. Each requires faith for closure. Each requires belief to work. Ask an innocent question about, for instance, who decided what would be called Best Practice, and notice the quivering eye movements that signal the search for qualifying references. Some noted authority, who invariably became noteworthy due to their own audacious commercial bluster, will be named. This dance can continue for as long as you care to play.
I call the dance between the management-ist and the human Idiot Making. Where another presumes to know better than you what your experience is. Where their 'superior' judgement co-opts your inferior perspective, robbing you of your experience and leaving little more than a promise that, with diligence, you could know better, too. This is where the fear will crawl up your spine and tickle the short hairs on the back of your neck. You will be in the presence of a person capable of justifying almost anything, of dis-qualifying anyone except, of course, himself. Be afraid. be very afraid.
If you glimpse yourself in the management-ist role, as I have glimpsed myself in the past, be even more afraid. This peek took my breath away. Whether or not you suffocate on this unwanted insight, hope to be changed by it.
Next time: Changed By It
In the last installment, I introduced the character behind management-ism. The 'can't manage what can't be measured' mindset that seeks metrics for measuring everything. Peter Block once asked the question, "If performance appraisals are so good, why don't we perform them on our spouses?" We don't perform them on our spouses because we have better ways to assess the goodness of that relationship. In absence of relationship, though, where we merely inhabit roles and perform process scripts, managing by such metrics might seem to make all the sense in the world. The management-ist sees no contradiction in employing 360 degree feedback strategies. The rest of us certainly do!
Within industrial-scale organizations, some new (read:old) paradigms are emerging. When Nike realized that the gas used in their air-cusioned sole was a volatile greenhouse gas, a movement started within the company. As Peter Senge explained it, three people—not executives, not powerful middle managers, but three rank and file employees—started a movement. They hosted lunch-time chats. They networked to gain influence. Their goal? A carbon-neutral Nike. Impossible? Certainly not on the corporate radar at that time. It is now. Nike's long-term strategy includes carbon neutrality. This started as a conversation among the powerless to become the stated goal of the whole organization!
How did THAT happen? You already know!
This is no isolated incident, though it might serve as the model or pattern for an under-recognized reality operating within even industrial-scale organizations. Innovation isn't top-down. Inspiration isn't either. The motive power that actually moves even the behemoths is organic, not mechanistic. Though the literature focusing upon processes and the improvement thereof leans heavily upon mechanical metaphor, the mechanism they fail to describe isn't mechanical, but organic. Quite remarkably human-scale. (Don't let the management-ist know, okay? They think they're in charge.)
If the management-ists aren't in charge, who is? As unlikely as this might seem, you are. I can't count the conversations I've had with individuals imbedded within industrial-scale organizations, where they cheerfully recount how they get away with things. These are not native sneak thieves, but deeply benevolent and loyal employees who routinely work the system so that system can work. The management-ists are blithely ignorant of the catastrophes avoided, believing, I guess, that their grand strategy is working more or less as they intended. It isn't. It never does.
The machine has remarkably little influence over this organic spirit. I have seen it thrive under the harshest conditions. In fact, harsh conditions seem to encourage it. Telling it "No!" won't deflect it much. This will just get its conniving imagination working harder.
The choice is not to work for someone else or work for yourself, you're always working for yourself, no matter who signs the paycheck. Working for yourself carries some ethical responsibilities, which can become lost in the overly-responsible dance management-ism embodies. In fact, everyone is managing all the time, it's not just the responsibility of the designated managers to manage. Where management becomes the sole purview of designated managers to do unto others and descends to the level of religious conviction, the net available management power within the organization plummets. These organizations are not certified organic. Where everyone understands that, regardless of what the mythodology claims, they are responsible for managing themselves first, interesting things happen. They happen as a resonance of a set of ancient ethical responsibilities that every human was born with but that the industrial, management-ist mindset scrupulously ignores. Kinda like what happens when organic methods reconnect a plant with its source of macro-nourishment. (Some just call this bullshit.)
