Complexity and health – yesterday's traditions, tomorrow's future

‘If it is complex it means we don't really understand it, and the way forward is to break the problem down into its parts to make sense of it’. This thought reflects the way we have been taught, and the way we largely practise in clinical care every day. But are we really functioning on this basis? Or is it the only way we know how to live? We all experience situations every day where the evidence does not really fit our understanding of a problem – the familiar reductionist approach limits our ability to fully explore new problems and to gain new insight. An increasingly persistent question has emerged in relation to what constitutes the knowledge we need for effective and efficient clinical care, an issue taken up by this new Forum on Systems and Complexity in Medicine and Healthcare. The biomedical approach to medicine has given us a most detailed understanding of the anatomy and physiology of the normal and abnormal functioning of our bodies. Nevertheless, or maybe simply because of this success, is the ‘biomedical taking it apart method of medicine’ starting to fail our patients 1? Our understanding of health as absence of disease has further strengthened a longstanding dichotomous medical world view, a view that is strangely, though not unsurprisingly, foreign to our patients 2. Historically, health care emerged in hunter and gatherer societies in response to the experience that caring for the sick and injured improved their own survival. As caring for the sick became more sophisticated, the role of the shaman/medicine man evolved to include three functions – curing the sick, directing communal sacrifice and escorting the dead to another world. In today's society, we have separated these roles into three professions: the doctor, the priest and the undertaker 3. Although these functions are separated in modern society, they are still important functions expected by society and remain exceedingly important for the patients' healing. The word ‘health’ arose from the old English ‘hal’ meaning ‘whole’– healing is ‘becoming whole’. From its beginnings medicine had an important social function; restoring the health of the sick and injured enabled them to once again become fully functioning members of the community. In recognition of the importance of the healer, society granted him, at that time healers were almost always male, the privilege of not having to hunt; besides being fed, he often also received gifts. These social perspectives remain fundamental to our understandings of health, illness and care 4, 5. If our reductionist approach to medicine is the cause of the crisis in patient care, can more of the same lead to its solution 1, 6-9? In Albert Einstein's view the answer is an unequivocal ‘no’. A better understanding of more of the parts will further remove us from understanding the whole; or using system philosophical language ‘the whole is different to and more than the sum of its parts’. Engel, in 1977, already recognized the deficiencies of the reductionist project on medicine and proposed a system-based model of health care to counterbalance and complement the prevailing worldview – the now widely acknowledged but rarely practised biopsychosocial model of health care 10, 11. The notion of complexity, meaning that something is ‘complex’ if it is made of (usually several) closely connected parts, is not really new. William Osler already remarked in the late 19th century that ‘It is much more important to know what sort of a patient has a disease than to know what kind of a disease a patient has’12. He recognized the importance that factors other than identifiable pathologies were interconnected to the patient's health and health experience. The importance of the patient's health experience was the driving force for the Mayo Brothers too, not only in terms of the care needs for the patient, but also in regards to education, research and health care organization. It is this core value that reverberated through the clinic and helped it to emerge as one of the most highly regarded institutions in the world. Though neither Osler nor Mayo explicitly used systems or complexity language, they both clearly articulated the interconnected nature of the patient with his environment and the collaboration among highly qualified and motivated health care workers in an a fully integrated organization. Despite rapidly increasing biomedical knowledge about diseases and technological advances for treating those neither Osler nor the Mayo Brothers saw the need to separate the disease from the patient, the Cnidian approach. They embraced the well-proven Hippocratic traditions of the Greek School of Cos that saw the disease as inseparable from the patient 2. The best doctors have always tried to find the balance between these two ideas. The development of the patient-centred clinical method 13-15 and relationship-centered care 16 are yet other moves in the same direction. Medicine needs well-rounded practitioners who are comfortable with and conscious about making decisions in a particular context, and aware that variations in practice in any given situation is natural and to be expected 17. A key aim of the new Forum on Systems and Complexity in Medicine and Healthcare is to reinvigorate our traditional connections with the ‘complex messy world of health and disease’ as experienced by our patients and to strengthen the interconnected nature of thinking, knowing and acting in the field of health and health care. Knowing is complex 18; every issue we seem to know in medicine – and for that matter in general – is context sensitive and can be seen through another prism providing us with additional ‘frames’ of understanding. These ‘frames’ provide new mental structures that shape the way we see the world 19; systems and complexity science therefore offers an extension to understanding, rather than a panacea, to the current intellectual, therapeutic, organizational and educational crisis in medicine 8, 9, 18, 20, 21. Before exploring complex issues in health care, we need to revisit the lay term perceptions of the term complexity (Table 1). An essential concept of ‘understanding things’ arises from ‘seeing things’ in the context resulting from a number