Writing in organisations

After the Christmas break, I had a week without any official appointments and found myself sitting in my home office feeling slightly detached from the world. What helped me to feel reconnected most of all, I noticed, was two good conversations. But what made them "good"?

The first one was with an old friend who is a very creative thinker and who has spent much of his life in business. We sat in one of Hove’s many cafés bouncing ideas back and forth. Two hours zipped by and, at the end, I felt much greater clarity about what I wanted to explore next in my writing. 

When I reflect on what made this conversation so satisfying, I think first that we both felt able to express what was troubling us at the time – e.g.  the challenge of structuring our days when working from home. But we didn’t dwell on that problem. Instead, we quickly switched our attention to what was beginning to feel possible and exciting in our working lives. We also both seemed willing to listen closely and to enter imaginatively into one another’s worlds. And there was an openness in our talk – we both expressed strong ideas but were receptive to different ways of thinking.

My second encounter took the form of a skype call with a wise friend who is always open to conversation and is very generous with his thinking (see www.johnshotter.com). Among other things, John and I discussed what hinders dialogue. Often, we agreed, it is overuse of abstract concepts. In the world of work, words like "impact", "culture" or "management" can easily close down further exploration, while in the wider world it might be "freedom", "equality" or even "migrant". If we use such concepts without saying what they mean to us personally, or without giving examples or relating stories from our own experience, we risk either ending up in conflict, or just seeming to agree with each other.

Much has been written about dialogue but on a practical level I think we all recognise a good conversation when we see it. For example, we know when people are listening attentively; we can tell when they are exploring as they talk, rather than offering finished thoughts; and we can judge when they are talking from within a real experience rather than generalising in an aloof way.

To my mind, it's well worth giving the quality of conversation close attention, and seeking out conversations that uplift us.

Related reading
John Shotter: "Against 'concepts' and 'definitions' –available here.

John Shotter: "Getting it: withness-thinking and the dialogical in practice" (Hampton Press, 2011).

The recent Syria debate in the House of Commons gave me an appetite – for the first time – for watching the Parliament channel on TV. The experience reminded me what an important part debate plays in democracy (as Bishop Richard Harries said on BBC Radio 4 next morning). But I also noticed - as did many others - just how easy it was to be swayed by a rousing speech.

As I watched the MPs, I paid as much attention to how they spoke as I did to their opinions. I only had time for a few of the speeches but I was especially moved by one – even though the speaker, Tom Tugendhat, was in favour of military action whereas I felt highly sceptical about it. When I listened to his speech again on the web next day, I noted that, after first making his view very clear, he went on to recall his own fear and nervousness as he prepared to go out to Iraq in 2003 as a member of the armed forces. He also expressed his sorrow in learning of the destruction of monasteries and murder of friends in Syria. It became obvious that he had spent many years in the Middle East.

So how does a speech like this work? This question prompted me to go back to Aristotle for some insights on rhetoric. A good orator, he maintained, employs three modes of persuasion: logos (argument or words), pathos (feeling) and ethos (which roughly means the speaker’s character or credibility). Tugendhat, by speaking from his own experience, certainly came across to me as genuine, and I think he did a good job of combining all three modes of persuasion.

In contrast, some of the other speeches irritated me by overdoing the pathos. A number of MPs focused on stirring strong feelings against Daesh but failed to explain why military action was necessary specifically. (The motion before the House did at least acknowledge that “military action against ISIL was only one component of a broader strategy to bring peace and stability to Syria”.) I therefore had sympathy with Caroline Lucas of the Green Party when she said: “Some of us are more committed than others to looking at the full range of measures in front of us, and looking at the evidence that suggests that bombing to date has not been successful.”

Next morning, on Radio 4, shadow chancellor John McDonnell (much quoted since) made what seemed to me a valid point about the risks of rhetoric (with ambiguous praise for the shadow foreign secretary's performance!):

“I thought Hilary [Benn]’s oratory was great. It reminded me of Tony Blair’s speech taking us into the Iraq War. I’m always anxious that sometimes the greatest oratory can lead us to the greatest mistakes, as well.”

