Antonio J.-C. is a man who knows the smells of old coal and the sound of a brick shifting under a metal brush and he spends his days on the roofs of London where he sees things that most people only guess at when they turn on their heating in the cold months. He is a chimney inspector and he has a camera that he drops down the dark holes of old houses and it sends back pictures of gray dust and white salts and jagged edges.

He makes a report that says the flue is clear or it is not clear and he hands it to a mother who is worried about her kids and she looks at the paper but she does not see the dust or the salts or the heat. She only sees the words of a man she will not talk to again for another year and the meaning of that paper starts to die the moment Antonio walks down her front path and closes the gate because there is no one left in the house who knows why the dust was gray instead of black.

The report is a technical thing but the safety of the house is a living thing and they are not the same and they often go in different directions. This same gap opens up in the middle of a modern clinic on Harley Street where the tools are much cleaner than a chimney brush but the problem of the dying meaning is just as real.

A team of people work together to help a man get his hair back and they use machines like the WAW DUO or the UGraft Zeus to take grafts from the back of the head and put them on the top. These machines come with screens and they give out data and they tell the team how many grafts were taken and how deep the needles went and how fast the motor turned.

The technician sees the numbers and the surgeon sees the numbers and later the patient sees a summary of those numbers in a neat folder. But a number on a page is like the soot in a chimney because it only tells you what happened in the past and it does not tell you how to talk about it tomorrow.

The Crisis of Shared Reality

There was a day when a group of staff sat in a small room with a window that looked out over the rooftops and they had a printout of a digital assessment for a new patient who wanted a crown restoration. One person had the sheet with the raw data and another person had the brochure that explains the process to the patient and a third person had the notes from the first talk.

They looked at the numbers and they realized that the machine said one thing about the density of the hair but the patient had heard something else and the surgeon had a third idea about what was possible. They had all the information in their hands but they had no place to write down a shared understanding of what that information meant for this specific man and his specific head.

They could see the data but they could not find the truth of the situation because the truth was trapped in the space between their chairs.

It is a mistake that people make in every trade from chimney sweeping to high-end surgery and it happens because we trust the printout more than we trust the conversation. A digital assessment is a snapshot of a moment in time and it is very good at being a snapshot but it is very bad at being a teacher.

When the technician leaves the room and the surgeon takes over the explanation of the data can change and if no one is in charge of keeping that explanation the same then the meaning of the data starts to drift away like smoke.

The Maintenance of Meaning

The maintenance of meaning is a job that no one wants to do because it is hard and it does not have a button you can press. It requires people to talk to each other for longer than they want to and it requires them to agree on words that mean the same thing to everyone in the building.

In a place like the Westminster Medical Group the path of a patient is long and it can take 12 or 14 months for the hair to grow back and for the skin to heal.

During those months the patient will ask questions and they will look at their old assessment and they will try to remember what the numbers meant. If the team has not kept the meaning of those numbers alive then the patient will start to make up their own meaning and that is when the trouble starts.

I have been trying to finish this point for a few minutes now and I know you probably have a lot of work to do but it is important to see that an assessment is a shared resource. It is like a map that a group of travelers use to get through a forest but if one traveler thinks the green lines are rivers and the other traveler thinks the green lines are paths then they will never meet at the end.

The clinic must decide who is the keeper of the map and who gets to update the key when the weather changes. If the technical staff only care about the numbers and the clinical staff only care about the surgery and the communication staff only care about the patient feeling good then the map becomes a mess of ink.

When you look at patient case studies you see the end result of a long process and you see the hair and the hairline and the way the grafts have matured. You do not see the hundreds of small talks that had to happen to keep the meaning of the plan on track. You do not see the moments where a surgeon had to explain that a digital scan is just a guide and not a law.

The Bird Nest in the Flue

“Antonio J.-C. told me once that he found a bird nest in a flue that had been there for five years and the owner of the house had a paper that said the chimney was fine. The paper was not lying but the paper was old and the meaning of the word fine had changed because a bird had moved in and made a home.”

– Observations from a Chimney Inspector

The digital world is full of bird nests and we keep holding onto our old printouts as if they are shields against the truth of change. We need a way to record our clarifications and our updates so that the next person who looks at the file knows what we know now and not just what the machine knew six months ago.

It is a quiet kind of failure when a team has all the data but no common voice. It is a failure of the institutional memory and it happens one missed note at a time. We think we are saving time by not writing down the nuances of a conversation but we are actually just throwing away the value of the assessment.

If the explanation of how a scan should inform a talk is nobody’s task then the scan becomes a weight instead of a wing. It sits in the file and it stares at the team and it reminds them that they once knew something that they have now forgotten.

I should let you go now because I have taken up enough of your morning but I want to leave you with the image of that staff room. Imagine the three people looking at each other and realizing that the paper in the middle of the table is a bridge that does not reach either side.

They have the advanced tools and they have the registered surgeons and they have the patient who is waiting for an answer. All they need is to decide who owns the story of the data. Once they do that the data becomes useful again and the patient can walk out of the door knowing that the meaning of their assessment is safe.

It is not a technical fix but it is the only fix that lasts for the whole 14 months of regrowth and beyond.

The ink on the report is a dry wall that keeps the surgeon and the patient from seeing the actual life of the graft.