On the NHS integration journey we need to think about both the content and the structure of our language, writes MedeAnalytics medical director Dr Mark Davies.
A patient was discussed at a general practice critical event meeting where a delay had occurred in the diagnosis of a testicular tumour. He had presented to his GP with a painful testicle and although nothing abnormal was found on examination the patient was referred to the local ultrasound department. The radiology report was inconclusive and suggested that ‘a repeat ultrasound in two months would be helpful’. The GP assumed that the ultrasound department would be recalling the patient for the repeat ultrasound. The patient presented a number of months later with a testicular mass which proved to be a testicular cancer. The original ultrasound report was in fact asking the general practitioner to re-refer the patient for a repeat scan. This kind of misunderstanding is not uncommon and is a consequence of the loose way we use narrative in care.
We often rely on effective written communication to coordinate care from one professional to another, between professionals and those receiving care and to design and manage services. Unfortunately what we write and what is read are not always the same, that brain to brain chain is harder to link across disparate professional groups or organisations. This is partly because we have different phrases and expressions that have implicit meaning only in one context and also because our communications often have poorly thought out structure. We need to make these linguistic differences explicit if we are we are going to plan and manage integrated services effectively. People often talk about culture but language is just as important. As we start to integrate care between different care settings the currency of effective care communication will become more critical.
There is an important compromise here between structure and natural language. Natural language being the free flowing way we normally speak. The emerging computer techniques of natural language processing where software extracts meaning from free text are becoming increasingly reliable. However I don’t believe this can completely replace structure and if our care language adopted a more standard way of constructing these communications, it could make these information exchanges more efficient and safer. That is not to say that we should lose the richness of natural language nor the brevity and precision that ‘jargon’ enables within a specific group. My point is that labelling our written word would make what we are trying to say much clearer. A good example is the importance of specifying when transfer of responsibility occurs, as is illustrated by the anecdote above. Ambiguity leads to assumptions being made and where those assumptions are incorrect, there is potential for significant clinical risk.
I discussed this with Pete Johnson, something of an informatics genius who also speaks human, he helped me unpack some of this. The need to move towards more structured methods of communicating is being increasingly recognised but there is a need for a discussion on what this structure should be. The Royal College of Physicians in the UK has led the work in producing record keeping standards for handover, this is an important step in the right direction. The introduction of structured records and terminologies like SNOMED CT help drive out some of the uncertainty of our clinical language but there will always be a place for free text and this will need to exist within its own structure. Coding systems like SNOMED CT do not provide the whole answer and there is a danger in assuming they will. Coding systems generally give us the ‘nouns’ but they do not give us the ‘verbs’. What is required is a simple and useable classification of communication tasks or ‘verbs’ that works across different agencies.
More than 50 years ago linguists made the distinction between performative sentences and constative sentences – where a performative is itself part of the doing of an action whereas as constative sentence is a description[i]. When this distinction is not made clear in clinical communication, when for example a request to do something gets confused with a description of the author’s intention to do it, a medical error may result. Labelling our communications to make clear the distinction between describing and instructing would be a simple step in improving patient safety. Closing the loop by requiring the formal acceptance or rejection of requests would catch many errors of omission. More generally there needs to be a debate about what standards we apply to our communications in an integrated care environment. Too much structure and we risk losing subtlety and may stifle the natural flow of language, too little and we leave unacceptable room for ambiguity.
Once we have a clear understanding of what we are saying it is possible to process map subsequent events. This not only helps us to be clear about a transfer of responsibility but also leads to the documentation of subsequent actions e.g. accept, reject, perform. These process maps can then be used to inform the design of our digital templates and even paper forms. This discipline leads to a theoretical framework that also allows decision support to operate and audits to be developed that can track the delivery of care.
There is perhaps a natural resistance to the imposition of structure on our language as some people are concerned that it may lose its ‘humanity’ in some way. In addition we can all avoid our professional jargon when we are aware of it but there is much of what we say that only has our intended meaning in certain settings. However, I would suggest it is possible to provide context while retaining the narrative style of much of our communication and certainly possible to sense-check the phrases and words we use for multiple audiences. A little discipline is worth it to ensure that for our patients’ sake we ensure we say what we think we are saying.
“Everything is vague to a degree you do not realise until you have tried to make it precise.” Bertrand Russell.
[i] Austin, J.L. How to Do Things with Words Oxford: Clarendon Press, 1962.