Across all disciplines, at all levels, and throughout the world, health care is becoming more complex. Just 30 years ago the typical general practitioner in the United Kingdom practised from privately owned premises with a minimum of support staff, subscribed to a single journal, phoned up a specialist whenever he or she needed advice, and did around an hour's paperwork per week. The specialist worked in a hospital, focused explicitly on a particular system of the body, was undisputed leader of his or her “firm,” and generally left administration to the administrators. These individuals often worked long hours, but most of their problems could be described in biomedical terms and tackled using the knowledge and skills they had acquired at medical school.
You used to go to the doctor when you felt ill, to find out what was wrong with you and get some medicine that would make you better. These days you are as likely to be there because the doctor (or the nurse, the care coordinator, or even the computer) has sent for you. Your treatment will now be dictated by the evidence—but this may well be imprecise, equivocal, or conflicting. Your declared values and preferences may be used, formally or informally, in a shared management decision about your illness. The solution to your problem is unlikely to come in a bottle and may well involve a multidisciplinary team.
Not so long ago public health was the science of controlling infectious diseases by identifying the “cause” (an alien organism) and taking steps to remove or contain it. Today's epidemics have fuzzier boundaries (one is even known as “syndrome X”1): they are the result of the interplay of genetic predisposition, environmental context, and lifestyle choices.
The experience of escalating complexity on a practical and personal level can lead to frustration and disillusionment. This may be because there is genuine cause for alarm, but it may simply be that traditional ways of “getting our heads round the problem” are no longer appropriate. Newton's “clockwork universe,” in which big problems can be broken down into smaller ones, analysed, and solved by rational deduction, has strongly influenced both the practice of medicine and the leadership of organisations. For example, images such as the heart as a pump frame medical thinking, and conventional management thinking assumes that work and organisations can be thoroughly planned, broken down into units, and optimised.2
- The science of complex adaptive systems provides important concepts and tools for responding to the challenges of health care in the 21st century
- Clinical practice, organisation, information management, research, education, and professional development are interdependent and built around multiple self adjusting and interacting systems
- In complex systems, unpredictability and paradox are ever present, and some things will remain unknowable
- New conceptual frameworks that incorporate a dynamic, emergent, creative, and intuitive view of the world must replace traditional “reduce and resolve” approaches to clinical care and service organisation
But the machine metaphor lets us down badly when no part of the equation is constant, independent, or predictable. The new science of complex adaptive systems may provide new metaphors that can help us to deal with these issues better.3 In this series of articles we shall explore new approaches to issues in clinical practice, organisational leadership, and education. In this introductory article, we lay out some basic principles for understanding complex systems.