What is “Complexity”?
We all have a lay understanding of complexity – the word describes a system or object that has many parts, the workings of which may be difficult to understand. But many systems that appear complex are merely “complicated” – their many components are well described and understood, at least by someone. A Smartphone is such a system. A system that is “complex” is one that is comprised of many interacting components or systems which behave and affect each other in unpredictable ways. In our world there are many such systems such the weather, the economy, and large software projects as discussed in previous posts. We use mathematics to describe, analyse and design many of the objects and systems in use in our world today. But “Complex” systems are nonlinear and unpredictable – they are not easily amenable to mathematical analysis. (See my article on Complexity and Software design)
Another approach to Complexity is to consider that systems , clinical issues, or even patients can be regarded as an interconnected web with components that affect each other.
““Everything hangs together” defines complexity; the Latin word complexus literally means interwoven—studying complex problems thus is the study of interconnectedness and interdependence.
This notion is reflected in the definition of a complex (adaptive) system: A complex (adaptive) system is “a whole consisting of two or more parts (a) each of which can affect the performance or properties of the whole, (b) none of which can have an independent effect on the whole, and (c) no subgroup of which can have an independent effect on the whole.””(ref)
Most current protocols and research are based on a convergent, “reductionist” approach to diagnosis and treatment. Indeed much of of our Clinical Reasoning uses such a process. While this approach may help to “solve” a particular clinical presentation or issue, it often does not describe or capture the essential elements of the whole patient. As Primary Care Practitioners, we all are familiar with the patient with multiple issues whose condition does not improve in spite of our best efforts over time. A complex system is at the root of most “wicked” problems – could Complex System thinking improve our management of these clients?
In recent years there has been increasing interest in studying complexity in Health and developing some techniques for approaching these problems.
The Principles of dealing with “Complex” problems
“Start with Awareness”
If we recognize that a problem is Complex as defined above, we can then adopt a different approach. The first revelation is to accept that we may not be able to “solve” the problem but there may be elements that we can change.
Elucidate relevant issues and their connections
To understand the problem we must map out and model relevant issues and how they affect each other. There may be feedback “loops” – changing one issue will affect another which in turn will affect the first issue.
In most “wicked” problems there are multiple layers of issues which can be arranged in a hierarchy. Some are in our immediate sphere of influence, some are “high level” issues over which we can have no effect. Many of these issues are “wicked” problems in themselves. Of course, this map will always be approximate and imperfect, but it is a useful exercise to improve our understanding and document the problem.
Identify issues or connections that may be amenable to intervention
Evolutionary rather than revolutionary change
In the study of large “complex” IT systems, Bar Yam (ref) advocated incremental change in different areas of the system over time rather than a “Big Bang” revolutionary change. This principle can be applied to all Complex problems, even down to managing individual patients in Primary Care
Ongoing review, testing and adjustment of our interventions
Of course this requires continuity. This may be achieved by an individual relationship or by a well structured means of communication between members of a team.
Applying these principles to “Wicked” problems
The Primary HealthCare System as a Whole
At the recent WONCA conference in Sydney one of the Keynote speakers (Prof Trish Greenhalgh) described Primary Health as a “Sector Suffering”.
Could we apply Complex System thinking to this “wicked” problem?
To start to understand the issues, she outlined three broad areas where the Primary Health sector is suffering using the Buddhist “Three Poisons” as an analogy – Greed, Hatred/anger and ignorance/delusion.
Greed as epitomized by the pig describes the “Commercialization of Health” which now dominates and corrupts policy, research and indeed the evidence on which our practice is based. In my view, this is an “Elephant in the Room” which we should acknowledge and start to address.
Anger/hatred is epitomized by the snake. Many in the sector are burnt out and disillusioned, politics is combative and paralysed by vested interests. Anger can be negative and destructive, but it can also be harnessed to create positive change.
The Rooster epitomizes ignorance and delusion. Those managing the sector such as bureaucrats and politicians are either ignorant or choose to ignore the advice from those working in the sector. In the workplace of organizations we should build a positive team culture with active communication between all members
Clearly this analysis is only the start of deconstructing the issues, but it gives a framework to work from. There are many layers of issues and interconnections, some of which may be amenable to evolutionary change.
Complex system thinking on a population level – eg “Obesity”
The developed world is getting fatter and this issue underlies many Chronic Diseases. Obesity appears to be a “wicked” intractable problem at both population and individual levels.
At another session of the WONCA conference, the participants were invited to describe the population problem of obesity using the principles of complex system analysis. It soon became clear that there are many layers to the problem with many interconnected issues. Currently our approach is to exhort the patient to “eat less” and “exercise more”. But from even a cursory analysis it becomes clear that it is simplistic to rely on the individual to remedy the issue – this alone is a useful conclusion.
The individual patient encounter
Is this approach applicable at an individual patient/consult level? Are patient encounters “Complex”?
In Medical School we were trained to recognize and manage the patterns of single issue illness. Most of our education since has been also on individual conditions and medications with little emphasis on managing the whole patient. Yet much of Primary Care Medicine now is involved with managing Multimorbidity (see my previous article). In addition to the multiple medical issues and client factors such as language, there are social and family pressures, and resource and financial limitations imposed by payors. In my view these encounters are indeed “complex”.
Managing individual multimorbid clients using the principles of complex thinking outlined above would mean:
Identifying the issues and the connections between them, particularly those that are amenable to intervention and that positively affect others. eg Weight loss improving Diabetes and Hypertension. General Practitioners have been doing this intuitively for a long time using the Problem Oriented Medical Record is a mechanism. A good record can overcome many of the problems associated with lack of continuity. But Electronic Medical Records suffer from poor interface design, administrative “noise” cluttering the record and imperfect utilization. (see Software Design in Health )
Recognizing that there is no single discrete solution to the patient’s problems.
Aiming for evolutionary change
Testing our interventions over time. Here we must recognize the value of continuity and a professional relationship.
If we accept that the management of an individual multimorbid patient is a “Complex” problem, then prediction of their progress and the interventions required becomes difficult or impossible, particularly in the long term. Our current systems of Chronic Disease management rely on “Careplans” of scheduled interventions, often years ahead, by relatively unskilled and often “anonymous” practitioners. This approach is especially prevalent in Australia in settings where there is high staff turnover and/or a disadvantaged population, such as Remote Health, Corrections, or Refugee Health. These clients have a high burden of Chronic Disease and Multimorbidity.
If we were to adopt a “Complex Systems Thinking” approach, it is likely in my view that their care could be improved.
References
Approaching Complexity – start with awareness
Joachim P. Sturmberg MBBS, DORACOG, FRACGP, MFM, PhD
https://onlinelibrary.wiley.com/doi/10.1111/jep.13355
Josephine Borghi, Sharif Ismail, James Hollway, Rakhyun E. Kim, Joachim Sturmberg, Garrett Brown, Reinhard Mechler, Heinrich Volmink, Neil Spicer, Zaid Chalabi, Rachel Cassidy, Jeff Johnson, Anna Foss, Augustina Koduah, Christa Searle, Nadejda Komendantova, Agnes Semwanga, Suerie Moon, Viewing the global health system as a complex adaptive system – implications for research and practice, F1000Research, 10.12688/f1000research.126201.1, 11, (1147), (2022).
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