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The Craftsman (part 2)

July 19, 2009

One of the great obstacles to craftsmanship in our modern work is the conflict between what Sennett calls the “embedded” knowledge in a group of experienced workers, and the compulsion in institutions as they grow larger to codify ways of doing things.  His example is the UK’s National Health Service, in which “Fordism” has been applied – Henry Ford’s division of labor taken “to an extreme,” employing careful monitoring of the amount of time doctors and nurses spend with each patient. 

What I call the “Rule of the Binder” comes to prevail in situations where experience or (to reclaim the phrase from its right wing kidnappers) common sense would provide a solution – but the freedom to depart from the script has been removed.  You see it when you reach a call center (all seemingly located, when you press for the information, “outside Philadelphia”) and try to explain any unusual situation; you know that a human being with any degree of autonomy could fix the problem immediately, but you also know that the human being whose responses are being monitored by the All Seeing Eye is going to choose to fail to solve your problem if solving your problem means departing from the Rule of the Binder, which has codified the handful of phrases and actions which they can say and do.  It’s irritating in a customer service setting, and potentially fatal in a medical setting.  “If a patient is having a heart attack,” Sennett says, “you do not want to reach for your ‘Manual of Best-Practice Performances’ to discover the latest rules about what you are supposed to do.”

Craftsmanship “embodies conflicting values,” Sennett says – the desire to get the best practices down on paper and have them followed (especially by those who aren’t Dr. House-level geniuses of intuition) versus the fact that sometimes spending “too much” time listening to a patient’s narrative may lead you to a different diagnosis and a different, better care decision than you would have reached obeying the binder.  Human beings in organizations have a difficult time reconciling the need for both authority and autonomy – the need for a standard of good judgment and best practice, a respected hierarchy to take the credit/blame for decisions, and yet also the need to defy all of the above when perhaps only one person deems it prudent or urgent. 

The binder can also be set to Kill:  at the Kaiser Permanente HMO in San Francisco in the mid-90s, there was a policy of financially rewarding doctors who performed the fewest expensive tests; my best friend died of AIDS-related lymphoma after having been seen again and again for a foamy white growth in his mouth and, again and again, sent away with nothing but yet another antibiotic prescription until it was too late to do anything to save him.  The “best practices” of cost savings are all too often interwoven into the practices of life saving in our medical institutions; indeed in most institutions the “pure reason” of the Binder is almost always tainted with un-craftsmanlike diktats designed to shave a nickel off the total cost of everything.

Sennett fails to note one of the prime movers behind Binderization, especially in medicine – litigiousness.  Making the same decision a thousand other doctors have made a thousand other times (“more tests” for instance, if you’re lucky, or “more antibiotics” if you’re not) insulates you from the legal consequences of failure, regardless of the effectiveness of the decision.  The comfort and safety to be found in the bosom of the Binder is a greater danger to craft than anything else.



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