Systems and Complexity Thinking in the General Practice Literature: An Integrative, Historical Narrative Review

Here’s an interesting survey article. My regular collaborator (a pathologist, special adivisor for planning for a large medical school and a complexity theorist — all one person I might add) has been subtly implementing such an approach for many years. What is unusual (and I think right) about the graphic below is that though all of the giants of the complexity are there, Varela and Maturana are not typically viewed in such company. Nice touch.



What Drives Continuing Evolution of Careers in Medicine and Healthcare?

This by my colleague and regular co-author from the UBCMJ | SEPTEMBER 2012 4(1). As you will see, Dave has a rather unusual quality of mind in that he has a philosophical sensibility and so many reference points that typically few with his training would have.


Two major phenomena have driven dramatic changes in medicine and healthcare careers over the past century. One critical factor has been the almost logarithmic increase in knowledge, a general phenomenon forcefully evident in medicine over the past decades. The other significant phenomenon relates to social and cultural changes with gradual development of more accepting attitudes in a diverse medical and healthcare workforce. Each of these is paralleled by consequential, organizational, family, and institutional changes.

Knowledge has expanded at about 2% per annum, compound, over the past 200 years, according to economic studies using translation of knowledge into productivity increases as a surrogate measure.1 Creation of new knowledge has also led to innovative translation with huge changes in medicine. Whereas 100 years ago a single brain, that of Sir William Osler, could be the primary repository of what was known then in medicine and write the comprehensive textbook “Principles and Practice of Medicine”,2 today, one single mind cannot contain all that is known in medicine. Accrediting bodies such as the Royal College of Physicians and Surgeons of Canada and the American Boards of Medical Specialities in the USA now recognize over two dozen specialities, each of which requires a whole career focus and is in itself a brain full of knowledge. This profound increment in medical specialities continues with new subspecialties proposed each year. Similar proliferation of roles have led to an expanded number of new professional careers in nursing, pharmacy, physiotherapy and occupational therapy, and other healthcare activities — unlike years ago where each was a single profession.

Nowadays, this requires collaboration facilitated by electronic communications with practitioners cooperating as inter–professional “communities of practice” in the best interests of patients. Additionally the patients and practitioners are now exposed to web based knowledge that accentuates the requirement for caregivers to also have immediate access to detailed current knowledge. It also emphasizes the need for all practitioners to use continuing education programs to maintain an up to date knowledge base! This, together with patient-rights initiatives, is gradually leading to a balance with physicians being seen as having expertise and authority over medical therapy and patients exercising more control over which options for care are implemented according to their preferences.3 This is, however, a very complex set of interdependent professional relationships and will continue to evolve long into the future.

Fifty to one hundred years ago, single, apparently omniscient physicians, nurses, or others with comprehensive knowledge in their specialty or practice often presented themselves as authoritative, occasionally irascible bosses with structural authority.4 Such prescriptive behaviours often occurred in operating rooms or emergency rooms where definitive verbal orders were given with instantaneous action and compliance expected of subordinate nurses and others. Nowadays, there are numerous knowledgeable practitioners, each more accustomed to assuming the role of helpful expert to assist their teams, who display their own extensive knowledge as “sapiential” or “personal”4 authority, a much more benign professional presentation.

From a social and cultural perspective over the past century, major cultural shifts in Western-oriented civil societies have occurred: perhaps as a result of two World Wars and post-recession episodic changes. Changes in traditional family roles has been one of these shifts, with more women in the workforce at senior level workforce positions. If one reviews the pictures of UBC Medical graduates over the past 60 years in the Webber MSAC Alumni room, the number of female graduates in the 1950’s was 5-10% each year whereas in current classes 50-60% of graduates are female. Also, the racial makeup of classes has changed to more closely reflect population numbers. To a degree, these shifts seem to reflect a more balanced perspective towards a civil society with a move away from authoritarianism, thus encouraging a more egalitarian professional situation.

All of these social, cultural, and epistemic changes have impacted the overall orientation of healthcare and medical practice. While always required, added emphasis is now placed on empathy, dependability, and integrity as attributes required of our graduates and coworkers in addition to an ongoing need for critical analysis and reasoning skills leading to measurable clinical competence. This is not to imply that a focus on social issues never existed. I can personally recall having a medical school course on social and cultural values in the 1950’s and still remember and utilize the concepts today of a required essay5 where I proposed a balanced civil society that valued individual freedoms. Condemned was the authoritarianism of the “soul–less”, and absolutist anarchic or regimented states!

A further cultural shift has been towards an increasing emphasis on the need for economic efficiencies. Indeed, in medical research, the requirement for effective “bench to bedside” translation is emphasized today with increasing calls for “ROI” or return on investment. This has led to the need for effective ethics review committees to protect patients’ interests6 and reduce pressures on medical researchers from undue market involvement of commercial entities such as pharmaceutical companies.7 A further problem arises with the increasing clash of professional and corporate interests. A professional by definition practices medicine to the standards of their profession in their community—not as an “occupational” working to the imposed standards of a boss!8 Pressure is exerted by some healthcare administrators for doctors to practice according to administrative budgetary requirements, thus being more efficient and perhaps less effective in care of their patients. A number of years ago at the Canadian Red Cross Blood Services, the physician in charge appeared to have rejected blood testing for donor blood infections due to testing costs on the orders of his funding agency bosses—in that case provincial government bureaucrats. His unprofessional behaviour was ultimately outlined in the Krever Commission Report.9 This led to him being professionally discredited, the Red Cross Blood Transfusion Service being terminated, and the Canadian Blood Services Agency being created.