McDonnell’s words prompted me to listen to Benn’s speech in full on the web. Benn's final plea that “We must now confront this evil. It is now time for us to do our bit in Syria” was hard to disagree with. But I just still wonder if military action will help. Only time will tell.
 
In the days following the vote, I happened to be reading Richard Sennett’s book “Together” and this got me thinking about the difference between debate and dialogue. The purpose of debate is typically to reach a collective opinion or decision within a limited time-frame. Dialogue, on the other hand, is a more open-ended exchange in which people may “become more aware of their own views and expand their understanding of one another”. Sennett suggests that modern society is much better at debate than dialogue. But, as he writes, it’s not “either-or”. We need both. That's a topic for another post, though...

Related reading and links:

Richard Sennett: Together. Penguin Books.

Aristotle (1991): The art of rhetoric. Penguin Books.

Wikipedia on modes of persuasion

Tom Tugendhat’s speech in full

Excerpt from Caroline Lucas’s speech

John McDonnell’s words on the Today Programme

Hilary Benn’s speech in full

Bishop Harries’ “Thought for the Day” on the Syria debate

Franklin also devoted much of his spare time to writing exercises, in order to teach himself “Method in the Arrangement of Thoughts”. He observed: “Prose Writing has been of great Use to me in the Course of my Life, and was a principal Means of my Advancement.”
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As I read these words, I found myself wondering whether people today recognise the benefits of “learning a little to scribble”, as Franklin put it. For that matter, do those benefits still hold in today’s world of mobile communication, tablets and social media? Personally I think the answer is a resounding “yes”. And certainly when I reflect back on my own life, I can see how being able to write reasonably well helped me acquire academic degrees, secure good jobs, earn the respect of colleagues, and finally earn my living through the written word… not to forget the satisfaction of the craft itself and the deep learning that it has generated for me.

As well as practising his writing, Franklin made a point of studying the art of conversation. For instance, as a young man he read about the Socratic Method. This persuaded him to drop the habit of “abrupt Contradiction” and adopt instead the attitude of “humble Enquirer and Doubter”, and eventually he developed a lasting habit of expressing himself in terms of “modest Diffidence”. This meant, when making a proposal that might be disputed, he would refrain from using words such as “certainly” and “undoubtedly”. I loved his explanation: “…a positive dogmatical Manner in advancing your Sentiments, may provoke Contradiction & prevent a candid Attention.”

Looking back on his life, Franklin felt his diffident habit had been of great advantage to him, enabling him to succeed in promoting a wide range of causes. And these included many things that we now take for granted, like a police force, a fire service and a public library*. That was all in the colony of Pennsylvania, but ultimately of course he became one of the Founding Fathers of the United States of America.

Further reading

Benjamin Franklin’s “Autobiography and Other Writings” -- highly recommended for anybody who wants a real flavour of 18th century life and food for thought on what the phrase "a good life" could mean.

The same volume includes Franklin’s delightful “Remarks Concerning the Savages of North America”, which reveals the author's appreciation of “Indian” customs. He tells a marvellous story of how, in 1744, Indians in the colony of Virginia politely declined the offer of sending some of their sons to a college. They even made a counter-offer, saying:  “…if the Gentlemen of Virginia will send us a dozen of their Sons, we will take great Care of their Education, instruct them in all we know, and make Men of them.” 

* I borrowed Franklin’s Autobiography from my local library, which sadly can no longer be taken for granted.

​Recently I visited an amazing project in Glasgow that is helping people affected by cancer get support for any worries they have, including physical problems but also emotional, financial and practical ones. It's called 'Improving the Cancer Journey' (ICJ). Afterwards I reflected on what a key role stories, conversation and writing play in the project.

Stories that move and convince

​When I sat down with Sandra McDermott, the head of the service, she started by telling me the experience that originally moved her to throw herself into it. She had seen a woman who was dying of cancer and who was due any moment to leave hospital to stay with her mother, as her own flat was damp. Within a couple of weeks, drawing on her own knowledge of local services, Sandra was able to arrange more suitable accommodation for the woman and her four children. When the end came, the woman died with her family around her in a warm and comfortable flat. Sandra also helped her make guardianship arrangements, so her children would be well looked after in future. 

