Dealing with Bureaucracy

The power which a multiple millionaire, who may be my neighbor and perhaps my employer, has over me is very much less than that which the smallest functionaire possesses who wields the coercive power of the state, and on whose discretion it depends whether and how I am to be allowed to live or to work.

--Friedrich von Hayek, The Road to Serfdom

A feeling of powerlessness ranks high among factors contributing to suicidal ideation in physicians. Futile confrontations with bureaucrats amplify this feeling. And bureaucrats seem to be everywhere. We encounter them in all levels of government, hospital administrations, insurance companies, group practices, health care systems, and seemingly everywhere we turn. How can we begin to understand these puzzling creatures? Why are they so rigid? How do they think?

Different Reality Tunnels

They think differently. To understand, we must compare and contrast their world view and our own.

Robert Anton Wilson refers to the concept of reality tunnels to describe world views. We only permit what we see through our personal reality tunnels to be part of our conception of the world. Like rejecting a round peg for a square hole, we exclude those facts and perceptions that we can't make fit.

Physicians and bureaucrats tend to have very different reality tunnels. This is simply a fact of life. Physicians need to deal with a vast amount of constantly changing information. Patients' symptoms vary from day to day. Every day brings new medical discoveries, some of which drastically alter treatment protocols. Sudden changes in course may result from a new MRI finding or lab result. Physicians deal first and foremost with individual flesh and blood, human beings. Success for a physician depends on observation, objectivity, communication, flexibility, empathy, being available to patients and families, and a personal relationship with each patient. Physicians are ultimately concerned with outcomes.

Bureaucrats see the world through a completely different reality tunnel. Their perspective demands consistency and predictability. They deal with statutes, regulations, populations, spreadsheets, protocols, policies, administrative procedures, accounting, and processes. They require structured information. They report to other bureaucrats. They deal first and foremost with policies. Success, for a bureaucrat, depends on rigid conformation to rules and administrative procedures. Bureaucrats are ultimately concerned with processes and properly following procedure.

At the end of the day, the physician asks, Did the patient get better? The bureaucrat asks, Was the process followed correctly?

It's easy to understand why doctors and bureaucrats often find it frustrating to deal with each other.

Tips for Interacting with Bureaucrats

1. Avoid interaction if possible. Unfortunately, this often isn't an option. However, you may be in a situation in which you can delegate the interaction to someone else. If you have a willing bureaucrat or administrative employee, they may be able to communicate more effectively with the external bureaucrat.


2. Try to appreciate the bureaucrat's reality tunnel. Most bureaucrats are nice, intelligent people who are trying to make the world a better place. As physicians, we focus on one patient at a time. Bureaucrats focus on the public. We, as physicians need to understand that bureaucrats tend not to be concerned about the specifics of an individual case, but rather attend to addressing issues affecting populations. This doesn't mean they are uncaring, but it does mean they may not give your particular patient's issues much weight.


3. The bureaucrat's employer's interests may clash with your patient's interests. This, unfortunately, is a big problem. If the bureaucrat represents a company or an agency that stands to benefit from denying services to your patient, you have an uphill battle. This type of situation often occurs when pleading for approval of necessary tests, treatments, or studies denied by insurance companies. It can appear as pressure to prematurely discharge a patient from the hospital. The bureaucrat makes determinations based on tables and aggregate data. Such information omits the specifics of your unique patient's presentation. The bureaucrat's decision will often preempt your well-reasoned and highly tailored recommendations for your patient. A one size fits all solution rarely fits anyone well. The bureaucrat does not recognize the value of the insights and lessons you have acquired through years of experience. There is little room for judgement in bureaucracy. In this situation, you may need to take some time to educate the bureaucrat, and allow her to come to a rational conclusion on her own after grasping the facts and the logic of your appeal. If unsuccessful, you can ask to speak to her superior. Most bureaucracies have well-trodden pathways for making appeals. Or, you can try number 4, below.


4. Appeal to the bureaucrat's desire to wield power. This technique works like a Jedi mind trick! The scenario plays out like this:

You: Thank you so much for agreeing to talk with me today.

Bureaucrat: Certainly. What can I do for you?

You: Well, I hear you have the power to approve a cervical spine MRI scan outside the guidelines under special circumstances.

Bureaucrat (with some satifaction): That's true.

You: That's fantastic! Thank you. Here are the reasons I need you to use your authority to help this patient get his MRI scan. . .

Bureaucrat: I agree with your reasons. I can help you.

Bureaucrats love to feel powerful and useful. Give them a chance.