There is a discipline in medicine most people outside it have never heard of. It is called deprescribing.

For years, we assumed the job is to add. A new symptom, a new drug. The list grows, one sensible decision at a time, until an elderly patient is on fourteen tablets a day and nobody can say which ones are still helping, which are interacting, and which are quietly causing the next problem.

Deprescribing is the deliberate, careful work of taking things away. Stopping what no longer earns its place. It is harder than prescribing, because every drug on that list was added by someone who had a good reason at the time.

Most organisations are on fourteen tablets a day.

This is the fourth and final letter of PACE, and it closes on the question leaders avoid most. What stops when you stop doing it? Presence puts you in the right work. Accountability gave it an owner. Clarity defined what finished means. Elimination asks what you can take away now.

Every problem gets a response. A new meeting to coordinate it. A new report to track it. A new step in the process to prevent it from recurring. Each one is a reasonable answer to a real issue, added by a capable person on a sensible day.

What almost never happens is the reverse. Nobody is assigned to remove things. Adding feels like progress and shows initiative. Removing feels like loss, and often like admitting that something was once a mistake.

There is good evidence this is a genuine cognitive bias, not just laziness. When people are asked to improve something, they reliably reach for what they can add and overlook what they could take away, even when removing is the better and easier answer.

So the list only grows. And a leader can be adding sensible things, one at a time, all the way to an organisation that can barely move.

Each of these was added by someone with a reason. None has been reviewed since. And review, not addition, is the missing discipline.

We do not stop everything at once, and we do not stop things at random. We review the list, one item at a time, and ask a single question of each.

If this patient were not already on this, would I start it today?

If the answer is no, the item becomes a candidate to stop. Then we stop one thing and watch what happens, rather than guessing at the effect. If nothing worsens, it stays stopped. If something does, we have learned exactly what that item was doing, which we never knew while it sat unexamined on the list.

The same method works on an organisation, and the same question does the work. For every recurring meeting, report, and process, ask it plainly. If we were not already doing this, would we choose to start it today? The things that fail that question are your fourteen tablets. You do not have to stop them all. You have to start looking.

List every recurring commitment in your calendar and your team’s week. Meetings, reports, standing processes, approvals.

For each one, ask two questions.

Would we start this today if we were not already doing it?

And what actually breaks if it stops?

Where the answers are no and nothing, you have found something to deprescribe. Choose one this week. Stop it, tell people you have stopped it, and watch. Nothing will break, and you will have your first hour back. Next week, stop another.

An organisation where everything had quietly begun to take longer, and nobody could say why. No crisis. No single failure. Decisions that once took a day now took a fortnight, and every explanation pointed somewhere else.

The presenting symptom was an organisation moving through treacle. The diagnosis was accumulation without review. Fourteen years of process, each piece added by someone with a good reason at the time, and not one of them ever removed.

The full case, the diagnosis, and the prescription are inside The Diagnosis Room.

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Presence. Accountability. Clarity. Elimination.

Four weeks, four moves that close the gap between motion and output. Presence puts you in the right work. Accountability gives that work an owner. Clarity defines what done means. Elimination clears everything that no longer earns its place.

That is the whole diagnosis. The series ends here, but the questions do not. The strongest leaders I know run them on their own week, quietly, all the time.

Am I in the right work?

Who owns this?

What does done look like?

And the one almost nobody asks.

What could I stop?

Last week, I asked who your LinkedIn profile should primarily represent.

Read the post and join the conversation here

Subtract, Leidy Klotz.

An engineer's investigation into why human beings systematically overlook removing as a way to improve, and reach for adding even when less would clearly be better. The research is genuinely surprising, and once you see the bias, you cannot unsee it in your own organisation or your own calendar.

Find it here

The elderly patient on fourteen tablets did not arrive there through one bad decision. They arrived through fourteen good ones, each made in isolation, each sensible at the time, and not one ever revisited.

Organisations decline the same way. Not through a single disaster, but through the slow accumulation of reasonable things that no one is responsible for removing.

Before you add your next solution, ask the harder question. What could you stop?

Lead honestly. Lead clearly. Lead where it matters.

Dr Ikechukwu Okoh, The Leadership Diagnostician

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