One of these ethical responsibilities is:
Enough for today. More next time
Continuing the investigation of the secular religion of Management-ism started HERE, continued HERE and HERE ...
The last installment introduced Dr. Bob Ironside, an Internist who fled the managed care system to start a subscription-based health advocacy clinic, where his clients actively collaborate WITH him to maintain health rather than simply treat illness.
Dan Starr, in his comment on the third installment, noted that the HMO (Health MAINTENANCE Organization) concept originated in just this idea, a physician/client partnership focused positively, to maintain health and so reduce health care costs. It morphed into its opposite, where the object became negative, to reduce health care costs by aggressively "managing" allocation: dictating delivery terms, questioning diagnoses and treatment recommendations, and tightly limiting reimbursements to minimize costs. How maintaining health shifted into minimizing costs might serve as the general pattern defining the difference between the manager and the management-ist.
Management-ism thrives on homily and abstraction. Read any number of popular management books and you might reasonably conclude that management is more art than science, or so many commentators have concluded. The science seems rooted in something other than carefully considered propositions, relying heavily upon rumor, personal preference, and "consensus". It can't quite qualify as an art, either, as anyone who's formally studied art or lived as an artist quickly acknowledges. Some descriptions devolve into the even murkier realm of "leadership", which has all of the sparkle and promise common to personality cults.
In a Harvard-sponsored teleconference on leadership training, one of their B-school researchers admitted that not even Harvard knew how to train for leadership, and that their efforts would probably be best focused not on the B-school, but upon the Divinity School. She characterized B-school candidates as being more aggressive and self-centered than D-school students. Neither of these preferences are closely associated with good leadership. They are, however, common to forceful governance.
But how to transform responsible guidance or leadership into forceful governance? One must have a code, an ethic if you will, that justifies aggressive, self-centered acts. A force, ahem ... to be reckoned with. And that force was found in rules of thumb elevated to imperative, in promoting specific experiences into Best Practices, and otherwise mindless homilies into mind-numbing necessities. By creating an enforceable myth, a compelling story, and, above all, a plausibly believable fiction: Organization Man. (I imagine a kind of superhero who wears a spandex Brooks Brothers suit, high-luster wing-tips, and a sixties-style, narrow snap-brimmed hat. What Frank Loesser called "a Scarsdale Galahad, the breakfast-eating, Brooks Brothers type." Think Bob McNamara in his prime.)
Where to begin? Lets begin with what managers, according to their mythodology, can't do. They "can't manage what they can't measure." Moral: Anchor the organization to clear, objective, measurable metrics: SMART (Specific, Measurable, Achievable, Realistic, and Time-bound) goals. "Balanced" Scorecards. Focus upon predicting the future as the present reality. Tether everything to numbers. [Or, as everyone with much experience "managing" to these knows them, "NUMB-ers."] There, the perfect ambiguity cocktail, a steady diet of which utterly fogs reality.
One thing I noticed missing from Dr. Bob's description of his practice was the absence of any mention of specific, measurable, achievable, realistic, and time-bound goals. I'm certain his operation carries a few of these, as all businesses do, but they were nowhere apparent in the space between Dr. Bob and I. They were not foreground dominant. There, he seemed to be managing by instinct, by gut feel, by sparkly-eyed purpose. Exactly how he will satisfy his mission was not even germane to his realization of it. His clarity of purpose was obvious in his very presence. He was not managing his clinic, he was being it.
