Complexity in medicine and healthcare: people and systems, theory and practice

To many colleagues working in health services research and public health policy, notions of ‘complexity’, ‘complexity science’, ‘complexity theory’ and ‘complexity thinking’ will be entirely novel concepts, far from immediately understood and in urgent need of clarification and explanation. But, as Sturmberg and Martin 1 point out in the first paper of this new Forum on Systems and Complexity in Medicine and Healthcare of the Journal of Evaluation in Clinical Practice, the basic notion of complexity per se is, in reality, hardly new. Osler, for example, is recorded as having emphasised that ‘It is much more important to know what sort of patient has a disease than to know what kind of a disease a patient has’2, illustrating the recognition that factors other than identifiable pathologies were interconnected to the patient's health and health experience and that ‘the whole is different to and more than the sum of its parts’; indeed, that a detailed consideration of the disease is inseparable from a detailed consideration of the whole person – or should be. But complexity science is not just about an individual's clinical condition and its optimal management. Whether visiting a primary care consulting room in a rural village on the one hand, or entering a tertiary referral clinic in a major university teaching hospital on the other, patients become rapidly subject to the influence of a multiplicity of processes and services as part of the healthcare system environment, few of which could be described as remotely simple in their nature. Thus, we see human individuals, inherently complex in terms of their characteristics of body, mind, spirit and social context, entering an inherently complex and multi-faceted organisational infrastructure. This is hardly major, revelatory stuff, of course. But the fact that there is little evidence to speak of which illustrates clinicians', healthcare scientists' and managers' concerns with the complexities of patient presentation and organisational functioning surely demonstrates the necessity for far more systematic study of systems and complexity in medicine and healthcare than has been conducted to date. The results of such scholarship and research have the potential to develop, separately and together, the theoretical basis of medicine, and of health services science and management, and thus to make a major contribution to the quality of patient care and to the effectiveness and efficiency of health services organisation, delivery, evaluation and development. So, if complexity science, as a relatively nascent discipline, is invested with such potential – and the JECP certainly believes it to be, hence the new Forum – then how are doctors and healthcare professionals dealing with complex clinical scenarios and organisational issues at the current time? For Sturmberg and Martin 1 the answer is clear and may be summarised as not very well. Why should this be? Clinicians, as a function of the way in which they have been taught, have an inbuilt tendency to break problems down into what are perceived to be their constituent parts in an effort to make sense of them, rather than trying to understand the complex relationships between them, so that this ‘reductionist instinct’, as it were, does not really achieve what it sets out to achieve. Indeed, Newtonian science 3, 4 is unable to answer what Sturmberg and Martin 1 refer to as the dynamical and phenomenological questions challenging medical care and health care organisations and it is these sorts of questions – integral to medicine and patient care – that benefit from the thinking and approaches of complexity science 1, 5. Indeed, reductionism and scientism have ill-served medical progress in recent years 6-16 and so if reductionist approaches in medicine are the cause of the current crisis in patient care and health services organisation, it is incontrovertibly the case that we do not need more of the same 17-23. Has the time not come, then, to move away from models determined to impose crudely simplistic thinking and decision-making processes upon complex clinical situations in attempts to manufacture simple answers to complex problems and to consider the value and benefits of newer, more rational approaches? 1, 5, 16. Complexity theory, science and thinking will, as they develop and are properly utilised, assist clinicians and healthcare scientists in dealing with some of their most intractable difficulties in day-to-day practice, difficulties that never have been, and cannot be, by their nature, understood and dealt with through simplistic linear thinking alone, but rather through a thinking based on a developed understanding of the relevance of non-linear, complex and multidimensional processes to patient care and healthcare systems organisation. In the first two papers of this new Forum on Systems and Complexity in Medicine and Healthcare, which are usefully read together, Sturmberg and Martin 1, 5 reflect on all of the above in considerable depth and provide an admirable account of the inescapable imperative to progress our understanding of complexity in medicine and healthcare, people and systems. Their intention is that the new Forum will contribute significantly to a reinvigoration of our traditional connections with the ‘complex, messy world of healthcare and disease as experienced by patients’ and to strengthen the interconnected nature of thinking, knowing and acting in the field of health and healthcare. In this way, the value of systems and complexity science can be seen for what it is – an extension to understanding, rather than the presentation of a panacea (as was the rhetorical and philosophical error of EBM), which can help address the current intellectual, therapeutic, organisational and educational crisis within modern medicine. The emerging research agenda considered by the authors is at once challenging, but also exciting and it's potential to develop the effectiveness of medical practice in 2009 and beyond, appears clear. The inclusion of a further five articles 24-28 within the current issue constitutes, then, the first Forum, with subsequent fora presenting a range of scholarly papers focussed on mathematical dynamics and clustering, philosophical analysis, narrative research, economic evaluation, health policy analysis and health professionals' education. The JECP looks forward to the publication of these works in its pages and congratulates Drs. Martin and Sturmberg on their vision and commitment as joint editors of this important new initiative.