HC Paradigms

In March 2014 Health Secretary Jeremy Hunt urged the National Health System (NHS)  in England to reduce the number of serious mistakes being made and save 6,000 lives over the next three years. Mr Hunt said NHS trusts should draw up plans to halve “avoidable harm” such as medication errors, blood clots and bedsores by 2016-17.

Doable? Yes, but only if there is paradigm shift  and the Healthcare system is treated not as a machine in a factory but as a Complex Adaptive System. This diagram from William Rouse’s article displays the HC intelligent agents acting autonomously and therefore, often with conflicting goals.

HC as a CASTo survive,  new behaviours emerge as the agents learn to adapt.  Those who can’t change die while others thrive through by collaborating. Rules change as new norms that are more attractive supplant them. Unlike a machine, CAS agents and system co-evolve.

As described in the Berkana Institute video, the guardians of the dominating HC machine bureaucracy will resist and attempt to crush the emergence of new ideas in order to maintain command and control. But in a CAS, there really is no one in control; influential power is more important than authoritative power.

Another paradigm shift required is moving away from measures focused on outcomes to measures focused on impact. Saving 6,000 lives over 3 years is an outcome. No one in their right mind would deem saving 5,999 lives was a failure because the target wasn’t met. Many of us have been trained to think: “What gets measured gets done” which holds in the Complicated domain. However, in the Complex domain, the non-linear phenomenon called emergence can happen and outcome targets go out the window,

Tipping PointMalcolm Gladwell in his book The Tipping Point captured several stories where adding more and more finally led to a change in the system. An idea, trend, or social behaviour goes viral.

Monitoring impacts will mean better managing of emergence (i.e., accelerating or dampening it) in a CAS.

Shifting the HC Paradigm: Complexity-based Medicine

The following are extracts from a blog posted on the International Clinician Educations Network.

1. What is complexity science?

Complexity occurs when many connected parts are intertwined. The clinical consultation is a good example of complexity. As part of the consultation, the clinician, patient and others (e.g., family members, social service agencies, media etc.) interact. It is through their interaction that the course of action emerges; a course which may be non-linear and unpredictable.

2. Why is complexity science important?

In healthcare we are surrounded by CAS. For example, at the level of the individual, health is a quality that emerges through the interaction between physical, emotional and social experiences. As already described, the clinical consultation can also be characterized as a CAS where numerous participants interact to produce healing. The healthcare system itself consists of multiple interacting agents such as hospitals, clinics, nursing homes, patients’ homes, health care providers, families and patients. Complexity science is important because it provides a way of making sense of the authentic world: dynamic, unpredictable, emergent, evolving and adaptable.

3. What challenges does complexity science present?

Typically, in trying to understand these systems, the approach has been to examine the individual parts. Such a ‘reductionistic’ or ‘mechanistic’ approach has its limitations; understanding the parts does not necessarily explain how the system functions as a whole. For example, although much is now known about the structure and sequencing of DNA, we still have limited understanding as to how a specific disease is triggered. What is required is a shift to examining overall system behaviour. Complexity science, with its emphasis on examining the relationship among parts, provides this focus.

4. How does complexity science apply to the CanMEDS Roles?

[CanMEDS is an educational framework identifying and describing seven roles that lead to optimal health and health care outcomes: medical expert (central role), communicator, collaborator, manager, health advocate, scholar and professional.]

Under conditions of complexity, knowledge is an uncertain and emergent phenomenon. This perspective has implications for each of the Roles. For example, in the Medical Expert Role, complexity requires the physician to be able to deal with uncertainty as part of the clinical consultation. Under conditions of complexity, clinical practice is described as being ‘emergent’ where treatment is not a static, single act, but rather becomes the accumulation of small acts which are continually revisited and reassessed on an ongoing basis.

It is important to acknowledge that not all situations exhibit characteristics of complexity. For example, in the clinical consultation complexity is minimized where there is a high degree of certainty about the correct course of action and agreement among the individuals involved. And so, it is important to note that complexity science is meant to complement, not replace, other (e.g. reductionist) ways of analysis.

Since 1990 Dr. Vivian S. Rambihar,  Adjunct Assistant Professor Medicine, University of Toronto has  been advocating for complexity thinking for medicine, health and medical education. He remembers how complexity emerged from chaos science, which was popularized by James Gleick’s 1987 book “CHAOS: Making a New Science”. Back then the terms chaos and complexity were often used interchangeably.

A proposal was sent to the Lancet Commission on Educating Health Professionals for the 21st Century. The aim is update evidence-based medicine with newer 21st century complexity science ideas.  These ideas were also presented at the 2014 Association for the Study of Medical Education Annual Conference (ASME) Brighton UK.

As a cardiologist, he has published  a few books and written several articles on the subject:

• “Using Complexity Science in Community Health Promotion: novel perspectives and a tool for change”: the last chapter of the “Complexity in Healthcare Organization: a view from the street”

• “Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world”  easy to read almost page per topic format, more like 200 blogs on complexity in medicine, health, science, society, peace, economics, development, humanity, etc. Inspired by the 2004 tsunami, updating our ideas to 2004

•“A New Chaos Based Medicine Beyond 2000” short chapters on Medical Education

• “A mathematical (chaos and complexity) theory of medicine, health and disease: refiguring medical thought” p273-7 of the ”Tsunami book”, written with Michael Baum, Professor Emeritus in Medical Humanities at UCL, UK

• “Millennium Heart @2000: Of Meteor Showers and Butterfly Metaphors – choice, chance and change for a fractal world” p154-62 of the ”Tsunami book”, a physician perspective of complexity and heart disease, reflecting on the history and science of medicine

• “Chaos: a new art, science and philosophy of medicine, health…and everything else” no links

• “From Cos to Chaos and From Cos to Cosmos”, reflecting on the origin and emergence of medicine and medical education,  no links

• Letters to the Editor include:

– Age of complexity, Canadian Family Physician
– Response to Evidence Based Medicine is Broken, BMJ, suggesting updating EBM with 21st century complexity science
– Response to Evidence Based Medicine – an Oral History, BMJ, proposing Complexity Based Medicine updated Evidence Based Medicine
– Complexity: the science for medicine and the human story, Lancet
– Complexity science may help in defining health, BMJ

 Related References

Eoyang GH, Holladay RJ. 2013. Adaptive Action: Leveraging Uncertainty in Your Organization. Stanford, CA: Stanford University Press.

Fenwick T. 2012. Complexity science and professional learning for collaboration: a critical reconsideration of possibilities and limitations. Journal of Education and Work. 25:141-162.

Hafferty FW, Castellani B. 2010. The increasing complexities of professionalism. Acad Med 85:288-300.

Johnson S. 2001. Emergence: The Connected Lives of Ants, Brains, Cities and Software. New York, NY: Scribner Publications. IBM Systems Journal 42(3):462-483.

Kernick D (Ed.) 2004. Complexity and Healthcare Organization. Oxon, UK: Radcliffe Medical Press.

Lingard L, McDougall A, Levstik M, Chandok N, Spafford MM, Schryer C. 2012. Representing complexity well: a story about teamwork, with implications for how we teach collaboration. Med Ed 46:869-877.

Lipsitz LA. 2012. Understanding healthcare are a complex system: The foundation for unintended consequences. JAMA 308:243-244.

NAPCRG. North American Primary Care Research Group. 2009. A complexity science primer: What is complexity science and why should I learn about it?

Sturmberg JP, Martin CM. (Eds). 2013. Handbook of Systems and Complexity in Health. New York, NY: Springer+Business Media.

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