Muir Gray: Viva Wittgenstein

Muir GrayThe single greatest influence on my work has been the inscrutable, often incomprehensible Ludwig Wittgenstein, philosopher and MRC Lab Technician. Much of his writing I find very difficult. The early paragraphs in Philosophical Investigations are a good introduction but even easier, for me, was the great Ray Monk Biography and the fascinating account of the tale of Wittgenstein’s Poker. The principles I have learned, which I call on daily, include:

  • The meaning of a term is best understood by studying its meaning in use
  • As terms become more widely used they acquire more meanings, even if there is only one in a dictionary
  • Almost all arguments are the result of those arguing using the same term with different meanings, “efficiency” for example.
  • There may come a time when a term causes more confusion than clarity, the term “need” for example
  • The clarification of meaning is always helpful even in the middle of a crowded agenda

For years I have been building a glossary of 21st Century healthcare language by collecting examples of how healthcare  terms, about 1000 in total now, are used. For some terms such as “process evaluation,” I have only one example. For others such as “judgement,” I have four, and for yet others such as “leadership,” I have collected twenty five before giving up. To illustrate here are two of the five examples of “efficiency” and one of the two examples of “productivity.” The first by a Nobel Laureate, Herbert Simon, whose book is one of the best about politicians and officials (don’t be put off by the boring title – Administrative Behavior) in which he describes how efficiency evolved from effectiveness

Until practically the end of the nineteenth century, the terms  ‘efficiency’ and ‘effectiveness’ were considered almost as synonymous.   The Oxford Dictionary defines ‘efficiency’:  ‘Fitness or power to accomplish, or success in accomplishing, the purpose intended;  adequate power, effectiveness, efficacy.’ In recent years, however, ‘efficiency’ has acquired a second meaning:  the ratio between input and output.   In the words of the Encyclopaedia of the Social Sciences:
Efficiency in the sense of a ratio between input and output, effort and results, expenditure and income, cost and the resulting pleasure, is a relatively recent term.   In this specific sense it became current in engineering only during the latter half of the nineteenth century and in business and in economics only since the beginning of the twentieth.”

However in health care we are careful to distinguish outcomes from outputs and a crisp brief example of a more modern meaning is given below from a good Priority Setting Toolkit

“….. efficiency can be defined as maximising well-being at the least cost to society.”

The term productivity is now used to describe the relationship between outputs and inputs.

“This paper explores ways of measuring the value of NHS output. This is different from inputs, i.e. what is spent. The focus is on measures for the NHS in England as a whole, rather than for separate NHS Trusts or Primary Care Trusts. And the main interest is on how output changes over time, using annual measures. It is then possible to assess change in productivity by dividing the time series for outputs by the time series for volume of inputs – that is, spending deflated to adjust for changes such as NHS pay and price rises.”

: Department of Health. In Healthcare Output and Productivity: Accounting for Quality Change, 2005:5

How important is this? “It’s just semantics,” someone said to me but “just semantics” are responsible for about 50% of wars, as the brilliant analysis of Robert S McNamara’s wars – the Fog of War– demonstrates and for 99% of confusion in modern healthcare.

Muir Gray is visiting professor of knowledge management, Nuffield Department of Surgery, University of Oxford.