Bureaucratic Ritualism in Medicine

Source: http://whatculture.com/film/blu-ray-review-the-trial-orson-welles-guilty-pleasure

Having once been a student of cultural anthropology, I still find myself taking the discipline’s participant-observer lens to  everyday social situations. It makes me kind of weird at dinner parties, but I just love the anthropologist’s calling to “make the familiar strange and the strange familiar.” Opportunities abound. Perhaps especially in the modern medical world in which I work.

I’d like to share a prime example of a professional interaction I had last week that I found fascinating (at least in retrospect). In part because of episodes like these, I’ve come to suspect that our world is full of symbolic rituals hidden in plain sight.

The Wild Letter Chase, a Story in Five Acts

ACT I: The ritual starts when an administrator contacts me to request a letter of recommendation for a colleague’s appointment to a new medical faculty position. I write a detailed and commendatory letter, providing verifiable context, endorsing my colleague fully and without reservations, and placing the text on professional letterhead in a proper serif font. I convert the letter to PDF and send it directly to the assigned administrator. I receive a thank-you reply and think to myself, job well done.

ACT II: A few days later, the administrator emails again to explain that a signature is needed on the letter. I think this is a bit absurd, given I’ve already provided plenty of information to verify my identity, and they wouldn’t know what my signature looked like anyway. What additional information could it possibly provide them? The request strikes me as an outdated habit from the pre-digital age. But what choice do I have? Since I’m working from home today without a printer or scanner, I photograph my signature with my phone, convert it into a simple black-line image, insert it in the letter and re-send it. I receive another thank-you reply.

ACT IV: A few days later, the administrator emails a third time to say the signature “was a little fuzzy” and would I please print out, hand-sign, scan, and email the letter again? Good god. Now we’ve crossed the line from ritual to ritualism.

Again, what choice do I have? Now at the office, I go through the prescribed rigamarole with the printer, pen, and scanner, and re-re-send the letter, now with a “real” signature, and perhaps a slightly salty message to the poor office lady. Sigh. Well, at least I can put this annoying episode behind me.

ACT V: Haha! A FEW DAYS LATER… I receive an automated email from some 3rd party medical credentialing contractor, insisting that I complete a web-form providing ADDITIONAL information on my colleague. I open the form, and lo-and-behold, it asks me to enter LITERALLY THE SAME INFORMATION I HAD WRITTEN IN THE LETTER into little boxes, check some tick-marks, and “e-sign” or whatever. I fill out the form, put my head down on my desk, and cry (on the inside).

EPILOGUE: So why did I even have to write an old-fashioned letter in the first damn place?

The only answer I can come up with is that the whole thing was an elaborate magical ritual. It served no inherently functional purpose, followed a formalized and prescribed script, took a great deal of time, required certain “magical” actions (drawing a signature) and special materials (professional letterhead, a scanner, etc.), and apparently required a certain amount of back-and-forth between at least two participants. If that isn’t some kind of modern bureaucratic witchcraft, I don’t know what is. By being so clearly excessive, though, I feel the wild letter chase crossed from simple ritual into heavy ritualism, as defined above (definitions from Google’s dictionary).

“AT LAST, THE PAPERWORK IS COMPLETE” (Apologies to The Craft, image borrowed from https://liberenalgeek.wordpress.com/2015/10/21/review-especial-halloween-the-craft/)

Bureaucratic Ritualism in Medicine

The thing is, this kind of ritualism is far more common in medicine than most people are probably aware (including the people who work in it). From the the check-in forms to the way personnel document clinical findings, from the appointment-setting process to the physical exam, from the ceremony of grand rounds to the hand-written signatures required on everything from controlled substances prescriptions to orders for adult diapers, the world of medicine is chock-full of tradition and ritual.

To a certain extent it makes sense: tradition fills in when we don’t have the time, evidence, or the collective will to come up something new, and ritual is soothing and reassuring in an uncertain and sometimes chaotic environment. I get it. But it also wastes a lot of time when these traditions and rituals become so deeply embedded in our health care bureaucracies that we can’t shed them when better or more efficient ways of doing things come along. It’s also extraordinarily emotionally draining for those of us who work in the system to spend so much time on paperwork, checking boxes, attending ritualized meetings, etc. when we urgently need to be caring for patients or producing useful research instead. And that’s to say nothing of patients who can so easily become hopelessly lost and confused in the midst of these byzantine systems of health care provision, to no fault of their own.

Writer, activist, and anthropologist David Graeber* correctly points out that vast bureaucracies have a way of making otherwise intelligent people stupid. Specifically, “Bureaucracies public and private appear…to be organized in such a way as to guarantee that a significant proportion of actors will not be able to perform their tasks as expected…they set demands they insist are reasonable, and then, on discovering that they are not reasonable (since a significant number of people will always be unable to perform them as expected), conclude that the problem is not with the demands themselves but with the individual inadequacy of each particular human being who fails to live up to them.” (From The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy.)

It’s high time we started seriously examining bureaucratic ritualism from within medicine and our systems of health care provision. Let’s not settle for being made stupid.


*Incidentally, Graeber is the only scholar I know of who has applied a critical academic lens to the pervasive phenomenon of bureaucracy in our lives. He also happens to be a lively and approachable writer. A transcript of his excellent lecture “Dead zones of the imagination: On violence, bureaucracy, and interpretive labor” is available with no paywall via the Journal for Ethnographic Theory.


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2 thoughts

  1. Jessica

    August 7, 2018

    Thank you for your recommendation of David Graeber. Please fill in the enclosed recommendation form, in triplicate, and return to us by yesterday.


    1. A.C. Pierian

      August 7, 2018

      LOL Can I apply for an extension?



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