Speaker A There are two worlds. There's the world out there the physical world, the world of hospitals, the world of non self, physical, chemical, biological dynamics, material things. And then there's the personal world, experiential, imaginative consciousness, self that we are not used to recognizing that these two worlds exist independently of each other. We just simply have lost that conception. Both these worlds contain things or entities. And the things or entities in the physical world have quality and quantity. They're quantities of them, and they have qualities. And the things and entities in the personal world have energy and form. We try to impose our will on the physical world, so it serves our need and aspirations. And that's, of course, what we've been talking about. We've got these hospitals and we have things in our mind about how we want them to run and what they want to do. And we're trying to change that world. That's what it's all about, right? We are trying to externalize, make real something that we have in our mind. Because when we observe, it's so much easier to see the physical world. When we try and describe the forms behind that, we don't see the way the context has crept into it. So, for example, Elliot, when he wrote about doctors and he wrote about healthcare, wrote about it from his experience of being trained as a doctor in whenever it was the during World War II, he went to Hopkins, the 40s. Well, medicine today is very different to the way it was in the 40s. He talked about healthcare, organization and so on. The world changes. What you see changes. So this applies for doctors. Now in England, doctors are fully employed within the system. They're employed by the organization. They also do some private work that's outside. But they're employees and they have to be managed and they have to be treated as accountable. And believe it or not, it can be done, right? So if somebody comes into there and tries to describe the nature of medical work and whatever, they're going to somehow be seeing something that looks different to what you're describing. Or looks different to what you're describing. So what we're always trying to search for is what can we say that is going to be universally true? What can we say that's going to be universally true, that's going to be eternally correct. I mean, if we look at levels, for example, that we believe, I think most of us in this room believe that there is such a thing as level three work, level four work, level five work. And that applies in any country. It applies irrespectively, irrespective of how chaotic an organization might be and people are going to have these capabilities. That applies irrespective of whether in any situation they're using them or it's being set up or they're being accountability exists in this world. And that applies whether in fact it's being managed correctly or incorrectly or with this particular cultural bias or that. So our challenge is we have to really have a feel for what's eternal and what's here. And then when we work with the actual world, we've got to do the best we can. There's no way, for example, in the American system, as you describing it, that various solutions that we've found in the English hospitals could ever be applied because just couldn't happen because the context wouldn't permit it. Doesn't alter actually any of the fundamentals. So the question is getting a grip in relationship to doctors, what are the fundamentals? So I'd like to propose just one example of the sort of fundamentals. One of the things that I found looking at levels of work was that you have 123-4567, but you can look at them at twos, in twos, one and two, two and three, three and four. You can look them in threes, in fours, fives. When you look at them in fours, I'm not sure if this is going to come out very clearly. Is that readable? Yeah, just scroll to the left, to the right. Remember, you spoke about domains. I prefer the word function. Right? Because what you have in any organization are an organization has to take into it bodies of knowledge and expertise. No organization grows all its knowledge or expertise. That's a property of society. So for example, no hospital is responsible for the nursing as a discipline, as a profession that recruits nurses. That doesn't mean it does no training itself, but it recruits nurses. So there are four types of functions and we found that functions operate over four levels and that medicine in this situation is a specialized assessment function. In other words, there's no such thing as doing medicine at level one. A medical practitioner, to be called a medical practitioner, has to be working at level two, has to be able to make an assessment. Another interesting thing we found is that the person who really controls the delivery is whoever is at the second level in the function. So in medicine, that's at level three, right? So that the actual controller of the medical performance actually has to work at level three. Even if when they're working at a seeing a patient, they're working at level two. Now, at level three and at level four, we're talking about responsibilities here for the function, for the medical function, for the quality of medicine. Something that nobody but a doctor can deal with. Right? So it's got nothing to do with any other no other profession can ever tell a member of a profession what its standards should be or what knowledge should be incorporated or what latest research is relevant. Now that has to be done, that's higher level work within the function. Another little interesting thing. I don't want to go too much into this. I'm just trying to give you the feel of how you can get to things that are permanent, eternal and culturally general. They have to apply across all cultures. We would create in the hospitals, the big hospitals, we're talking about hospitals with 200 million dollar revenues and this sort of thing. So big hospitals, divisions working at level four. There would be a general manager who was in the general management function working at level four. There were a lot of nurses often working in division enough to require a director of nursing services who was working at level four. Nursing is a specialist action function. And then we would try to get a doctor working at level four in there that was more difficult for various reasons, not to want to go into why and so on. And he did not have conventional managerial authority over all doctors because of the nature of medicine and so on. But he was working, we wanted him to be able to work at level four. Now what you see is on the system part of the function or on the assessment part, we wanted his medicine is a specialist assessment function. That means, which starts at level two, means that in any hospital of any size, there's going to be quite a number of level four doctors who are quite capable of working at level four. They could even be general managers, as it were, take over a division if they wanted. So we're simply saying that this person is interested and capable of turning his mind to problems of the organization which require a level four response. But in all three of the vertical functions, well, what you see is the nurse is at the top of their function, the doctor is at the third level in their function and the general manager is at the very bottom of his function. So you have this idly odd thing that the nurse is actually incredibly powerful in relationship to their function. The general manager is actually rather weak in the context of his function. The doctor is moderately strong. Now, these are phenomena that are thrown up by once you start looking at things in these sorts of ways, how they're going to manifest in any particular culture, in any particular health system, because that's going to vary. I think that's the only point I wanted to make to relate.
