Sunday, 5 March 2017

The Language of Healthcare

In this world of STPs, flat cash and level 4 alerts, there is a lot of planning about the shape of future healthcare services, and with it comes a string of new terms to learn. It reminds me of the 'language' that I used to share with my siblings: it made perfect sense to us, but to anyone else, it made us sound a little moronic. Indeed, it was the exclusivity of it that kept the 4 of us connected when we reconvened at home after term time at different boarding schools.
The language of families and siblings is a members-only club. Indeed, much of grown-up life is a members-only club, and one of the faux markers of success is which club one becomes a member of. It certainly used to be the case that medicine was a good club to be admitted to, but one has to wonder these days. It is perhaps more advanced that many in its craft-tradition, which is so complex, that one has to attend medical school for 5 years to get to grips with it. Indeed, given how hopelessly unprepared I felt in my first weeks on the wards as a doctor, I have to wonder whether those years at medical school were spent, not learning the knowledge one needs to be a doctor, but rather the language one needs to be a doctor.
Many times medicine has seemed to me to be an exercise in verbal fluency - from clinical exams, where the fluent do better than the knowledgeable, to talking with patients and families, where the key is the distillation of complexity into something more easily absorbed. Medicine often is not about the depth of thinking, but the clarity of it. Good medicine is often indicated by a parsimony of language and a decluttering of terms. The more experienced I become, the less I tend to say.
That, however, is not the case, when talking about the shape of future services, STPs and clinical service reviews. I credit myself with a good understanding of how the NHS works. I credit myself with a particularly strong understanding of how community services for frail, elderly patients work, and in particular, I like to outline the reasonable limits to our expectations and the boundaries beyond which the hopes for community services are fanciful, or even delusional.
I think I can create a clear narrative about a model of care for frail, elderly patients, based in the community, and starting in the patients' homes, with good coordination with GPs. I can share my learning until my voice is hoarse, but too often it seems that my messages gets lost.
And do you know where it gets lost? It is swamped in the language set of commissioning that uses different words, or non-words, to describe a tangentional vision of the healthcare services that has been sketched out by people who have visited services, but never worked in them.
I once remember walking along a tunnel in the Paris metro and hearing a busker sing a song. I knew I recognised the song, but I couldn't make out the words, and I just couldn't quite hang on to what it was, tantalisingly close though it was. A few minutes later, it struck me: it was November Rain by Guns and Roses; what had made it difficult to fathom was that the man singing it clearly did not speak English and had learned not the words of the song, but the sounds of the words. What came out of his mouth, therefore, was not the song November Rain, but an approximation of the noise of November Rain - and that is a very different thing entirely.
This is what meetings about the planning and commissioning of local health services sound like to me: they sound like November Rain sung by sound and not by words. And my response to this is to spend much of my time working out where the overlap between the language I use to describe services and the language I hear services described by is.
Spending time on the language of discourse is important. People from different backgrounds uses different languages to describe the same things. This creates the perception of difference, where the true difference is only one of lexicon. This would appear to boil down to semantics, but it is actually more than that, because it is also about parsimony, which is another personal preference of mine.
During my psychology degree, one of my favourite modules, after I had indulged my passing passion for the evolution of language and intelligence, was behavioural psychology. I do not know the state of psychology today, but at the time, behavioural psychology was the least fashionable area of the subject. Cognitive psychology was where all the interest was - but it didn't really speak to me. Cognitive psychology was all about box-and-arrow diagrams, with little adequate explanation of what happened in the boxes. Behavioural psychology, however, took the view that one couldn't know what was happening inside the box (or the brain for that matter) but one could make a decent stab at understanding what went into the brain, and what behaviours came out. Behavioural psyhcology is pared down, purposefully limited in its scope and wedded beautifully to the idea of parsimony: that is the most simple explanation for a phenomenom is likely to be the simplest explanation for it.
For half a term, I sat for a few hours in the week, listening to one lecturer (the only behavioural psychologist at UCL?) talk without interruption in a rather simple and engaging style about parsimony. And rather like his underlying thesis, everything about this man was  parsimonious - he never deviated from his uniform of blue jeans and off-white T-shirt. I never discovered whether it was the same pair of blue jeans and off-white T-shirt, or whether he had a wardrobe filled with mutliple copies. Behavioural psychology cannot explain all behaviour but it explains some very powerfully and very simply.
Throughout my medical training and practice, my mind has wondered back to my learning from behaviourism, as I have contemplated the possible explanations for a medical presentation. Ockham's Razor is something of a philosophical totem for some physicians and asserts that the explanation with the fewest assumptions or interpolations is likely to be the correct one. It is an argument of parsimony in medical practice that often holds true. In our office at work, a colleague of mine has mounted a 6 foot picture of a zebra, as a warning to the number of times he has ignored Ockham. He gets away with it, because in every way he is a brilliant doctor, and he never ignores the obvious - he just excitedly hopes for something a bit more exotic.
In my recent cognitive ramblings about health service commissioning and service transformation, I keep coming back to the concept of parsimony as a guiding principle  The complexity of the language we use to plan and design our service belies the fundamental simplicity of the concepts that should underpin them. The processes behind transformation are often difficult to navigate, but the principles guiding them are simple, and too often we turn our thoughts about the health service around, assuming that if the processes are complex, then so must be the concepts.
Yet there is something important about turning this habit on its head: too often, we find ourselves lost in service redesign when we lose sight of the destination. Too many conversations I have had about developing community services have happened in abstraction from the simple goal of everything we are trying to achieve. Not enough time is spent understanding where we are trying to get to, in language that is simple, easily recalled, and easily stated. This I take to be the goal of clinicians involved in service redesign: remember what we are trying to achieve, and frame it in a way that anyone can understand. Translate the language of complexity into the broad clinical goals, and repeat. And repeat. And repeat.
It is in that direction, i think, that success lies.

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