The tyranny of procedure
Procedures make machines better and people worse - why imitate machines?
Posted Jan 03, 2011
Why are we mesmerised by procedures? For example, ever more detailed, time-consuming and restrictive auditing processes exist in health care institutions, but the number of systemic ‘failures' continues unabated, and may actually be increasing. Why?
There is a facetious expression of a certain type of surgical point of view, often in fact quoted by surgeons against themselves: ‘the operation was a success, but unfortunately the patient died'. Most surgeons are in my experience robustly practical, and like us probably view such a detached and abstract appraisal, though it has an obvious meaning, as intrinsically ridiculous.
But there is a version of this thinking which has become worryingly widespread as medicine, surgery and psychiatry have had an alien managerial culture foisted on them: ‘the procedures were correctly followed, but unfortunately ...' Our sense of the ridiculous has stopped alerting us here. Why? Every time some calamity occurs, there is a pious hope expressed that it will ‘never be allowed to happen again'. More procedures are invented, and are monitored ever more closely. Yet the number of adverse incidents shows no sign of abating.
Why are we so memerised by the following of procedures?
First let's look at the business of surgery itself - or for that matter of delivering good care as a physician, or psychiatrist. At its heart is the difference between a living skill and the reliance on a set of procedures.
Dreyfus & Dreyfus have differentiated 5 levels of skill (Mind Over Machine: The Power of Human Intuition and Expertise in the Era of the Computer), which could be labelled ‘novice', ‘advanced beginner', ‘competent', ‘proficient' and ‘expert'. To achieve the first three of these steps on the road to true expertise - as far as ‘competent' - conscious attention to rules and procedures is necessary and even helpful.
However in order to achieve the next step, the ‘proficiency' with which true expertise begins, there needs to be a shift of emphasis away from conscious deliberate planning, and standardised and routine procedures. Instead there needs to develop an ability to see situations holistically rather than in terms of one aspect only at a time. An appreciation of the importance of exceptions, and deviations from a fictional norm, as well as the interactions of the various ‘components', means that maxims might still be used for guidance, but only while simultaneously noting that their meaning changes when the situation changes.
In the last phase, the true expert can no longer rely on rules, guidelines or maxims, but instead has to have an intuitive grasp based on deep tacit understanding. An analytic approach gets to be adopted only in unprecedented situations, when problems occur, and only then when there is time to do so. The true expert - one who, as the word implies, derives his skill from experience, not from a set of rules - has to have converted explicit rules into implicit intuitions.
What has this got to do with medical ‘untoward events', as they are now designated?
As so often the crucial issue is the nature of attention paid to the world. We seem to be using our brains to pay one kind of attention at the expense of another, in some cases to the virtual exclusion of the other. And the kind of attention we pay to the world changes what we find there - changes even, as I contend in The Master and his Emissary, what there is there to find. This may be the clash between the rules of a bureaucratic management culture and the skill and judgment born of experience. But it may go wider than that, and show us something about how we are changing the way we use our brains.
First of all, procedures, rules, algorithms all encourage a part-wise examination of the world. That examination is also inevitably sequential. It is, in other words, spatially and temporally, inclined to fragment the understanding of what is going on as a whole. It encourages a situation where it is possible to tick off the parts of an elephant as present and correct without saying anything about how they are working together, and whether the elephant is subtly sickening from an insidious disease. In the hospital setting it means that there is more attention to whether a thing is present - yes or no - than to the rather less graspable, but all important, nature of its functioning. On the 'what', not the 'how'. It means that attention is focussed narrowly on one thing, then another, not on the broader picture, where someone standing back and using their intuition based on experience can see there is a systemic problem here.
Second, it makes the representation of a thing more important than the thing itself. The fulfilling of a criterion on a piece of paper becomes more significant than the real world situation, since the criterion comes to stand for the real situation, and the plane of focus shifts from the world itself to the piece of paper. It's a bit like focussing, not on the view through a window, but on the pane of glass through which it is seen. This prioritises not what is actually present - but what is re-presented - literally ‘present at a later point', after some processing has gone on, and in a modified form, as if we mistook a map for the terrain to which it refers. This results in a mentality where we rely on the fact that the box has been ticked, and don't notice what is in front of our very eyes. It can make us less observant. It can in fact make us blind. And just filling in the boxes can take up so much time that we have less for doing what actually matters in the world beyond the sheet of paper.