In medicine, a major initiative that has had a profound impact is prevention of infectious diseases by immunization. This and other preventive measures have led to the survival of many who might otherwise have died. Now we are faced with an aging demographic, many of whom through excess nutrition and salt intake,10 suffer from obesity,11 hypertension, diabetes, and major cardiovascular issues. These will require additional attention in the decades to come!

So, what is the ultimate answer to the question posed at the beginning of this polemic? The enormous increase in medical knowledge, adapted to improve the quality of care of patients has led to an essential, major proliferation in types of healthcare providers. This in turn has led to significant shifts in professional relationships, not only of patients and doctors but also among healthcare providers. It is interesting to observe that such interdisciplinary activity is effected, based on a principle outlined by Adam Smith in the 1770’s as a significant concept of the Scottish Enlightenment—the Division of Labour.12 In that description, workers provided a defined activity based on their personal expertise and skill that built upon the different expertise and skill of other providers towards an ideal cooperative outcome. In Smith’s description, that outcome was the efficient manufacture of pins; in our current description for healthcare providers it is towards the optimum outcome of care for our patients in an increasingly complex healthcare environment. Cooperative inter–professional care will require greater provider empathy for all to understand and enable each other’s role in these complex, beneficent patient care related undertakings.


  1. Taylor T. Thinking about a “New Economy.” The Public Interest. 2001;143: 3-19.
  2. Osler W. Principles and practice of medicine. New York: Appelton;1892.
  3. Truog RD. Patients and doctors—evolution of a relationship. N Engl J Med. 2012 Feb 16;366:581-585.
  4. Paterson TT. Pay for making decisions. Vancouver, Canada: Tantalus Publications; 1981.
  5. Hardwick, D.F. Aldous Huxley and George Orwell: An assessment of their interpretation of their age and prognostications. Social and Cultural values course, unpublished term paper, Faculty of Medicine, The University of British Columbia, 1955.
  6. Millum J. Canada’s new ethical guidelines for research with humans. CMAJ. 2012 Apr 3; 184:657-661.
  7. Hardwick DF, Marsh L. Clash of the titans: when the market and science collide. Advances in Austrian Economics, Vol. 17. Bingley: Emerald;2012.
  8. Friedson E. Professional powers: a study of the institutionalization of formal knowledge. Chicago: University of Chicago Press;1988.
  9. Krever, Mr. Justice Horace. Commission of inquiry on the blood system in Canada (Government of Canada); 1997.
  10. Flegel K, Magner P. Get excess salt out of our diet. CMAJ. 2009 Feb 3.180(3);263.
  11. Eisenberg MJ, Atallah R, Grandi SM, Windle SB, Berry EM. Legislative approaches to tackling the obesity epidemic, CMAJ. 2011 Sep 20. 183(13);1496-1500.
  12. Smith A. An enquiry into the Nature and Cause of the Wealth of Nations – edited with introduction and notes by Edwin Cannan.New York:Modern Library;1994.p.1-13.

Experts and Epistemic Monopolies

Having just received copies of the book in which our paper appears, here is another excuse to plug both our paper and the rest of the book’s contents. Here is an extract from Roger Koppl’s introduction:

This volume contains papers given at the third biennial Wirth Institute for Austrian and Central European Studies Conference on Austrian Economics. The conference was held at a beautiful waterfront facility of Simon Fraser University on October 15 and 16, 2010. In spite of all warnings to expect fog and rain in the Pacific Northwest, the weather was sunny and mild, as were the spirits of the conferees. Our topic title, ‘‘Austrian Views on Experts and Epistemic Monopolies,’’ was perhaps a bit misleading because some of the views represented were not ‘‘Austrian.’’ Indeed, the editorial mission of Advances in Austrian Economics has been to promote dialogue between the ‘‘Austrian’’ tradition of economics and other traditions both within in economics and beyond. Participants discussed the problem of experts from several Austrian and non-Austrian perspectives. While representing different points of view, the participants did tend toward the view that experts may pose a problem in one way or another, especially when they enjoy an epistemic monopoly.


Science, the Market and Iterative Knowledge

The second paper co-authored with Dave Hardwick has now been published in Studies in Emergent Order:

Abstract: In a recent paper (Hardwick & Marsh, in press) we examine the recent tensions between the two broadly successful spontaneous orders, namely the Market and Science. We argued for an epistemic pluralism, the view that freedom and liberty (indeed the very concept of liberalism and civil society) exists at the nexus of a manifold of spontaneous forces, and that no single epistemic system should dominate. We also briefly introduced the concept of “iterative” knowledge to characterize the essentially dynamic nature of scientific knowledge. Herein lies a tension. The Market (and perhaps the prevailing culture at large) sees scientific knowledge in cumulative terms, that is, progressing to a conclusion in a linear fashion. This relatively static understanding of medical science as it relates to pharmaceutical studies can have a corrosive effect on the practice of medicine and ultimately, we believe, on the proper functioning of the market itself. In this paper we examine this tension in much closer detail by focusing upon the demands of the market, specifically the pharmaceutical industry, and the science upon which it is based. In other words, we expound upon a clash of epistemic value – one (science) that sees knowledge as essentially iterative (dynamic yet tentative) and the other (the Market) that harvests conclusive scientific knowledge (ostensibly as a fixed and firm commodity) functional to its own interests. Clinical Trials that are sharply focused with precisely determined deliverables often manifest this tension in the sharpest of relief. As a means of recovering drug development and testing costs, conclusive assessment is required to avoid creating serious financial problems for the companies themselves not to mention issues in the public interest.