The professional management-ist is careful to maintain clear boundaries between self, others, and organization; he remains above all else "professional." He is not emotional—the constant focus upon the numb-ers helps there. Not introspective, but extrospective, taking cues from what he characterizes as external objectivity. He keeps score. He is fiercely loyal to his allies and fiercely allied against his enemies. You'll never see him sweat. He plays high-stakes poker. He knows the odds, the margin, the vigorish, and the game. He makes the rules when he can, bends them when he can't, and is tenaciously competitive; but a cardboard competitor, two dimensional, shallow. He's ruthless if he needs to be, generous when he must, heartless in the face of doubt, and stingy extending trust. He's convinced of the rightness of his cause, skeptical about your reliability, and cynical about his fellow man. He's negotiated a generous package for himself that will guarantee that he leaves "whole", whatever the contingency. He is, above all else, politically astute.
Quite a stereotype, huh?
In practice, the management-ist might well exhibit all of these patterns, but would never characterize himself in this way. Or, he might well exhibit none of these characteristics. He is, as the soothing voice-over in a Walt Disney short describes Goofy, "just your average guy looking to get by in the world." He's been infected with a perspective, though, one which comfortably justifies cold-hearted compartmentalizing, removing the person from the personality, leaving a caricature, an actor playing a role. An abstraction. Not present. Human absent soul.
He is curiously not curious. He can be quite dismissive toward anything he doesn't a priori understand and especially toward anything he cannot measure. If you cannot speak in his curious, limited dialect, it's YOU that will be judged clueless. As a class, they suffer from the one truly incurable disease: certainty. Consequently, they are addicted to risk-taking.
The seductions of this life are huge and, not surprisingly, measurable! Money. Position. Power. Authority. Security. Tenure. The costs, too, are enormous but fuzzy. Obligation. Responsibility. Accountability. Indictability. And, curiously, tremendous insecurity. (What do you do when you reach the top of your profession? Move to a gated community!)
Their world is abstracted by objective measurement. Like the mythical character who falls in love with the swan, the management-ist falls in love with his gauges, managing what he can measure and trying to measure whatever he aspires to manage. This might explain what transformed health maintenance into managed care. The gauges associated with managing care might just be as close as any management-ist could come to getting their arms around health maintenance. Health is subjective. Care can be metered by definite abstraction. It's all in the numbers, somewhere.
More next time. I've gotta go check the bumps on my head. ...
This posting continues the story started HERE and continued HERE. This third installment of my investigation of Managementism, the profoundly popular theology influencing everything from food production to health care, looks at one example of one practitioner who choose to step "Off The Grid."
In the last installment, I introduced a doctor, Bob Ironside, who, dissatisfied with the management of the health care system he was a part of, took personal agency to make his part work much better. I was sitting in an extremely comfortable room—I would not call it a waiting room, because it was clearly not designed for any activity as wasteful as waiting—for a chat with Bob about his life off the grid.
...I spent the few minutes after the receptionist left checking out the room. My chair was extremely comfortable. Three other matched chairs were, like mine, set around a large, low table, which held a bouquet of fresh flowers. Just behind me, on a sideboard, a Bose Wave Radio softly bled classical music. The windows to my right overlooked the mansions and forest just above NW Portland. I sipped my water, wondering where this conversation would start. And where it might lead.
Bob quietly opened the sliding panel and slipped into the room. I stood, and we shook hands like old friends before settling back into those comfortable chairs. I asked, "Bob, why don't I feel like a cow in a cattle car waiting for the conductor to call my stop?"
He explained that people don't open up when you treat them like cattle. He'd designed this clinic to not feel very much like a clinic because the traditional design shuts people down, and he needs people to speak freely there.
He went on to explain how his clinic works. "If Tim Russert had been our client, I'm convinced that he wouldn't be dead," he asserted. Bob's clients do not suffer catastrophic illness. Sure, they get sick, but in every case, he's seen the trouble coming and caught it in the earliest, most treatable stages. He helped one client, an ex-Olympic athlete, avoid a heart attack by carefully listening to his family's health history. Though he was in excellent health and showed no symptoms of heart disease, he ordered a battery of tests which showed that he did, indeed have heart disease, which he's treating before it became a catastrophe.
