The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy

I have a large administrative role, overseeing myriad activities from recruiting to graduation. In between these two bookends of a resident’s time in our program, there are forms to fill out, letters of recommendations to compose, and the gathering, analysis and reporting of their academic progress both internally and externally. Given that such work is now the largest slice of what I do, I am surprised on two fronts: that I have no formal training to do this well, and that I haven’t really thought of understanding this work in a scholarly fashion. In other words, why haven’t I systematically studied these administrative processes? It turns out that most academics accept the bureaucracy of the institutions that they are part of.

I recently received a list of residents who hadn’t completed a conflict of interest form. Apparently, this was assigned last summer, and it clearly escaped the notice of many of them. As I thought this through, I wondered why I don’t seem to a get a timely list of what is assigned to the residents and when it is due. I’m often brought in to help solve these issues when they reach the proverbial eleventh hour. By the time they arrive at my doorstep, they are wrapped in urgent messages with the threat of taking away the resident’s access or getting docked in pay. It’s hard for a program director, who is primarily the residents’ advocate, to cross over to the space where these threats are emanating from. What’s more logical is for me to examine the process and take co-ownership at its genesis rather than at its finale.

I wondered if anyone had written about such situations. As it turns out, someone has. David Graeber discusses the origins and evolution of bureaucracy in his marvelous book, The Utopia of Rules.

One quote that resonated with me:

“Just as the invention of new forms of industrial automation in the eighteenth and nineteenth centuries had the paradoxical effect of turning more and more of the world’s population into full-time industrial workers, so has all the software designed to save us from administrative responsibilities in recent decades ultimately turned us all into part or full-time administrators.”

We have considerable but not unlimited freedom in the work we do. Paradoxically this freedom entails an increasing bureaucracy that catalogues, measures, analyses and ultimately manages this freedom. Perhaps Dr. Y is prescribing too many opioids, or Dr. Z’s length of stay is too long. Regarding conflicts of interest, the residents are not prohibited from having them, they just need to report them, and someone up there will decide if they need to be managed in some way.

Another Graeber quote:

“But the culture of evaluation is if anything more pervasive in the hypercredentialized world of the professional classes, where audit culture reigns, and nothing is real that cannot be quantified, tabulated, or entered into some interface or quarterly report.”

Process improvement, project management, implementation science, industrial and organizational psychology – most institutions will embrace one or more of these capabilities to help manage and optimize the rules and processes that are part of our daily work. As 2024 starts, I will attempt to understand and help manage all the bureaucratic tasks that residents encounter. The first step will entail comprehensively cataloging all that is expected of them and by when, the next would be to negotiate away that which is duplicative or of no value. I expect that over the course of their training here there may be upwards of 100 discrete administrative tasks. Except for a few quick ones, I cannot assume that they will get these done “on their own time.” Some are created by the program: evaluations, timesheets, surveys; others by your employers/hospitals: various compliance modules, immunization, TB testing, mask fitting, etc.

It is unfortunate that some residents were caught off guard by any last-minute administrative requirements accompanied by threats. I know that they are conscientious and eager to cooperate. I also realize that their clinical responsibilities and education are their primary priorities. Together we will find a way to manage what has become a recurring problem in our program – the urgent administrative task that threatens to take away their access and dock their pay. It should never come to that.

—Salahuddin “Dino” Kazi, M.D.