Orbiting around the hallowed nucleus of the doctor-patient relationship is an entire healthcare industry that occasionally – although not often enough – impacts on clinical practice. Having spent five years in this orbit one of the things I’ve concluded is that no one really knows what anyone else is saying.That may seem like an inflammatory remark so let me start with my favourite example.
A company I used to work for was once invited by a much larger company to participate in a bid for some NHS-funded work. The contract was potentially worth millions and was based around the use of “pathways”. You’ve probably heard the word “pathway” a few times, and you’ve probably seen a few examples. I’d wager that not all of them looked the same. Pathway is perhaps the most over-used word in the English language (well, in healthcare anyway).
It’s been used to refer to entire specialties, checklists, flowcharts, and any number of variations between them. A researcher once told me he’d identified close to 80 different definitions of the word.
We had three conference calls with the large company. There were at least three people on our end of the line and they were usually five. I was intimidated by them, not least because of their impressive job titles and polysyllabic patter, and I struggled to really understand what they wanted us to do. I assumed it was because they had brains the size of planets and I was intellectually out of my league. It was towards the end of the third call that I realised what the problem was – we were using completely different definitions of pathway. They were thinking of entire specialties and we were thinking of specific conditions.
“Can I just ask what you mean by the term pathway?”, is what I asked, very nervously. It’s hard to describe the awkwardness of the silence that ensued. When people found their voices, we tried to muddle through for a while, but it was impossible. We weren’t just on different pages, we were in entirely different books, in different libraries, on different continents. I’ll never forget the moment that one of them, so completely confused at this stage, said, “Err, so what are we talking about again?”.
It’s tempting to malign the large, highly-profitable company for being full of incompetents but the truth is the original NHS tender did not define what it meant by pathway either. The large company had interpreted it one way, us another, and never the twain were going to meet. I have no idea who won the contract and – more importantly – how the bids were scored but I was left with the feeling that no one knew what anyone else was saying.
It’s important to note that the service being procured was aiming to improve patient care. People not knowing what each other are saying is not just an awkward farce but a possible root cause of why patient care struggles to improve.
The above example could be described as an error by two well-meaning parties but I suspect some people use this general confusion as a cover. I was once involved in some meticulous work to try to define the most important clinical topics for the English NHS. We couldn’t find any good examples of how to do this so we defined our own methodology: we measured eight variables, scored them, weighted the scores, and then combined them to create an overall rating. It took months but we were proud of the output and started telling people about the methodology. The Department of Health (DH) heard about it and sent one of their medical advisers to find out more. She listened patiently, nodded at the right moments, and raised her eyebrows at the complex spreadsheets. We’d allowed ourselves to think she might suggest the model be adopted by DH to prioritise the use of resources. At the end, all she said was, “Is this evidence-based?”.
We had no idea what the question meant and I have no doubt that she didn’t either. I think she just felt the need to say something smart and threw in some terminology to boot. Much to my own disgust I actually offered an answer about how we couldn’t find any good examples so we may, in fact, be defining a new type of evidence, but even I didn’t really know what I was saying. I just thought I had to say something smart because she had to say something smart. An utterly pointless dance.
There are numerous examples of this kind of behaviour, and it’s not even a recent thing. Commenting on the terminology of quality assurance in 1982, Avedis Donabedian, a pioneer in measuring quality in healthcare, said, “We have used these words in so many different ways that we no longer clearly understand each other when we say them”. Examples from today are evidence-based, portal, QIPP, procedures of low clinical value, personalised medicine, to name just a few. What do they actually mean? Different things to different people, I fear.
The next time you’re in a meeting and suspect that not everyone is speaking about the same thing, ask the dumb question: “Err, so what are we talking about again?”. I wager that the more silent people in the room will breathe a sigh of relief and the more vocal will fear that their house of cards of confidence and jargon is about to collapse.
Competing interests: None that pertain to this article.
This post was first published on my original blog, Optimising Clinical Knowledge, and co-posted on BMJ Blogs.