He shared several examples of clients who came to him dissatisfied with the diagnoses (and mis-diagnoses) they'd received (or not received) from their harried managed care physicians. Bob's great skill, I knew from my earlier relationship with him, was his exceptional ability to create rapport and really get to know his clients. He gets to know their story and can weave the intricate threads together. Perhaps just as importantly, his clients get to know Bob's story, too. He discloses a lot of his personal stuff as a part of his work.
This, it seems to me, is one hallmark of the self-manager. They do not aspire to an emotionally or intellectually or politically-neutral professional presence, but a disarmingly personal one. He is a very skilled and deeply respected practitioner, but he doesn't present himself as a Mr. Know-It-All. Instead, he creates a sense of joint inquiry, fueled by deep personal interest and, as I already knew but was about to learn even more profoundly, an uncommon advocacy.
His practice is now all about advocacy. When he refers a client to a specialist, he visits the specialist WITH them. He doesn't second-guess or upstage the specialist, and rarely says a word during these visits. If the client has questions, he lets the specialist answer unless explicitly invited into the conversation. Too many times, Bob noted, clients have questions after a specialist visit or don't understand that they don't fully understand what the specialist tells them. Bob forwards extensive patient history to each specialist beforehand, but admitted that specialists do not always make time to review them before the client arrives. Having been there, Bob can help position the puzzle pieces so the whole portrait makes sense to his clients, their specialists, and himself, too, making for much better-informed choices.
I was astounded! I wondered how he could possibly schedule those visits. (He also visits any client who's hospitalized.) Bob explained that client load has a lot to do with disabling a doctor's ability to fully advocate. Under managed care, he needed to carry a client load of about 3000 to make the numbers work, and even then, the numbers didn't work very well. Fully three-quarters of his staff then worked on billing and collections, and his performance was hampered by the normal intrigues that come with any large staff. Now he has a client load of about a hundred.
Incredulous again, I wondered, "So, you can do more with less, but what about the bottom line."
"It's much healthier than it ever was before," he smiled."
How does this work? People subscribe to Bob's service, paying an annual flat fee in advance. In exchange, Bob provides exceptional internist attention and health care advocacy. One of his clients, the Board Chair of a local hospital, was dissatisfied with the specialist Bob had referred him to at that hospital. "He was brusk, and 'all-knowing,' and we didn't feel like he'd delved deeply enough before diagnosing. So, I looked nation-wide, and ended up referring him to a colleague at the Mayo Clinic in Minnesota, who found a potentially life-threatening condition before it could threaten. Did Bob accompany his client there, too? You betcha!
This is an admittedly small-scale operation, but it's getting noticed by the HMOs. Bob's clients are healthy because they proactively attend to their health, rather than retroactively respond to often avoidable illness. The reimbursement for treating a single modest health crisis could pay for a lot of pro-active advocacy. Bob's practice doesn't replace the need for personal insurance coverage, but it quite effectively reduces the need to resort to it in crisis.
I asked Bob if he'd become a pariah in the local medical community, and he recounted a conversation with a local cardiologist at a recent meeting. "You're the envy of everyone practicing medicine in this town," his colleague confided. To those who might criticize Bob for taking an admittedly top-tier clientele, he responds that he's always treated the indigent and still does. Some of his clients pay noithing. Under the 'put on your own oxygen mask first' principle, Bob claims to be much more interested in volunteering his time now that he has time to volunteer. And now that his practice is supporting him well, rather than struggling to make ends meet. What was once mostly obligation has become a welcomed and more frequently engaged in opportunity.
I'm afraid that this posting has grown much larger than I intended, so I'll sign off here. There's more story to come. To be continued. ... ...
This post is the second installment in a series considering Management-ism, which I started here.
