The Calm Company

Amidst desires for simultaneous growth, quality, profit, and patient satisfaction, the delivery of healthcare has gotten more…complicated. But the disconnect between the powers that be and the providers who actually work on the ground has turned work for big hospitals and institutions into something increasingly more like working for a big widget factory.

Spurred by rising costs, healthcare in the US has felt the need to “catch up” with the “best” business practices. Have more meetings. Look at more processes. More management. More managers for the managers we just hired.

A few bits from the intro to the forthcoming book, The Calm Company, on Signal v. Noisethe blog from 37Signals (the company behind the team management software Basecamp):

Work claws away at life. Life has become work’s leftovers. The doggy bag. The remnants. The scraps.

You’d think with all the hours people are putting in, and all the promises of tech’s flavor of the month, the load would be lessening. It’s not. It’s getting heavier.

Technology has been used to add capacity, not to improve workflow. As an example, MyChart is a great tool that allows patients to communicate with clinics and providers without calling repeatedly or making an appointment just for a routine refill or to answer a simple question. But you don’t get paid to answer MyChart messages. They’re added on to your workload. The more you’re willing to meet patients where they are and do things on MyChart, the more unpaid work you do and the more time and energy you lose. That’s a system flaw. This is part of why the average physician spends 1-2 hours at home charting daily. More uncompensated time.

Crazy companies all tend to be especially great at one thing: wasting. Wasting time, attention, money, energy.

The answer isn’t more hours, it’s less bullshit. Less waste, not more production. And far fewer things that induce distraction, always-on anxiety, and stress.

I am routinely impressed at how good healthcare systems are at wasting dollars to save cents. Skimping on cheap patient transporters so that highly paid specialists sit around waiting for the next case to start and then run overtime. Understaffing clinic nurses and MAs, leaving the physicians to deal with more phone triage and data entry. The money in some cases comes from different pots, which sometimes allows departments to seem more profitable or efficient than they really are.

Hospitals make changes like real enterprises do but mostly without the critical reflection to see if process improvements are actually improvements. We tokenize quality through small projects to avoid dealing with foundational infrastructural failures—because those are actually hard.

On-demand is for movies, TV shows, and podcasts, not for you. Your time isn’t an episode recalled when someone wants it at 10pm on a Saturday night, or every few minutes in the collection of conveyor belt chat room conversations you’re supposed to be following all day long.

When breath becomes air

I actually posted this excerpt once before, but I just finished Paul Kalanithi’s When Breath Becomes Air and was moved anew by his missive to his infant daughter:

When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

Earlier in the book, in conversations with his oncologist about coming to terms with how to spend his life with cancer, this entreaty comes up multiple times:

Find your values.

In his moving memoir (which doesn’t at all belittle fields like radiology), Kalanithi softly and compellingly argues that this is the key to how you live like you were dying.

Obama thinks about the future

The New Yorker has a fascinating article about Obama dealing with the fact that Trump won. It’s eminently quotable, but I particularly liked his brief discussion on the futility of trying to “bring back” lost industry through protectionism:

The prescription that some offer, which is stop trade, reduce global integration, I don’t think is going to work,” he went on. “If that’s not going to work, then we’re going to have to redesign the social compact in some fairly fundamental ways over the next twenty years. And I know how to build a bridge to that new social compact. It begins with all the things we’ve talked about in the past—early-childhood education, continuous learning, job training, a basic social safety net, expanding the earned-income tax credit, investments in infrastructure—which, by definition, aren’t shipped overseas. All of those things accelerate growth, give you more of a runway. But at some point, when the problem is not just Uber but driverless Uber, when radiologists are losing their jobs to A.I., then we’re going to have to figure out how do we maintain a cohesive society and a cohesive democracy in which productivity and wealth generation are not automatically linked to how many hours you put in, where the links between production and distribution are broken, in some sense. Because I can sit in my office, do a bunch of stuff, send it out over the Internet, and suddenly I just made a couple of million bucks, and the person who’s looking after my kid while I’m doing that has no leverage to get paid more than ten bucks an hour.

I recently read The Wealth of Humans, in which Economist writer Ryan Avent presents an engaging argument about how things have and are likely to change with increasing automation. I think people are generally pretty quick to believe that robots will eventually replace everything but have nonetheless been far less inclined to think about what that will actually mean. For the economy, for humans, for society as a whole.

Organizational stupidity

Please read and cherish this incredibly cynical essay in Aeon, “Stupefied: How organisations enshrine collective stupidity and employees are rewarded for checking their brains at the office door.” I’m going to superblockquote a chain of some of my favorite parts. Please tell me this doesn’t describe every hospital you’ve ever worked in:

No matter how hard you search there is little – if any – leadership to be found. What most executives actually spend their days doing is sitting in meetings, filling in forms and communicating information. In other words, they are bureaucrats. But being a bureaucrat is not particularly exciting. It also doesn’t look very good on your business card. To make their roles seem more important and exciting than they actually are, corporate executives become leadership addicts. They read leadership books. They give lengthy talks to yawning subordinates about leadership. But most importantly they attend many courses, seminars and meetings with ‘leadership’ somewhere in the title.

Ha, yes.

But often there are very weak reasons for following ‘industry best practice’. For instance, when the Swedish armed forces decided to start using Total Quality Management techniques, some officers naturally asked: ‘Why?’ The response: ‘This is presumably something we benefit from, since this is what they do in the private sector.’ In other words, we should do it because others are doing it.

Applying methods and policies wholesale because they worked somewhere else without then evaluating those changes is a critical role of most middle managers.

At the outset of our research, we suspected that organisational life would be full of stupidities. But we were genuinely surprised that otherwise smart people would go along with collective stupidity, and be rewarded for doing so. Mindlessly following rules and regulations – even if they were completely counterproductive – meant that professionals would be left alone. Using empty leadership talk would get ambitious people promoted into positions of responsibility. Copying other well-known organisations meant a firm could be seen as ‘world-class’. Launching branding initiatives meant that executives could focus on the easier work of manipulating surface images and avoid the much messier realities of organisational life.

This is just brutal.

Working in a stupefied firm often means blinding others with bullshit. A very effective way to get out of doing anything real is to rely on a flurry of management jargon. Develop strategies, generate business models, engage in thought leadership. This will get you off the hook of doing any actual work. It will also make you seem like you are at the cutting edge.

This is what people are hoping to master when they go back for that MBA.

Literally every business/leadership/whatever book I’ve ever read should have been a few blog posts or a short essay. While a lot of people have been piling on recently and calling BS on the organizational psychology and tedious bureaucracy that compose the contemporary large organization, I’m actually tempted to pull the trigger this time and read the book (if only for the refreshingly direct approach).