Fieldwork before frameworks

If you don’t know the story of Dr. Paul Farmer, you should.

He’s saving thousands of lives while changing how the world thinks about poverty, about disease, and about what’s possible.

As we try to change how companies work, we can learn a lot from his approach.

“Mountains beyond Mountains”

Paul Farmer grew up in an unconventional, poor family in various parts of the US. Always smart, he wound up graduating from Harvard Medical School and doctoring in two of the most different places on earth – Brigham and Women’s Hospital in Massachusetts and a hospital he built in Cange, Haiti.

In “Mountains Beyond Mountains”, Tracey Kidder chronicles how Paul Farmer could be in a crowded hut one day caring for a TB patient and in a posh conference hall the next day trying to change World Health Organization policy.

Besides making for fascinating reading, that contrast is instructive.

“Journeys to the sick”

On several occasions, Kidder accompanied Paul Farmer on long hikes to see patients in remote parts of Haiti. Farmer would speak to the family in Creole. He’d observe, listen, and touch – not as a doctor from Harvard with superior knowledge but as a human being who genuinely cares and wants to learn. What are their living conditions? How is the rest of the family? What else is going on in their lives?

By seeing the patients in their own environment, speaking to them in their own language, he can see more than the disease. He can see the entire environment around the disease.

“Every patient is a sign. Every patient is a test.”

But is it “appropriate”?

Not everyone agreed with Paul Farmer’s methods. Should a doctor who could affect worldwide medical policy be spending time seeing individual patients in remote huts? Kidder talked with him about it on the hike back after one of their visits:

“Some people would argue this wasn’t worth a five-hour walk,” he said over his shoulder. “But you can never invest too much in making sure this stuff works.”

“Sure,” I said. “But some people would ask, “How can you expect others to replicate what you’re doing here? What would be your answer to that?”

He turned back and, smiling sweetly, said, “Fuck you.”

It wasn’t that Paul Farmer did’t have better answers. It was that people were asking the wrong questions. You needed the fieldwork to make sure what you were doing was even worth replicating.

He faced similar questions about money, particularly about “appropriate technology.” Could Haiti afford to treat AIDS and TB?

“We can spend sixty-eight thousand dollars per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international community jumps on you for creating nonsustainable projects.

When “theory outruns practice”

This is the trap we fall into at work. We create strategies and frameworks and lists of “5 most effective ways to…” without enough testing of those ideas in the field. We talk about ROI and antiseptic approaches to the diseases (ineffective work practices) without seeing and touching and understanding the entire environment that’s making the diseases flourish.

“If you focus on individual patients, you can’t get sloppy….In public health projects in difficult locales, theory often outruns practice. Individual patients get forgotten, and what seems like a small problem gets ignored, until it grows large…

…a willingness to do ‘unglamorous work’ is the secret to successful projects.”

If you really want to change your company

Sure, we need frameworks and strategy to scale what we do. But they’re useless if people back in their cubes are working like it’s 1995.

I don’t want to just write about change from a safe distance. I want to actually change things.

And if a genius who’s saved thousands of lives and changed worldwide opinions about disease can spend time with individual patients, so can I. So can everyone who’s trying to change how companies work. Just as entrepreneurs keep testing their product with real customers in real conditions, we need to test our ideas about change in the field.

A close colleague observed that Paul Farmer’s visits to patients “refresh his passion and authority, so that he can travel a quarter of a million miles a year and scheme and write about the health of populations. Doctoring is the ultimate source of his power, I think.”

To change how we work. that combination of fieldwork with longer-term, larger-scale thinking is exactly what we need.

About John Stepper

Helping organizations create a more collaborative culture – and helping individuals access a better career and life – by spreading the practice of Working Out Loud.
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6 Responses to Fieldwork before frameworks

  1. Guy says:

    Thanks for that – it is something that I’ve noticed as well. Too often we see HR managers that don’t deal with people, principals that don’t teach, change consultants that don’t care about the people who they’re affecting, and I believe the value of their work is diminished as a result. Staying in the real world, with real people is the only way to be sure that you’re making things better.

  2. Reblogged this on Ayiti P'ap Peri and commented:
    A reflection on Tracy Kidder’s book Mountains Beyond Mountains.

  3. I spent fifteen years experimenting with participant-driven conference designs before I even considered writing a book about what I had learned. (2½ years later, a supplement is due, since I’m still learning from every conference I facilitate.) So it irritates me to see a steady stream of five-ways-you-can-improve-your-event posts listing discrete ideas that aren’t woven into any kind of conceptual framework that has been developed through long-term experience and experiment.

    Many of our important problems are not going to be solved via incremental changes to existing process. Unfortunately, the approach of having an idea and bolting it onto the currently dominant model is far easier, safer, and simpler to sell than doing the kind of thorough field research and thinking needed to come up with something that is, in hindsight, demonstrably and fundamentally better.

  4. Guy says:

    I’ve thought about this a bit more.

    I think every good idea has negative side effects, and is in conflict with other positive ideas. Frameworks and models work by simplifying the world. Which is why you should always be careful when implementing change based on a framework on a model – observing the side effects that are being created, which may not have been predicted by your framework or model, or which may have been predicted but not the extent. Spending time in the field, and continuing to spend time in the field, is the only way to observe these side effects and moderate what you’re doing.

  5. Pingback: Changing habits: a personal experiment | johnstepper

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