Listening to this story, I could see just how powerfully it demonstrated the need for the service. But Sandra also gave some convincing figures – the sheer numbers of people affected by cancer in a city the size of Glasgow, the billions spent on cancer treatment in the UK, especially in deprived areas, and the relatively modest cost of running a service like Improving the Cancer Journey. It was a good example of how numbers and stories can complement each other.

Sandra was herself clearly moved by the woman’s story and she told me she was nervous of telling it to an audience she was going to speak to in London the next day. She feared she would feel too upset. We agreed that what made it so moving probably had something to do with the sense of the community pulling together and making a difference to somebody in need. (I was glad to hear later that Sandra did manage to tell the woman's story in London.)
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Sandra emphasised that it was luck that she had been there at the right moment for this particular woman. The experience convinced her of the need for a new joined-up service to make sure that others could get similar support.

Conversations that ease worry and point to help

I learned from Sandra and her colleagues how Improving the Cancer Journey works. Every person diagnosed with cancer in the Glasgow area now receives a letter inviting them to get in touch and to have a conversation with a link worker. So far, about 40% have taken up the offer. Family and friends who look after the person with cancer can also get help.

The link worker listens to what the person has to say and invites them to identify their needs and concerns, whether physical, practical, emotional or spiritual (in NHS-speak this is a “Holistic Needs Assessment”).

While in Glasgow, I met one of the link workers. Andy immediately struck me as a warm and open person with extensive local knowledge. I had no doubt whatsoever that he would set people at ease and listen with empathy. And the conversations would not be hurried – he told me they last up to 90 minutes, occasionally more than two hours.

​During the conversation, Andy will make suggestions about which of more than 200 local services might be able to help. This could include things like housing or benefits advice, an exercise programme, or a way to meet other patients to ease feelings of isolation. In other words, the service is very much about helping with “all the other things” that typically trouble people who have been diagnosed with cancer.

One woman said that her biggest fear was that her daughter would not remember her after she had died. The link worker in this case suggested that mother and daughter create some kind of memory box together, which the daughter could keep and look at in years to come. 

Paperwork that helps not hinders the conversation

I also noticed that the team makes good use of paperwork. One example is the simple one-page form providing people with a list of possible concerns. They can simply run down the list, ticking off the ones that apply.

Being sceptical about how paperwork is used, I asked Andy if he felt this checklist was helpful. He said, yes, it helps to get people started. It also makes it easy for him to explore with them which main concerns they want to focus on.

Also, there’s a space at the bottom where people can score their overall level of concern on a scale of 1 to 10 (1 = lowest, 10 = highest). This creates a “stress thermometer”, which gives an idea of how seriously worried they are now, but also becomes useful if they meet the link worker again, when they can provide a new score. The before-and-after comparison provides the team with a simple way of measuring how effective the service is (its 'impact').

At some point, patients are invited to record and share their personal story on a separate card, which simply asks, “Tell us briefly about your cancer experience.” This provides another measure of the service’s impact. It also allows the team to contact the person again and (with permission) use their story in the media to help publicise the service.
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The project has even formed a group of patients who can help improve the service, and these patients have already helped to reword the letter sent to all those diagnosed with cancer.
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All in all I felt that stories, conversations and intelligent uses of paperwork combine to make Improving the Cancer Journey very special. No wonder the team in Glasgow want it to spread all over the UK.

Notes
Improving the Cancer Journey is a partnership between Macmillan Cancer Support, Glasgow City Council, Glasgow Life, NHS Greater Glasgow & Clyde, Cordia Services and Social Work Services.

More information on the project's web pages. ​

“A desk is a dangerous place from which to view the world.” For me, that sentence, written by John Le Carré, instantly conjured up bureaucrats sitting comfortably in their offices deciding the fate of powerless people. But it also evoked other common habits – managers issuing instructions in emails that won’t engage people, researchers writing reports that will never be read properly, or people creating strategic plans that will never be followed.

There are several problems with these habits, not least of which is the implementation challenge. People may not read the written word (and in my experience, many people are reluctant to follow written instructions); those who are meant to implement the plan may be less rational than the author assumes; and by the time the plan has been completed, the environment will probably have changed.

