Clinical and Health Affairs
Complexity Science
Core Concepts and Applications for Medical Practice
By Ashok M. Patel, M.D., Thoralf M. Sundt III, M.D., and Prathibha Varkey, M.D.
Abstract
Complexity science is a useful construct for physicians trying to cope with the escalating sophistication of health care and pressure to control costs. The science of complexity suggests that outcomes are not always linear or predictable. Physicians need to learn to expect unpredictability, respect autonomy and creativity, and be flexible in responding to emerging patterns and opportunities. Assessing and managing complexity in the health care environment involves understanding why medical practice is a complex adaptive system and how to work within such a system to achieve the best outcomes. The goal of this article is to help physicians understand the basic concepts of complexity science and how they might be applied to medical practice.
Providing high-quality, cost-efficient care to patients and their families is a complex endeavor. Every patient is different and may respond differently to a particular treatment. The physician’s job is to help each patient make informed decisions about their options. But that task is complicated as scientists discover new illnesses and treatments; as fields such as genomics, proteomics, and bioinformatics offer new tools for understanding the mechanisms of disease; as budgets shrink; as policies and guidelines change; and as patients have greater access to health care information and treatment options.1,2
The partnership between patients and their physicians remains the centerpiece for ensuring that individuals get the most accurate information and best care possible.3 Increasingly, the physician’s role in the relationship is to be a coordinator of care: to organize and mobilize appropriate resources including physiologic data, medications, devices, and the services of nurses, therapists, and allied health professionals. When patients have complex or multiple medical conditions such as diabetes, COPD, and depression, caring for them also demands interprofessional collaboration.4-6
The science of complexity may be a helpful construct for understanding some of these dynamics of medical practice. The goal of this article is to help physicians better understand the basic concepts of complexity science, how they apply to the process of caring for patients, and why medical practice is an example of a complex adaptive system.
What is complexity science?
Complexity science is the study of nonlinear, dynamic systems and the process of self-organization. It is a field derived from multiple disciplines—physics, chemistry, biology, and mathematics. Definitions of complexity are often tied to the concept of a complex system—something with many parts that interact to produce results that cannot be explained by simply specifying the role of each part. This concept contrasts with traditional machine or Newtonian constructs, which assume that all parts of a system can be known, that detailed planning produces predictable results, and that information flows along a predetermined path. Elements of complexity theory have been incorporated into a number of fields including genetics, immunology, cognitive science, economics, computer science, and linguistics. Currently, the most robust research in complexity science involves the study of inanimate systems such as computer networks and hydrodynamic systems as well as certain cellular networks.
A complex system, as a whole, exhibits emergent properties that can only be understood within the context of the entire system and that system’s relationships with other systems. Order emerges at a global level; but often, it is the outcome of many interactions following simple rules at local levels. As the level of complexity increases, the observed phenomena exhibit properties that do not meaningfully exist at a lower level.
The degree of difficulty in predicting the properties of a system when the properties of a system’s parts are known defines the level of complexity of a system.7 Disorganized complexity is a system that appears random, out of control, or far from equilibrium. It may be what a physician experiences during the initial encounter with a new patient, when there is no prior knowledge of their needs, health status, or social circumstances. It is a system out of balance. Organized complexity is a system that has a more recognizable pattern and may be in dynamic equilibrium. Fractals are an example of organized complexity. The pattern or structure of the whole is repeated within the parts, either exactly or approximately, at different scales. In physiology, fractals appear as spatial structures; eg, the branching patterns of the airways. Living systems are another example of organized complexity, and living systems theory is often used to describe structures, interactions, behavior, and development at various levels of organization.8 In medical practice, physicians might strive to organize complexity by developing checklists and protocols, automating processes, or developing prediction models. Examples of complexity science applications are emerging in critical care medicine, in caring for people with multiple chronic conditions, and in primary health care.6, 9,10
Complexity Science and Medical Practice
Health care in this country can certainly be considered a complex system in that it is nonlinear, dynamic, and in a state of constant self-organization. Complex adaptive systems are systems that change or adapt their structure to meet demands that arise from outside or within. Medical practice can be considered a complex adaptive system, as patients, physicians, health educators, and others must interact with and adapt to the constant changes in the health care environment.11 Complex adaptive systems have 7 main characteristics (Table).12 The following are examples of how these characteristics relate to medical practice:
1. Processes may not be linear and systems have fuzzy boundaries. Fundamentally, caring for a patient involves learning about a person’s symptoms and needs; identifying gaps in knowledge, skill, or attitude that require further research or assistance; and then compassionately sharing solutions with patients and others. Viewing this set of responsibilities through the lens of complexity science, we recognize that one provider cannot possibly understand all of a patient’s needs and expectations, have all the necessary knowledge and skill, or discover all of the possible solutions. Thus, teamwork and collaboration have become necessary. Yet there may be boundary issues when physicians work with multiple providers, particularly when cases are complex. For example, caring for an obese patient with asthma, obstructive sleep apnea, diabetes, and hypertension may require therapy that targets each condition at the same time and involve a number of people from within and outside the medical community. Deciding who addresses which issue may be difficult, and clarity about roles may get blurred.