I first met Bob Ironside in the early eighties. He was then an Internist, working in a typical clinic he shared with a half dozen other docs. The waiting room was large enough to hold twenty or thirty patients. Staff worked behind a counter with a sliding glass window. A receptionist, several nurses, rows of shelves with patient files. The doctors saw patients in small rooms along a central hall, which was closed off from the waiting room by a door, guarded by one or another of the nurses. When a doctor was ready, a patient's name was called out, and the door to the examination rooms opened, and that patient was ushered down the hall.
In other words, a typical doctor's office.
The most important information, more important it seemed than the patient's condition, was the condition of their insurance, for upon entering the office, every patient visited the sliding glass window and discussed how they would be paying. I was using my insurance, so the receptionist photocopied my insurance card, calculating the co-pay amount while I filled out forms. I felt like I was purchasing a vacuum cleaner on the installment plan.
All typical doctor's office stuff.
I waited quite a long time, and since I had left work in the middle of the afternoon for the appointment, I noticed the time going by. Finally, my name was called and a nurse accompanied me to the examination room where she weighed me, took my blood pressure, and told me that the doctor would arrive momentarily. A few minutes later, Bob entered the room.
We chatted. His "manner" was casual and focused. He seemed genuinely interested in knowing about me. A few minutes into the examination, he explained that he was breaking a rule. What rule, I wondered.
"The Health Management Organization (HMO) monitoring this clinic," he reported, "has calculated that I should need to spend no more than seven minutes with any individual patient." he announced. "But I need at least a half hour to get to know anyone well enough to diagnose for them, so I break the rule, especially when the patient is someone interesting like you."
I felt flattered, but also felt the indignation Bob was spewing. He was genuinely upset. He continued, explaining that the geniuses at the HMO were not doctors but statisticians, accountants, auditors, and professional managers, none of whom had ever performed even the simplest diagnoses on any patient. I felt as oppressed as Bob obviously did.
He spent his half hour, made a recommendation or two, and we parted.
Over the following years, I followed Bob to a couple of other clinics, one's he and his colleagues started to try to sidestep the hated HMO. Over a decade later, he confided to me that he was not making it, that the management oversight had become simply absurd. Three quarters of the employees of his latest clinic worked not in patient care, but in billing and collections. Insurance companies further discounted standard charges by an average of 40% (for the service they provided processing their client's claims), and extended payment terms beyond 180 days. "How can anyone run a business with conditions like this? The efficiency experts claim savings by adding overhead to my organization, while the insurance companies walk away with terms favorable only to them. They're bankrupting me!" He also reported that insurance coverage seemed to encourage patients to be less responsible about their health, seeing health care as a right rather than a shared responsibility. He went on to say that he was thinking very seriously of simply going off the grid.
I'd not heard that term before, so he explained that his vision was to start a clinic where insurance would not be accepted as a valid form of payment, where patients contracted directly with him for his services, prepaying to eliminate billing and collections, in return for care without the management.
Fast forward a decade. I have been thinking about the off the grid model, and wanted to get a horse's mouth description of it, so I emailed Bob, asking for some face-time to chat. I spoke with his admin, and scheduled a late afternoon hour in his new off-the-grid office.
The offices of D2 are on the top floor of a medical office building directly across one of Portland's familiar tree-lined streets from Good Sam Hospital. I take the elevator up, and find the smoked glass door inscribed with the message "Admittance By Prior Appointment Only." A speakeasy doorbell adjacent. I ring the bell and the shadow of a young woman appears behind the door. The receptionist is not dressed like a nurse. She greets me by name, shakes my hand, and escorts me down a dimly-lit hallway, decorated with fine Oriental art, to a small sitting room overlooking the West Hills. Classical music softly fills the background space as she asks me if I'd like anything to drink. I order water and she brings a bottle and a glass, pouring from the bottle before closing the thin Japanese room divider panel to give me privacy while I wait for Bob to appear.
To be continued. This posting is long enough for today.
This entry might turn into a bit of a rant.