Of course it is often vital to express ideas in writing to help others understand what we are trying to achieve. And the act of writing can help produce greater clarity, at least for the authors. But having produced a document, the risk lies in thinking that the job has been done, when in fact the work of making a difference has only just begun. This is the moment when we need to get away from our desk – or the boardroom table – and talk to people.

So why do some managers continue to spend so much time at their desks? Why do they remain detached from people on the ground? I suspect that for many the thought of a conversation with anybody other than a few trusted colleagues can seem quite scary. I have been there myself. When I worked for McKinsey as a communications specialist (a kind of writing coach and editor) in the late 1980s, one of my challenges was to convince the busy and brainy consultants about the benefits of working with me (it was optional for them). Sometimes I really had to steel myself to walk up to a table of consultants at lunchtime, seat myself down next to them and open a conversation. 

Conversations with strangers may take both confidence and courage. We never know how others will respond or how the conversation will unfold. That uncertainty can be exciting but it can also be uncomfortable. Sometimes it feels so much easier to put down our thoughts in writing and then just send them off. So let’s keep reminding ourselves that the desk is a dangerous place from which to view the world.

Related reading

Zaid Hassan, ‘The Social Labs Revolution: a new approach to solving our most complex challenges’ (which is where I came across the quote from John Le Carré).

Henry Mintzberg, ‘The Rise and Fall of Strategic Planning’ (also quoted by Hassan). See also @Mintzberg141 on Twitter.

In his inspiring booklet ‘Gelassenheit’, Heidegger explored what it meant to think. I was especially struck by his distinction between two kinds of thinking. These have been interpreted as ‘calculative thinking’ (‘rechnendes Denken’) and ‘meditative thinking’ (‘besinnliches Denken’), but a more current translation to my mind would be ‘instrumental thinking’ and ‘reflective thinking’ (or perhaps even ‘contemplation’).

Let’s start with the instrumental kind of thinking. This is what we are doing whenever we calculate, analyse or plan - and it is indispensable. But it is only one kind of thinking. If we rely on it too much, we neglect our capacity for reflective thinking. We then become thought-less, in a sense.

The value of reflective thinking on the other hand is that it allows us to stand back and contemplate the meaning of commonplace things, including our own inventions. It is this kind of thinking that enables us to be thought-full about how we use technology.

The dangers of today’s communication technologies

At the time of Heidegger’s talk (1955), the technology at the forefront of people’s minds was atomic energy, but his insights can help us think about the communication technologies that increasingly dominate our lives today. To my mind, thoughtless uses of such technologies include things like: peering endlessly at a tiny screen while sitting with a friend; writing an email about a sensitive or complex subject when a conversation would have been more useful; or commissioning a report and then failing to engage with the author’s findings and insights.

Yet the real risk facing us, warns Heidegger, stems not from technology itself but from the fact that we are so ill-prepared for the profound changes that are quietly at work. In this situation, the best we can do is to pause occasionally to reflect on how we are using our machines and gadgets. We can take time to contemplate whether we might be in danger of becoming slaves to the very inventions that were supposed to improve our lives.

In my writing I put a lot of effort into advocating things like dialogue and storytelling, but two striking moments in the past 24 hours have made me stop and think again. One was a conversation with a friend who had just read one of my papers bemoaning the lack of conversation in organisational life. His immediate response was to say that what he often sees is “too much dialogue”.

This exchange prompted me to wonder “What if, for a change, I were to take a critical stance towards conversation and to praise the use of writing to organise, analyse and manage?” After all, I am often the first to use writing in these ways. For instance, I reach for pen (or keyboard) whenever I want to develop clarity about a complex project, or to work out what I want a meeting or presentation to cover.

I also use the written word to keep important information in easy-to-find form. For example, I have a program called Evernote where I deposit all those bits of information that would previously have covered scraps of paper or filled little notebooks. My Evernote now has nearly 500 notes in it, which I can access from my laptop, ipad or phone. They are organised into no less than 21 searchable online “notebooks” with names like “House”, “Garden”, “Food”, “Money”, “Client work” and “My writing”. How organised is that?!