2. Complex adaptive systems are embedded within other systems and may change along with other parts of a larger system. This concept helps explain why medical mistakes need to be addressed at the system level. Medical errors usually occur as a consequence of many elements in a system. So in order to address a particular problem, it is important to examine it within its system. If a perfusionist, for example, makes a mistake adjusting the temperature of the arterial inflow during a cardiopulmonary bypass procedure, simply admonishing the individual will not be enough to ensure patient safety in the future. Hence, to ensure that the error does not occur again or to prevent a similar one from happening, one has to understand the systems in which the perfusionists and surgeons work. Correcting mistakes one perfusionist at a time will be far less effective than changing the system—the protocol used by all perfusionists and/or surgical teams.
3. Tension and paradox are normal. The pull between competing forces is not only normal, it can lead to positive outcomes. The creative tension between competition and cooperation, or the need for consistent, universal evidence-based standards of care versus the need to address a patient’s individual situation have encouraged many novel ideas including the development of electronic health records and expert decision-support systems. With health care costs rising, there is a tension between the goals of providing health insurance coverage for all and funneling resources into innovation and caring for people with special needs. Leaders of complex systems must learn to manage such tension.13-15
4. Change happens as a result of catalytic events. Complex adaptive systems change in response to challenges. But because these systems naturally have some resistance to change, stressors often need to be significant such as a disaster or other cataclysmic event. For example, the tornado that hit Olmsted County in 1883 prompted the creation of Mayo Clinic. Only when the tornado made it apparent that there were not enough hospital beds to meet the needs of the population did the health care system respond. More recently, the I-35 bridge collapse in Minneapolis has compelled state government leaders, engineers, health care providers, and emergency responders to re-evaluate road safety, the condition of bridges across the nation, and disaster preparedness.
5. Small changes may have a big impact over time. Because of their cumulative effect, a series of small, single actions may eventually cause important reactions. For example, a patient’s long-term success at smoking cessation may be the cumulative result of prior attempts to quit as well as multiple instances during which a physician or other health care provider offered advice. But small changes may also be more challenging to make in a complex system. For example, requiring all staff to wash their hands before interacting with patients may seem like a goal that’s easy to achieve. But in the context of the complex adaptive system that is a hospital, such a change is not so simple to implement because of the myriad processes, personalities, and interactions that occur within the larger system.
6. Emergent properties arise in response to new agents or de novo perspectives. Emergence is hallmark of complex adaptive systems.16 Novel and unexpected structures, patterns, or processes spontaneously arise. Such unpredictability can lead to positive change.17 For example, the emergence of a new disease might lead to a novel approach to treating or preventing it and similar diseases. We might develop a better disaster-response plan or invent a new vaccine. An error might inspire development of safer, more efficient protocols that can prevent future errors. Building a diverse network of cross-functional teams offers the opportunity to develop such novel solutions.
7. Organization happens through the application of simple, locally applied rules. In response to the needs of their patients and to lessons they learn on the job, health care providers will create simple principles for structuring their work. At Mayo Clinic, for example, the practice structure and work environment have been organized around the simple goals of promoting peace of mind and healing for patients. Core values and principles such as for collegial, multispecialty teams; unhurried examinations; and respect for the patient and his or her family have emerged from this to shape the overall culture of the organization.18,19
Conclusion
Complexity science is a useful construct for understanding why caring for patients or designing systems for health care at the community or national level is so difficult. It is important to recognize that complexity science does not provide all of the solutions for the problems of health care. Rather, the study of complexity and complex adaptive systems reveals why having limited knowledge is unavoidable.20 However, the study of complexity helps us better describe the interactions between parts of systems while suggesting a more realistic range of expectations. When we acknowledge our limits, we may be more open to using innovative tools to achieve our goal of helping maintain and improve the health of individuals, organizations, and communities.
To cope with escalating challenges in health care such as information overload, changing health policy, and emerging diseases, physicians need to learn to accept and expect unpredictability and uncertainty, respect autonomy and creativity, and be flexible when responding to new opportunities and situations. They need to see medical practice as a collaborative endeavor, where partnership with patients, families, and other providers lead to evidenced-based solutions. By understanding and applying these principles from complexity science, physicians and others will be better prepared to respond to future challenges. MM
Ashok Patel is in the Division of Pulmonary and Critical Care Medicine, Thoralf Sundt is in the Division of Cardiovasular Surgery, and Prathibha Varkey is in the Division of Preventive, Occupational, and Aerospace Medicine at Mayo Clinic.
The authors are indebted to Dianne Axen, Renee Bergstrom, Amit Ghosh, Celia Kamath, Bhavesh Patel, Julie Prigge, Judy Samson, and Colleen Sauber for their assistance in reviewing this manuscript.
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