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150 Years ago, phrenology---the practice of interpreting bumps on the head---was considered perfectly reasonable. Today, we have Management-ism instead of that foolish practice.

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. ...

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