Pritpal S Tamber: Err, so what are we talking about again?

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 there were usually five people from the company. 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 the 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, although I provide consultancy to organisations to help them make better use of established knowledge, which can include helping them work out what each other are saying.

Pritpal S Tamber is the director of Optimising Clinical Knowledge Ltd, a consultancy that helps organisations improve how they use established clinical knowledge. He was previously the medical director of Map of Medicine Ltd, a company that creates clinical pathways to help health communities design services. He was the editorial director for medicine for BioMed Central Ltd and he was also the managing director of Medicine Reports Ltd. He has twice been an editor at the BMJ, the first time as the student editor of the Student BMJ.

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  • Richard Smith

    A great blog. People wasting hours talking about X when they all have a different understanding of X happens all the time. That’s why Muir Gray says that all meetings should begin with 15 minutes defining terms. Philosophers always tend to begin their essays with definitions.

    Other words and phrases in health care that have many meanings are commissioning, quality, patient centres, self management and integrated care. Let’s generate a list and then prepare some definitions.

  • The list is endless, if you ask me, especially in some of the marketing material out there. There are two that worry me most right now – value and portal. 

    The first is a subjective thing and yet is being used all the time at healthcare conferences. I am sure that no one knows what anyone else is saying with that one. 

    The second was an annoying term that became a dangerous one off the back of the recently published NHS Information Strategy, which seemed to boil down to “we’ll let people innovate locally but we reckon portals are a good thing”. What do they mean by portal? And note that Muir Gray is planning to make his “lexicon” available online – see http://www.bvhc.co.uk/products/. 

    Pritpal

  • Hi Anon, 

    You’re right, I’m potentially as guilty of using jargon as anyone else. I can help, however, describe the first quotation as I wrote it (and thought about it a lot), but the second you need to ask the company involved. So, regarding the first:

    – “organisations”: the intention is to help any kind of group, public, private, charity etc 
    – “established”: quite what this means depends on the speciality, but in most there is some amount of ‘truth’ out there that they can work from (although I always advise soft-wiring – see http://blogs.bmj.com/bmj/2012/06/21/pritpal-s-tamber-soft-wiring-knowledge/ for an explanation
    – “clinical”: as opposed to scientific/pre-clinical knowledge that does not yet apply to clinical practice 
    – “knowledge”: this one can be debated but Wikipedia has a useful summary of data, information, knowledge and wisdom, and the differences between them – see http://en.wikipedia.org/wiki/DIKW

    I hope that helps to explain my thinking. This discussion helps to make the point that we all need to establish what each other mean before we can get into productive discussion. 

    Pritpal

  • April Harding

    This is a problem across all the domains I’ve ever worked in.

    I note that, like philosophers, economists also common introduce a topic with definitions – but we often undermine the benefit of such clarification by spending a lot of time haranguing listeners with the very important reasons why OUR definitions should be used by everyone else (that is, we try to get everyone to try to speak our language….it is usually a waste of time). 

    In any event, from the health and development world, I’d like to add: public private partnership (used to refer to everything from the Global Alliance for Vaccines Initiative, to contracting with NGOs in rural Guatemala); and governance ( I couldn’t begin to list the varied concepts this word is used to refer to).

    Great blog post!

  • Notactualsize

    What, exactly, is ‘health’, anyway?