of individual components and their interactions. Kurtz and Snowden described four different states of relationships, three of the four we identify with easily – the ‘known’, where cause and effect relations are repeatable, perceivable and predictable; the ‘knowable’ where cause and effect are separated over time and space and ‘chaos’ where no cause and effect relationships are perceivable. The fourth state of relationships is ‘complexity’ where cause and effect are only coherent in retrospect and are not repeatable. We find this more difficult to comprehend 22 (Fig 1). In part, this may relate to the psychology of certainty and uncertainty. As Dörner has shown, when confronted with a complex problem we feel to not be fully in control as it is exceedingly difficult to hold all the relevant information about the problem in mind and to foresee the consequences of a particular decision for the whole. He demonstrated that this phenomenon is fairly universal and independent of subject matter knowledge or general level of education 23. The insight has emerged that complex problems can only be understood ‘after the event’, which can be infuriating particularly when we have to realize that we may have made the wrong judgements or decisions (Fig 1). Cynefin framework of sense-making. The indicates a causal agent; the ● indicates an effect agent. Solid lines indicate strong relationships between the agents; dotted lines indicate weak relationships between agents. Complex systems have been described in detail by Paul Cilliers in his book Complexity and Postmodernism – Understanding Complex Systems24. Living and social systems, including individual animals and humans, ecologies, economies and social institutions, are inherently complex. As much as each system functions in a specific context, they also share a number of general characteristics. Complex systems consist of many different components that interact in non-linear ways. They are open to their environment, and interactions occur at many different levels and influence each other through recursive feedback loops. Complex systems are self-organizing; pattern and organization develop iteratively through interactions among the system's components in the absence of any external supervisory influence, as is seen, for example, in the flocking behaviour of birds. Some simple rules for self-organization in human systems include shared values and principles, connectivity and feedback, dialogue, memory and interdependency. Importantly a complex system is not defined by its constituent components but rather by its relationships or patterns of interaction. As a consequence the behaviour of a complex adaptive system cannot be reduced to the behaviour of specific components and such is said to be emergent. Complex adaptive systems are dynamical. They change over time as a function of the flow of energy and information, they adapt to environmental pressures and evolve to new states 24. Table 2 illustrates common terms and provides examples from clinical practice and health system organization. As the many examples in Table 2 have illustrated many contemporary issues turn out to be perplexing and counterintuitive. As much as Newtonian science has helped in understanding mechanistic aspects of medicine, Newtonian science is not able to answer the dynamical and phenomenological questions challenging medical care and health care organizations. These questions benefit from the thinking and the approaches of complexity sciences. Complexity science is a way forward out of the reductionism that currently binds us. However, before blindly embracing a new path we should take stock of where we have come from and where we are going. In this context, we wholeheartedly agree with Isabelle Stengers 25 who emphasized emphatically that the discovery and study of surprising phenomena – like the observation that more intensive glucose control increases mortality 26 or increasing the dose of chemotherapy not improving therapeutic response or survival 27 or the large investment in health services not being matched by a similar magnitude of improvement in inequity between social classes 28– should not result in a rupture inside the medical sciences, but rather create the opportunity to entertain a different relationship with our past approaches – highlighting ‘openness, surprise, the demand of relevance, the creative aspect of the scientific adventure, and not reduction to simplicity.’ The intellectual challenges that researchers experience in medicine and health services at the beginning of the 21st century are no different to those experienced by researchers like Gallileo and Newton, Heisenberg, Currie and Einstein, and Weiner and Prigogine when trying to address the pressing new questions arising from the inconsistencies observed in their respected fields. The crisis in health care is probably better understood as the instability in the health care system. This provides an opportunity to study and understand the historical patterns and interactions of the current system and to apply that knowledge together with the workings of complex adaptive systems in order to explore meaningful ways forward for those we serve, as clinicians, health service planners, researchers into pathologies and teachers. To succeed in this endeavour, we need to explore how complexity approaches can provide different solutions to the problems in health care than the prevailing Newtonian ones. To this end, the new Forum on Systems and Complexity in Medicine and Healthcare provides a place for scientific debate and promulgation of research findings. It also offers a means to engage with those who struggle at the margins of the current system and who are looking for new ideas. The interactions in complex adaptive systems occur within their historical constraints that live on into the future. In terms of the health care system, our patients' elementary needs for care and understanding have not changed. We may have a better understanding of the tissue reactions that are associated with clinically defined disease entities; still, each disease entity occurs in a unique individual who experiences it in her unique personal way in her unique social context 2, 14, 29-31.

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