Variability, continuity and trust – towards an understanding of uncertainty in health and health care

Increasingly we are moving from a world of problems – which demand speed, analysis and elimination of uncertainty to solve – to a world of dilemmas – which demand patience, sense-making and an engagement with uncertainty. Dilemmas span disciplines and frustrate attempts to craft elegant and final solutions. Dilemmas require a different orientation, decision process and set of skills. Senior Advisory Council (SAC) of the Global Environmental Management Initiative (GEMI) by the Institute for the Future (IFTF) Medicine struggles to shake off the belief in certainty. Faced with the collapse of the EBM-dogma even certainty fanatics are now acknowledging that the subjective interferes with the holy grail of truth as the basis for ‘clear cut’ decision making. Knowledge in medicine goes beyond simple physiological measures and morphological descriptions of healthy or diseased body parts. Knowing the person's perceptions and understandings, family, social and physical environments are of equal importance 1–3. Then there is the relational knowledge factor, knowing each other resulting from a stable doctor–patient relationship that leads to trust, is a prerequisite for healing and sense-making in an uncertain world 4–6. And lastly there is epidemiological knowledge, most people are healthy most of the time, and despite all the variability in clinical presentations, personalities and socioeconomic circumstances, most patient get better after a visit to their trusted general practitioner or family doctor without requiring any further interventions 7. The papers in this edition of the Forum on Systems and Complexity in Medicine and Healthcare illuminate some of the diverse ways of knowing in and about health and health care in the context of continuity of care and trusting relationships. In the first paper West 8 highlights that natural world phenomena distribute along log-normal curves with their typical long tail first described by Pareto. These non-linear distributions entail complexity, they are not homeostatic. The underlying variability in these distributions is a sign of health, not disease. Sturmberg et al. 9 approach the complex nature of the health systems and its interactions through a metaphorical perspective, ‘Music in the Park’. Health care systems are diverse in their settings, their services and their patients; diversity in attitudes, beliefs and preferences for health care require well-functioning health systems to be sufficiently self-organizing to manage disparate needs. Martin et al.'s 10 metaphor, ‘the evolving tree of knowledge’, argues that health systems need to be learning organizations. Katerndahl's paper 11, describing the health care utilization of patients with panic disorder, shows how patients’ perceptions about their problem impact on health care utilization. These findings should help to improve consultations to achieve amelioration of disease burden and reduction in unproductive/expensive health care utilization. The diverse nature of beliefs, trust, economics and family dynamics underpinning the behaviours of patients when being sick is illustrated by Sarkar and Sarkar12 in the context of paediatric emergencies in India. And finally Schneider et al. 13 shed light on the interrelationships of gender, the personal psychology of handling uncertainty and experience, on clinical decision making. What links the papers in this edition of the Forum can be summarized by VUCA, an acronym to describe volatility, uncertainty, complexity and ambiguity of conditions and situations. The origins of the concept go back to the military 14 in the late 90s, and shortly after emerged in the strategic leadership literature. Health professionals are leaders at many levels – in the consultation, their workplaces, their professional organizations, their community, etc. – and VUCA serves as a handy reminder how to enhance leadership through insight and foresight, and an understanding of individual and group behaviours (Table 1). Volatility, uncertainty, complexity and ambiguity perfectly describe the nature of the consultation, and the interactions within health care organizations. As practising health professionals we observe the volatility, or the rate of change, in consultations on a daily basis. A single consultation can turn the life of one patient around, whereas months of consultations show no appreciable improvements in another. Uncertainty clearly is a hallmark for primary care doctors, who are mostly confronted with early and undifferentiated disease, with chronic disease and with the issues surrounding the late stages of people's demise. Complexity, the interconnected nature of the problems on the whole patient, can easily be added to the defining characteristics of primary care, and certainly stands in sharp contrast to many of the issues that ‘single condition’ providers are confronted with. Ambiguity, the lack of clarity about the meaning of the illness experience, is a major stumbling block to achieving complete healing of the person rather than solely of the disease. VUCA also is an acronym that guides leadership action – you cannot predict the future, but you must make sense of it in order to thrive (Table 2). Vision, understanding, clarity and agility are attributes that succinctly describe the nature of interactions in complex adaptive systems. Vision drives the system, understanding and clarity reflect the processes underpinning the dynamics of the system, and agility highlights the networked relationships of the agents within a system. Leadership, seen in complex adaptive systems terms, is about facilitating change and progress; it is not about solving specific problems. Or, as Ronald Heifetz 16 put it, leadership is about facilitating the adaptive work that needs to be done, not about providing solutions.