A Referral as Mirror of the System's Soul
A Short Reflection
Susanna Latham's masterful master's thesis on the radiological referral got me thinking about something fundamental about how our welfare systems actually function. We often talk about the physician's assessment or quality of care as if it were about isolated professions' performances. But what Susanna shows is something entirely different.
A referral - that administrative document that's supposed to be so simple - turns out to be a perfect X-ray of the entire system's complexity. By following the little referral from arrival to response, we get to see how enormously many actors actually must collaborate for healthcare to function.
The invisible work that holds everything together
Max navigating between different coding systems, Klara calling around to gather patient information, Charlie adjusting the grayscale of images - this isn't just support functions for the real healthcare. This IS healthcare. Without their knowledge, their improvisation, their ability to translate between systems that don't talk to each other, no diagnosis would ever be made.
It reminds me of my own reflection on permanency planning in child welfare. We talk about the child's best interests as if it were a simple decision a social worker makes. But in reality, it's the result of hundreds of small translations - between law and practice, between systems and human needs, between different conceptions of time and priorities.
Democracy in the everyday
When Ellis gets angry because radiologists want her to review 1500 referrals manually, when Klara lets a patient go ahead because they have a long journey - here we see democracy in practice. Not the formal democracy of policies and guidelines, but the lived democracy of daily trade-offs between justice and empathy.
This is what I've tried to capture in the discussion about Ancient Wisdom - that behind all our sophisticated systems are people making wise decisions every day. Decisions that never appear in any statistics but that determine whether the systems work or not.
The entire chain counts
Susanna's thesis shows that when we talk about evidence-based care or knowledge governance, it's not just about getting the right research to the right doctor. It's about an incredibly complex chain where administrators translate codes, technicians adjust machines, radiography nurses assess what's good enough, and radiologists formulate responses that others can understand.
Every link in the chain requires both technical precision and human judgment. Every step is both standardized and unique. This is precisely the complexity I've tried to capture when writing about the interplay between Human and Machine.
We can no longer talk about system failures as if systems were machines that broke down. The systems ARE the people. And the people use both their hearts and their computer programs to make it work.
A small referral - but it tells the story of our entire society.