This all got me wondering why I so often argue that people overuse the written word and underuse conversation. I think the main reason is that I feel a need to counteract received wisdom. I feel I live in a world where people produce written strategies, plans, reports, agendas, minutes and wordy slide presentations without radically questioning their practical value. I also see unthinking documentation and measurement as habits of mechanistic management, based on inappropriate application of scientific methods to human affairs.

Scientific thinking has its place, and it has certainly changed our world. I am currently reading about the scientific revolution of the 17th century and I am struck by how sensible I find Francis Bacon’s thinking. He wanted to counteract old patterns of thinking and traditional prejudices and to develop a new method of acquiring knowledge:

“This method was to be fundamentally empirical: through the careful observation of nature and the skilful devising of many and varied experiments, pursued in the context of organised cooperative research, the human mind could gradually elicit those laws and generalisations that would give man the understanding of nature necessary for its control.” (Tarnas 1991, page 272)

Sounds refreshingly clear and reasonable. The trouble only arises when people use this rational, scientific approach to address everything, including complex social and political issues such as how best to run a large organisation like the NHS, how to achieve quality in education or how to stop destroying life on this planet.

Related reading

Richard Tarnas. The Passion of the Western Mind. Pimlico, 1991

Iain McGilchrist. The Master and his Emissary. Yale University Press, 2012

One of my readers commented not long ago that, in my writing, I often draw attention to everyday phenomena which we take so much for granted that we hardly notice them, let alone question or challenge them. It’s a bit like not being able to see the air we breathe, or even not being aware of breathing.

For example, in this blog I often draw attention to everyday examples of the barely noticed in organisational life, such as the way many people run conferences without questioning common habits, even when they aren't particularly effective. 
 
Or here is another example from a conversation with a psychotherapist friend of mine: when I used the word ‘intersubjective’, he asked me what I meant. I tried to articulate why it was such an important word to me because it points to the way in which we are constantly creating our world together through our conversations and other interactions; so for me nothing we say is, strictly speaking, either subjective or objective. Indeed, the assumption that any observation must be either subjective or objective provides us with a small clue about taken-for-granted thinking in our society.

In recent years I have become aware of a whole body of literature that speaks to this unnoticed background to our lives. For example, over his lifetime, the French sociologist Pierre Bourdieu came to distance himself from the notion that the true nature of the social world lies behind or beneath the world of appearance – that it is only to be found in some kind of 'structure' (hence the term structuralism). And in his writing he used the term “habitus” to refer to the unseen ways in which we naturally classify the world, depending on the milieu we find ourselves in. 

Similarly, Henri Bortoft, in his book Taking Appearance Seriously, lays out how, over the centuries, modern science developed in a way that moved us away from experiential knowledge and towards theoretical knowledge, which provides rational explanations about the world. Bortoft acknowledged that scientific explanation has been extraordinarily successful but, he wrote, it has “shifted our attention away from the phenomena themselves”. 

Numerous other writers have addressed these questions, including Goethe in the nineteenth century, and the phenomenologists in the twentieth century. They were all inquiring into how we can cultivate our ability to notice our experience. But much of our taken-for-granted thinking and speaking today remains in the thrall of modern science.

Note: the phrase "invisible background" is drawn from Wittgenstein's writings. For more on this, see this article by John Shotter.

Related reading

Henri Bortoft (2012): Taking Appearance Seriously. 

Richard Jenkins (1992): Pierre Bourdieu. Revised edition (2002). Routledge.

John Shotter (2015): The “Background” in Wittgenstein and others. Accessible at: www.johnshotter.com/2015/03/21/the-background-in-wittgenstein-and-others/ 

I recently went to a university symposium – a kind of mini-conference – on the subject of ‘Heritage in the 21st century’, which was interesting. It also prompted me to reflect again on how we combine writing and talking, and I couldn't help concluding we could do a better job of it.

I found the topics interesting – e.g.the role of sound in ruins, or places in Britain associated with authors and literature. And most speakers brought their subject to life by showing plenty of photos. But during some of the talks, I found myself drifting away after just a few minutes. I think my lapses of concentration had a lot to do with the general format of the event: people reading from scripts with the audience seated in rows of chairs all facing the screen.

