When you affect one part of a complex system you affect the whole in unpredictable ways. Knowing this about complex non-linear systems, how might medicine and healthcare move away from reductionist, linear approaches and learn to embrace complexity?
Health, wellbeing, or ill health don’t happen in isolation. A person’s past, present, predicted future, expectations and beliefs will influence how they respond to adversity or interact with their world. Life itself depends on the organism’s capacity to maintain its integrity. However, for reasons – biological (eg nutrition), psychological (eg adverse childhood experience, traumatic events) or social (low status, poverty, pooreducation) the body and mind may lose their ability to differentiate between what’s actually dangerous and what’s not, and so they respond inappropriately.
How might medicine and health-care move away from reductionist, linear approaches and learn to embrace complexity?
Even though this biopsychosocial picture is widely understood, very often psychological or social problems come to be ‘medicalised’. Opioids and anti-depressants,
for example, are more frequently prescribed to those living in poverty, often with health-negative lifestyles. Medicating their ill-effects does nothing to address the root problems which, though they obviously require intervention at the appropriate level, few doctors are able to provide. Complex, dynamic, organic systems are hard to get your head around; it’s much easier to simplify and compartmentalise even though we lose sight of the person we are supposed to be helping. This is bad for doctors as well as patients. Surely then the time has come for the medical toolkit to expand.
Linear pathways of care have measurable outcomes, clear boundaries with procedures and pathways to follow. But people and their lives are not like this. And the longer someone lives with long-term health problems the messier and more complex it gets. As a result, someone living with long-term health problems will often have multiple labels, each one with its individual care pathway, in ‘delivery systems’ unable to consider the whole or communicate between specialties. In large-scale industrialised medicine this all too easily happens. In fact, given how the NHS is structured and organised, this fragmentation is all the more likely. Faced with the overwhelming enormity of the problems society now must face, it is helpful to keep reminding ourselves that:
- complexity gives hope because it offers many avenues for change
- small changes to one part of a complex system can trigger a big overall effect
- simple changes can have a big impact.
Alleviation of symptoms and improved function are welcome of course, but long-term conditions present greater challenges still. Former public health director
Margaret Hannah has observed that ‘Recovery is not simply about function and the activities of daily living, but about personhood, identity, self-worth. So often in current healthcare the focus and attention is on functional improvement’ (Hannah, 2014). If, as this implies, longterm illness can be an opportunity to discover (perhaps for the first time in a person’s life) a sense of agency and a more fulfilled, meaningful, life, how then are practitioners to support such a recovery of identity and self-worth?
It will be important to create the right context for recovery to happen. The clinician/patient relationship is key. This relationship can be a powerful enabler of change if there develops mutual trust, respect, belief and kindness: where two complex beings engage, connect and interact, together making sense and finding meaning that would not be possible acting alone.
Recognising and respecting the struggling humanity of the person seeking our help is vital; to see them as people who have complex problems, not as difficult patients, not as a list of symptoms or labels. This involves looking after our own wellbeing because when we are stressed it’s communicated in our approach, body language, the way we speak, little things that people pick up on. It’s important to be fully present, aware and receptive. It makes the difference between reaching a shared understanding of issues and simply being seen as a source of medication. In a YouTube interview, Kieran Sweeney, a GP academic who died from mesothelioma in 2009, describes how medicine involves ‘being with people at the edge of their human predicament’. He talks about how any inadvertent small humiliations can add up – being instructed to ‘take your top off, get on the bed’ with no introduction, smile or humanity – to traumatise and humiliate a person when they are already at a low point. He also reminds us that ‘what’s routine for you will be a big life issue for your patient.
Patients long for doctors who comprehend what they go through and who, as a result, stay the course with them through their illness. A medicine practiced without a genuine and obligating awareness of what patients go through may fulfil its technical goals, but it is an empty medicine, or, at best, half medicine.