Systems and complexity thinking in general practice: part 1 - clinical application

Many problems encountered in general practice cannot be sufficiently explained within the Newtonian reductionist paradigm. Systems and complexity thinking - already widely adopted in most nonmedical disciplines - describes and explores the contextual nature of questions posed in medicine, and in general practice in particular. This article briefly describes the framework underpinning systems and complexity sciences. A case study illustrates how systems and complexity thinking can help to better understand the contextual nature of patient presentations, and how different approaches will lead to different outcomes.     

How to teach holistic care--meeting the challenge of complexity in clinical practice

CONTEXT: Removal of underlying pathologies through the application of science and technology alone will not restore a patient's health; that will require connecting with the person behind the disease. Being ill changes physical and social functioning, emotional well-being, and last but not least, it affects one's self-concept. It invariably leads to questions of the meaning and understanding of being ill, hence Pauli et al. (2000) termed the notion of a somato-psycho-socio-semiotic paradigm of health. OBJECTIVE: Understanding health in this context allows the conceptualization of health as a balance between these four domains. METHODS AND CONCLUSIONS: This paper describes, through a systems-based methodology, the translation of the somato-psycho-socio-semiotic understanding of health into a flexible teaching approach for students and in a postgraduate setting for registrars. This teaching mode, by making the different dimensions that affect a person's health transparent, has helped learners to rapidly progress towards our goal of becoming holistically practicing clinicians.     

A new clinical complexity model for the Australian Refined Diagnosis Related Groups

BackgroundThe Australian Refined Diagnosis Related Groups (AR-DRG) underwent a major review in 2014 with changes implemented in Version 8.0 of the classification. The core to the changes was the development of a new methodology to estimate the Diagnosis Complexity Level (DCL) and to aggregate the complexity level of individual diagnoses to the complexity of an entire episode, resulting in an Episode Clinical Complexity Score (ECCS). This paper provides an overview of the new methodology and its application in Version 8.0.MethodThe AR-DRG V8.0 refinement project was overseen by a Classifications Clinical Advisory Group and a Diagnosis Related Groups (DRG) Technical Group. Admitted Patient Care National Minimum Dataset and the National Hospital Cost Data Collection were used for complexity modelling and analysis.ResultIn total, Version 8.0 comprised 807 DRGs, including 3 error DRGs. Of the 321 Adjacent DRGs (ADRGs) that had a split, 315 ADRGs used ECCS as the only splitting variable while the remaining 6 ADRGs used splitting variables other than ECCS: 2 used age and 4 used transfer.Discussion and conclusionA new episode clinical complexity (ECC) model was developed and introduced in AR-DRG V8.0, replacing the original model introduced in the 1990s. Clear AR-DRG structure principles were established for revising the system. The new complexity model is conceptually based and statistically derived, and results in an improved relationship with actual variations in resource use due to episode complexity.     

Prevention of childhood household injuries: a controlled clinical trial.

Injuries claim the lives of more children each year than the next six leading pediatric disorders combined, and produce injuries that require medical attention for one in three children. In the preschool age group, 91 per cent of these accidents and over one-half the resultant fatalities occur in the home. This paper reports the results of a controlled clinical trial conducted to evaluate the implementation of a health education program intended to reduce the risk of childhood household injuries. The study population was randomly assigned into two demographically comparable groups. Only the experimental group mothers received an educational intervention consisting of a tutorial, home safety-proofing assignments, and follow-up. The homes of the two groups were later assessed for hazards during an unannounced visit by an interviewer who did not know to which group each home belonged. A home safety score mean for the two groups was almost identical. The program stimulated heightened interest and stated intent to improve, but did not result in actual reduction of household hazards. Active health education, as used and evaluated in this study, appears to have limited effectiveness when applied to home safety. Approaches such as "passive" measures may offer greater potential for household injury reduction.     

A commentary on the complexity of tinnitus management: clinical guidelines provide a path through the fog

There is a desire among many tinnitus researchers and clinicians for greater standardization in the assessment and management of tinnitus. In their commentary on the complexity of tinnitus, Hoare et al. have highlighted the need for strong evidence-based protocols. The authors make many valid and important conclusions as to the current state of clinical guidelines; they identify clear gaps in evidence and limited consensus as to clinical practice. While I agree with the bulk of their commentary there are a few areas where I will offer a counter view. In particular I will address their view that only high-level evidence has a place in forming practice guidelines for tinnitus.     