What sometimes puzzles me is that, all around us today, we see high standards of public speaking and writing – in radio, TV, books, newspapers, web talks, and so on. Yet those who organise and speak at conferences generally seem to be lagging behind. I’m not saying that the speakers I saw did a bad job, given the context and culture that they work within. Indeed, one of the keynote speakers was brilliant: it was obvious from the moment cultural historian Robert Hewison stood up that he would be a pleasure to listen to. Even though he clearly had a script in front of him, he projected his voice, his talk flowed and was both provocative and informative. And he spoke without a single PowerPoint slide. 

But my experiences of academic conferences does leave me wondering what is going on here. I feel that people convening and participating in such events are really missing a trick. Below a few immediate thoughts and suggestions:

1. To read or not to read? I think it is completely understandable that people give talks with a piece of paper in their hand. Often we fear that, without a script, we might forget what we wanted to say or that our thinking will come across as unstructured. But there are ways of reading out loud that keep the attention of the audience – by reading slowly, making frequent eye contact with those listening, and finding opportunities to extemporise and expand beyond the script, to name a few. (I watched Mike Leigh do all these things last night at the BAFTA ceremony, and despite losing his place in the script once or twice, he remained engaging and interesting.)

2. The (lost?) art of oratory. Rhetoric, or the art of public speaking, was central to education for centuries in both the Ancient and Mediaeval worlds. Isn’t it time to return to studying the art of oratory? Aristotle distinguished three aspects of rhetoric: logos, pathos and ethos and that still seems a good starting point. I was once schooled in the McKinsey way of organising presentations, which is based on Barbara Minto’s Pyramid Principle. This method is useful but it privileges just one aspect of rhetoric – logic.

3. Storytellers’ methods. Another way of thinking about structure, commonly used by storytellers, involves identifying the ‘bones’ of your story and then improvising. Or you can imagine you are taking your listeners on a journey, in which case all the preparation needed is to identify a few significant landmarks or stages in the journey before setting off.

4. Putting asides in the centre. Going back to the symposium that got me thinking about all this, I should declare an interest: one of the speakers was my husband. What I noticed particularly about his talk was that the most engaging moments were those where he looked up from his script and improvised, usually by making asides that gave us a glimpse of the depth of his knowledge about his subject and of his sense of humour. When he and I were reflecting on the event, I wondered out loud if there might be a way of putting asides and improvised remarks at the centre of the talk. In my experience, any form of structure can work, even a very non-linear one, provided the speaker believes in what he or she is saying and speaks with energy and confidence (one could call it ‘presence’).

5. What if we all had to earn our living from our writing and public speaking? I was struck by the thought that Robert Hewison, the most engaging speaker, has earned a living from his writing and broadcasting. The need to earn money may be a healthy constraint. Those who need to do so cannot afford to write dull texts. They have to pick subjects that interest sufficient numbers of people, be willing to say something provocative, express themselves clearly, tell a good story and be good at both writing and speaking. 

6. Innovative forms of gathering people together. There are many newish ideas and practices out there – ‘open space’ events, the ‘fishbowl’ method, large group meetings with everybody sitting in one big circle, to name just three. One newer and refreshing form that I have come across more recently is the ‘pecha kucha’, where speakers are limited to a maximum of 20 slides (images) and can talk for 20 seconds per slide (making a total of 6.7 minutes). 

One of the most radical forms I know sounds the most deceptively simple: the convening and conducting of a grown-up group conversation.

Which form works best depends on what we are trying to achieve. In my experience, the grown-up or free-flowing conversation without any formal agenda is rare but well suited to sharing and exploring lived experience or discussing ideas. I personally find this form of gathering both fruitful and fascinating, because it also allows those taking part to notice what is happening in the room and reflect on it in real time. 

Related reading

Aristotle: The Art of Rhetoric, Penguin Books, 1991. Translation by Hugh Lawson-Tancred.

Barbara Minto: The Pyramid Principle: logic in writing and thinking, BCA, 19991.