My question, How did we manage to f@#^ up our age-of-Aquarius opportunity in the world? When I look around, I notice that, not only is my generation worse off than the prior one, it's worse off than the one before that! The next generation seems to be even worse off than mine was. How did we manage to do that?
I just finished reading Michael Pollan's In Defense of Food, which continues his commentary, started in The Omnivore's Dilemma, on the sorry state of food production and distribution. He cites the close correlation between the introduction of what he calls Nutritionism and increases in everything from heart disease to attention deficit syndrome. Pollan speaks at length about the curious science of nutrition, which he claims more closely resembles a religion than a disciplined science. Post WWII, food became increasingly replaced by nutrition, typically vitamins and minerals added to a corn starch base and sold in lieu of food. This strategy enables industrial food producers to enjoy huge margins, but it ignored something important about food. Food apparently cannot be successfully separated from its context. We can't just distill a meal into a prescribed set of nutritional elements and expect to thrive. a) We don't yet understand what all the elements are and how they actually relate, and b) We have been misusing science to support the notion that we DO know what we actually do not. (Oh, and successfully lobbying to make this speculation the law of the land.)
... We have apparently been following a similar path in other areas, too. What Pollan noticed in the food system is at work in other areas of our society as well. His description of the Industrial Food System and the emerging Industrial ORGANIC Food System can pass for a reasonable description of our Managed Health Care system, too, and our Homeland Security System, as well as our business management system. What do these systems have in common?
Managers!
Not, as my daughter used to explain when she came home from grade school, "Self Managers," but what might be best described as "Other Managers." People who's primary job is to manage the interactions of others.
Who am I pointing my finger at? An old friend once confided an old bit of Brazilian folk wisdom: If it smells like dog shit where ever you go, check your own shoes first." Full disclosure: I have a degree in management. It seems as though I've been trying to unlearn ever since what I learned to earn my degree.
Okay, this IS turning into a rant. Perhaps a rant aimed at myself, but a rant nonetheless.
Peter Drucker claimed that the rise of the professional manager was the most significant achievement of the 20th century. I'm thinking that the replacement of the professional manager by the rise of the self manager might be the most significant achievement of this new century. If we can pull it off.
The professional manager is informed by a body of knowledge referred to as "management science," but like Pollan's description of nutritionism, management science is a curious kind of science, indeed. Based, as Stafford Beer noted a generation ago, more on authority, a priority, and tenacious belief than replicable science, and much more reductionist than holistic in perspective. My management training did little more than indoctrinate me into a way of thinking that separated me from some of my more important human capabilities, inducting me into a social class bred to be nourished by self sacrifice and rewarded according to my ability to encourage others to sacrifice themselves, too. For this effort, I was paid more than the rank and file.
Pollin labels nutrition science "nutritionism" because it became science in service not to nutrition or to humanity, but to short-term competitive advantage. Why would anyone create Wonder "helps build strong bodies twelve ways" Bread when the bread everyone was already eating built stronger bodies in innumerably more ways? Because if you take all of the complexity out of flour and replace some of it with simple, artificial ingredients, it won't spoil AND the producer can realize the mammon of all mammon, economy of scale! Big success.
In the same way that nutritionism misused nutritional science, manage-ism misuses science, employing it primarily as justification for what the machine already intended to do anyway. What's the primary problem with project management? Managers. Why does Scott Adams continually poke at the PM as the lowliest life form? People do not like to be managed. They are perfectly capable of managing themselves. But we've lost that knowledge somewhere. Somehow.
In conversation with an engineering manager recently, he was recounting how, early in his career, he would hop on a plane without any authorization, and fly to corporate headquarters to chat with the CEO. He noticed in that conversation that he had never done anything that outrageous or productive in his current job, that he'd "shut down" here. I asked him when he'd shut down, and he responded "nine years ago, about a week after I started working here." There, where management managed everything, creating a permission-focused culture where otherwise sentient adults ask their managers permission before doing anything.