Internal complexity and environmental sensitivity in hospitals

Theory suggests that organizations should respond to external complexity with internal complexity. We examine whether "environmentally sensitive" hospitals are more internally complex than "environmentally insensitive" hospitals. Results show that environmentally sensitive and insensitive hospitals differed on three of the measures of internal complexity: goal complexity, strategic complexity, and relational complexity.     

A simple guide to chaos and complexity

The concepts of complexity and chaos are being invoked with increasing frequency in the health sciences literature. However, the concepts underpinning these concepts are foreign to many health scientists and there is some looseness in how they have been translated from their origins in mathematics and physics, which is leading to confusion and error in their application. Nonetheless, used carefully, "complexity science" has the potential to invigorate many areas of health science and may lead to important practical outcomes; but if it is to do so, we need the discipline that comes from a proper and responsible usage of its concepts. Hopefully, this glossary will go some way towards achieving that objective.     

Commitment and ambiguous complexity in scientific research

The manicheistic temptation of concluding that the good, but also the best science, is the science made by scientists morally and ideologically committed to alleviate both physical illness and health and social inequalities, would take us far away from the painful complexity of the mixture of good and bad, right and wrong, bright and obscure, and from the ambiguities and ambivalent situations that may originate from it, in which not only scientific research but our entire existence is soaked. The scientist should see very clearly his obligations toward society and his fellow humans in order to resist the ambiguous complexity where the interest for a scientific result can be exploited for ignoble purposes or, as Robert N. Proctor reminds us in his recent book "The Nazi War on Cancer", where "the routine practice of science can so easily coexist with the routine exercise of cruelty." Research committed to prevention and to the struggle for health and social equity was for quite a while successfully hampered by closing the financial channels and depriving it of the necessary means. The block by lack of funds has been replaced in recent times by a block by plenty through the attraction exerted on many scientists by availability of conspicuous and sure funds for research on themes chosen by the economic power.     

Prevention and health promotion in clinical practice: the views of general practitioners in Europe

BACKGROUND: Disease prevention and health promotion are important tasks in the daily practice of all general practitioners (GPs). The objective of this study was to explore the knowledge and attitudes of European GPs in implementing evidence-based health promotion and disease prevention recommendations in primary care, to describe GPs' perceived barriers to implementing these recommendations and to assess how GPs' own health behaviors affect their work with their patients. METHODS: A postal multinational survey was carried out from June to December 2000 in a random sample of GPs listed from national colleges of each country. RESULTS: Eleven European countries participated in the study, giving a total of 2082 GPs. Although GPs believe they should advise preventive and health promotion activities, in practice, they are less likely to do so. About 56.02% of the GPs answered that carrying-out prevention and health promotion activities are difficult. The two most important barriers reported were heavy workload/lack of time and no reimbursement. Associations between personal health behaviour and attitudes to health promotion or activities in prevention were found. GPs who smoked felt less effective in helping patients to reduce tobacco consumption than non-smoking GPs (39.34% versus 48.18%, P < 0.01). GPs who exercised felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs (59.14% versus 49.70%, P < 0.01). CONCLUSIONS: Significant gaps between GP's knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention in primary care.     

Scientific languages and the science of complexity

For centuries the goal of galileian and newtonian science has been the discovery of the universal laws of nature governing all natural phenomena. But, starting with the sixties of this century, advanced research has concentrated on the study of the characteristic aspects of irregular and unrepeatable evolutionary processes. Signs of this change are the rediscovery of Poincaré's results on the dynamics of non linear systems, and the extraordinary development of evolutionary thinking. Three properties characterize complex systems: the multiplicity of their levels of organization, the presence of self-referential loops of internal communication, and the irreducible nature of their past history to structural properties. The traditional cartesian gap between mind and body therefore falls down, as argued at length by the works of Gregory Bateson. His arguments are further strengthened by the neurologist Antonio Damasio in his book on reason, emotion and human brain, whose title is L'errore di Cartesio (The error of Descartes), where the negative consequences of this error on the development of science in general and on contemporary medicine in particular, are illustrated.