Walter J Ong: The Presence of the Word, Yale University Press, 1967.

Patricia Shaw: Changing conversations in organizations, Routledge, 2002.

Pecha Kucha: www.pechakucha.org/ 

We have created a pretty mad world in some of our larger organisations. I am thinking especially of health and education, where bureaucracy and top-down control seem to have taken over – and that’s not just in the UK. 

Over the Christmas period we had a visit from an old friend of my husband who is a General Practitioner in southern Germany. Prompted by my curious questioning, he began to overflow with stories about documentation gone mad. For example, after every patient visit, he now has to enter his diagnosis into a computer system by selecting from a long list of codes. He is also supposed to note whether each diagnostic code he selects is: (a) certain, (b) suspected or (c) can be excluded. 

This system, he says, not only creates extra work but also encourages doctors to provide “invented” diagnoses. In other words, it distorts how they record a patient’s condition. The system originated in Australia, but “the Germans have perfected it”, he noted with a smile. The computer even offers blocks of text for cutting and pasting.

Documentation is not a bad thing in itself. But when taken to excess, it robs practitioners of time they could otherwise be spending in conversation with people. Our GP friend explained that he has always taken proper patient histories/stories (same word – Geschichte – in German). He also continues to handwrite his notes, as in his view patients prefer their doctor not to be glued to the computer. 

As I reflected on his words, it occurred to me that those who put in place these systems implicitly undervalue health professionals’ experience, memory and ability to make connections and patterns.

How has this madness come about?  As always, there are multiple influences at work. The one I immediately think of, given my interest in uses of writing, is that many people simply do not understand, or stop to think about, how written communication works – and how it can actually hinder communication. Managers and policy makers in particular seem to accept without question the value of detailed documentation. Additionally, they are often remote and disconnected from what is happening on the ground – they don’t and can’t be present to the human exchanges between patients and health professionals, for instance. And of course all the bureaucratic rules and procedures are reinforced and perpetuated by the inevitable power relations among practitioners, and between practitioners and managers or policy makers.

After talking to our doctor friend, I happened to be reading a book called “Wilful Blindness” by Margaret Heffernan. In it, the author describes how most people in organisations – even when they sense or know there is something wrong – tend to stay silent. She provides copious examples (in banking, in the army, in private companies, and also in the NHS) of people following orders, clinging to convictions or submitting to groupthink. And on top of all that, many work long hours and are under relentless pressure to pursue efficiency and cut costs. These conditions make them even more likely to develop tunnel vision and just do what they are told. 

In the face of what he sees as senseless bureaucracy, what does our German GP do? “Resignation” was the word he used. But he did nevertheless point to some small acts of subversion. For example, having handwritten his patient note, he only enters the absolute minimum information (the diagnostic codes) into the computer. Or he refuses to sign what he sees as time-wasting, superfluous documents presented to him by staff in the care home that houses some of his patients. He knows that the nurses there spend hours documenting everything in great detail, and presumably therefore less time really caring for patients. Why should he sign a piece of paper just because the computer system adopted by the home spits out a whole page detailing each patient’s medication? 

These small subversive acts make our friend unpopular with some of his colleagues. But he works in a single-handed practice and only has a few years left before he retires, so he can afford to risk being the odd-one-out. 

No doubt much of what he experiences is equally in evidence here in the UK. 

What would it take for this bureaucratic madness to change – a new generation of doctors willing to challenge and question? So far, according to our friend, junior doctors in Germany show little sign of starting a revolution. If anything they are more compliant than his contemporaries. 

He also regrets that the trainee doctors he comes across are no longer taught how to take proper patient histories and are less likely than their older colleagues to examine patients physically. Instead, they rely on technological scans and tests. People going through medical education today also get fewer opportunities to see patients than he did. This is because (mercifully perhaps) they no longer work such long hours.
 
Perhaps one day the current culture of bureaucratic control will just become outmoded. People may decide it has run its course or that it has simply generated too many distortions. I suspect it will take not only some very obstinate and courageous individuals but also some kind of collective rebellion. 

Related reading
Margaret Heffernan. Wilful Blindness, 2011.