In the next installment, I'll tell the story of a doctor who decided to go "off the grid" and stop accepting insurance claims as reimbursement for his services. His break-even patient load fell from 3,000 to under a hundred. His office staff went from 3/4 dedicated to billing and collection to two, with no one doing any accounting of any kind. His story describes how taking the manager out of managed care resulted in ... ahem ... more care.
Huff Puff.
Earlier this year, I
posted a start of a sticky idea to mixed comments. I've been
considering what I said there. I can spend a lot of time in
consideration sometimes. Here's the link back to the earlier
piece: Link Back
This past weekend, I received a notice from my friends at the International Society for Systems Sciences about a new field of study they're promoting called Relational Science. Smelled interesting.
Here's a link to the wiki they're put up to outline the basic idea: Link Here.
Feels like I stumbled upon an old friend. The material points out at least one powerful idea for me: that present investigations assume that the future can be some kind of derivative of the present. That, for instance, the present causes the future. This perspective can't quite explain discontinous change, however. And this omission seems material.
The models we create influence the future we experience, and this modeling behavior---how we characterize what we're in and what we expect to come next---needs to be included in our consideration to achieve a full understanding of what we're in and what we expect next, creating a recursive, self-referential relationship with ourselves, others, and our context. And also, seems to me, with our future, too. This relationship seems fundamental to understanding most everything.
Got me thinking. Considering some more. ...
To expand a bit on the earlier The Multi-tasking Myth, we might call this the Explicit Direction Myth. The Explicit Direction Myth claims that providing explicit direction improves performance. How that direction is provided might matter more than anything. If I must refer to an ink-blot of a plan or unfold a passenger compartment-sized map---or, take my eyes off the road --- to access the information, explicit direction might well undermine my performance.
One final short video which better explains the Explicit Direction Myth. There's always something more than we expect!
He seems small and scared when I arrive. Dressed in his bathrobe, not breakfasted yet. I found the tubing and extra connectors and plugged him in. Stayed to assemble breakfast. Coerced my mom into calling hospice ("They don't work weekends," she insisted!), and the nurse returned the call in five minutes. She called back an hour later. Stopped by to check vital signs an hour after that, and called every hour into early afternoon, when the morphine and the attention had lulled him into sleep in his chair.
Back later, made them some lunch. Back later to make some dinner.
He, embarrassed that he slept the day away while I puttered in the yard, plotting sprinkler positioning and well pump capacities. The huge yard half watered by day's end, I came home to my own dinner, my own life.
My own life is melding back into theirs now. I'm on call. I've been lurking, waiting for the moment when I might make a difference. They only call when they are really scared, and who am I to make a difference then? No one special. Able to move across the room as if their special gravity didn't affect me. As if I were immune. For now.
I can warm leftovers. Prepare the green beans so they are more than just a color contrast on the plate. Properly sauce the strawberries so they taste right, even to someone who's taste discolors every flavor. Small contributions. Just about the best anyone can do.
These are long days. The longest days of this year, and the longest days of any I remember experiencing in my own short life. Neighbors are disappearing. Old age is reaping her harvest. Across the street. Down the block this week. He sends cards for every occasion, especially the final ones. These he takes special care to acknowledge.
Now that he knows he's on the final approach, his temper is sharper. His patience thin. He submits to the help he needs, but complains about having to accept it, and, truth told, doesn't fully accept any of this.
So, a publisher's interested in my new book. I spent the morning until the phone call shuffling chapters and fine-tuning the stories. I left my marker, $$&&, at the point in the manuscript I was interrupted. I'll get back to my work early tomorrow, before the sun comes up. And I'll work until the phone rings or until my curiosity gets the better of me, then I'll go do that other work that consumes my days these days.
This is what's really going on. If I seem distracted, it's only because I'm distracted. I moved here, close, seven years ago, in preparation for these long days, but I'm no better prepared than I ever was to live them. I live them anyway.