Third, it encourages a curious attitude that mistakes happen less often, not if we train people well and allow them to use their skill, but micro-control their skill, thus effectively rendering it useless.
All three of these aspects of the way we see the world suggest an over-reliance on the left hemisphere of the brain alone. The fundamental difference between the hemispheres is the nature of the attention they bring to bear on the world.
It is evolutionarily important for birds and animals to be able to combine two types of attention. For example, a chick needs a narrow-focussed attention in order to distinguish, say, a seed of corn against the background of gravel on which it lies. This a kind of attention that works well when you already know what it is you are interested in, and are interested only in getting hold of that one thing. At the same time however it needs something apparently quite incompatible with it - a wide-open attention to whatever else is going on, while it's busy focussed on that detail. Without being able to do both things simultaneously, it will end up being someone else's lunch.
This is why birds and animals, like ourselves, have the capacity to use their two hemispheres differently - the left hemisphere to provide narrowly focussed attention to detail and the right hemisphere to see the broader picture. In doing so we have developed a simplified‘representation of the world in the left hemisphere, a ‘re-presentation' which, for it, takes precedence over the complex, living, less precise, less graspable, reality that underlies it, of which the right hemisphere remains aware.
So the focus on parts, not the whole, and on the re-presentation rather than what is present, all suggests over-reliance on this way of thinking. The left hemisphere also proritises the general over the particular - its thrust is to create general categories and to ignore the unique, which the right hemipshere is better able to recognise. And, additionally, the combination of lack of trust, and the belief that all will be well if only we can control things ever more tightly, characterises the neuropsychological profile of the left hemisphere of the brain, whose whole purpose is to pin down and control.
This is of course a very valuable function, for reasons that will be obvious. But it is short-sighted. It doesn't get the bigger picture. It is fatally unaware of what it does not know. So it can't see why it keeps misunderstanding what it examines, and can only recommend more of what it has already recommended.
We need procedures up to a point. We need controls - up to a point. But we need to let go at a certain point, too, and allow the more complex, intuitively grounded understanding of the experts to have its part to play as well. That is why we trained them, and that is why, if we can trust them at all, we trust them (and if we can't trust them at all, the whole system breaks down). I am not arguing that we should abandon all attempts to make professionals accountable. They are as capable of corruption, arrogance, and denial as anyone else. Of course it is good that they should be made to examine what is going on in their professional area. But the best way may not be through ever tighter rules, algorithms and procedures. It may be to hold people more loosely accountable to outcomes.
Let me give an example. I prescribe medication for some of my patients. There are now guidelines as to how I should do this, and in what order I should try the different medications.
But this is patently absurd. Guidelines are based on what has been gleaned about generalities. But I have never seen a single patient who is a generality. What I know is that a different patient - every single patient of mine - requires a different package of therapy, or medication, or both. And the differences are things that could never be demonstrated by the blunt instrument of a clinical trial, which can only identify the grossest differences in general terms, and often fails to identify what is grossly obvious to any experienced clinician. Such evidence is, in any case, notoriously open to manipulation in a variety of ways, so that it should neither be dismissed, nor blindly accepted as the best path to sound understanding.
All in all, it seems to me in the best interests of my patients to be held accountable for the consequences to my patients, but not micro-managed as to what it is I do for them. Similarly it might actually help reduce the number of ‘untoward incidents' if, instead of relying on procedures, we asked clinicians to assume global responsibility for what they do, and held them to account whenever they failed to discharge it.
Although I have talked about healthcare here, it is of course just part of a wider picture that applies across society at large. Many academics, researchers, teachers, social workers, policemen and policewomen, lawyers, business people and others will recognise the problem. What I hope to do here is not point up a problem, which I think is all too familiar, but point to why it has come about - through an ever greater reliance on just one thing our brain helps us do, and one way of conceiving the world, to the almost total exclusion of another more sophisticated way of seeing the world that has a greater approximation to reality. That might explain the otherwise paradoxical finding that everywhere by pursuing apparently rational means to reach a rational end, we end up, not closer, but further away from our goal.