Challenges of implementing complexity in healthcare

Abstract

Complexity is a form of system that is relevant in virtually all aspects and levels of healthcare. The importance and relevance of the science of complexity for healthcare has been written about extensively for over two decades. The problem this article addresses is that complex systems and how to manage them still appear to be relatively unknown nor well understood by most stakeholders of healthcare. The ignorance of complexity science includes multiple dimensions of healthcare, including frontline practitioners, support staff, and healthcare administrators. An additional challenge is to also involve policy-makers, and indeed the general public in advancing their appreciation of how this still evolving field of study can improve healthcare efficiency and outcomes. A third challenge is acceptance and willingness to embrace complexity. This article discusses a framework for evaluating complexity acceptance, as well as the unique challenges that the existing healthcare infrastructure and culture exhibit that are hindering adoption of complexity. Suggestions are put forward for further exploration and consideration.

Introduction

Complexity is a form of system that is relevant in virtually all aspects and levels of healthcare. The importance and relevance of the science of complexity for healthcare has been written about extensively for over two decades. ¹ The problem this article addresses is that complex systems and how to manage them still appear to be relatively unknown nor well understood by most stakeholders of healthcare. The gaps between the relevance of healthcare complexity, the lack of understanding of complexity, as well as the limited acceptance of complexity tools, tactics, and thinking, lead to ineffective courses of action. The ignorance of complexity science includes multiple dimensions of healthcare, including frontline practitioners, support staff, and healthcare administrators. An additional challenge is to also involve policy-makers, and indeed the general public in advancing their appreciation of how this still evolving field of study can improve healthcare efficiency and outcomes. A third challenge is acceptance and willingness to embrace complexity. This article discusses a framework for evaluating complexity acceptance, as well as the unique challenges that the existing healthcare infrastructure and culture exhibit that are hindering adoption of complexity. Suggestions are put forward for further exploration and consideration.

Compared to the discipline of medicine, complexity science and systems thinking are relatively new fields of study. However, complexity science is a rapidly developing field in both the social as well as the natural sciences with a wide range of implications specific for healthcare.^2,3 There are three major types of systems relevant to healthcare. Those systems are simple, complicated, and complex. ⁴ Additional systems are wicked problems and chaotic systems. These latter two system forms are of limited applicability to the medical profession currently due to their specific nature.

Historically, the medical and biological sciences have explicitly or implicitly acted as if all relevant issues are complicated. Since the 1970s, a broader approach to systems thinking has evolved, with complexity science becoming more prominent, in part, due to the rise of computing power completing many of the more mundane simple and complicated tasks in a variety of professions. Although extensively studied for applications to healthcare, knowledge, recognition, and implementation of complexity science seem to be lagging amongst healthcare practitioners and administrators.

Complex systems may arise when agents (for example, cells, viruses, human organs, humans, medical professional, healthcare administrators, policy-makers, and the general public) can interact (for example, through contact, through meetings, and via social media) and can adapt (change their chemical make-up or structure, change their opinion, or change their habits). ⁵ These three conditions for complexity, (agents, connectivity, and adaptation) exist at many different levels of medical care and administration. They may exist at the chemical level, cellular level, organ level, and at the individual human level. Furthermore, and perhaps most importantly for the importance of complexity in healthcare, the three conditions also exist at a societal level.

The reason that an acceptance of complexity is important and is that complexity exhibits unique characteristics quite different from simple or complicated systems. Among these characteristics are the properties of emergence, adaptation, self-organization, non-linearity, nested systems, and unpredictability. ⁶ Complicated systems meanwhile exhibit very different traits such as linearity, predictability, and reducibility that are more commonly thought of as the basis of medical science. Furthermore, complex systems require a very different form of management and a different expectation of outcome control.^7,8 Complex issues need to be managed in a much more holistic manner than complicated issues which can be managed in a reductionist manner. This management difference has relevance for not only patient level care, but also at the level of healthcare administration.^9,10

The experience of COVID-19 provides a specific example of the multidimensionality of complexity. COVID-19 exhibited traits of complexity (emergence, adaptation, inflection points, and social organization as opposed to central control) at the virus level, at the individual patient level, at the hospital and public health level, and even at the global societal and political level. Furthermore, a little thought will make clear that each of the levels affected the actions and outcomes at each of the other levels. COVID-19 provides a vivid demonstration of the multidimensionality of a complex system.

It is important to note that many healthcare issues are composed of a variety of system types. Elements of patient care will be complicated, and other parts will be complex, while other parts may be simple in nature, or even chaotic or wicked. The same is true of healthcare at the organizational and social levels. Each type of system needs to be managed in an appropriate manner, and in a way that is cognizant of the other systems involved. ¹¹ This requires management that is much more holistic than just complicated style solution implementation. As will be discussed, complexity is not amenable to “solutions” per se and requires a more nuanced, “manage, not solve,” or “try, learn, adapt” set of approaches. ¹²

A framework for analyzing complexity acceptance

Complexity acceptance or more generally systems thinking acceptance requires two key dimensions. These two dimensions are awareness or knowledge about complexity and, secondly, a willingness to adapt a complexity mindset. Using these two dimensions, the matrix, shown in Figure 1, has been proposed to analyze the preparedness of professionals to manage within a complex system. ¹³

Figure 1.

Complexity acceptance matrix.

The four quadrants represent the characteristics of the relevant stakeholders in healthcare. The ideal is those agents who are already in Quadrant 1. They are not only knowledgeable about complexity, but also have a willingness to enact complexity ideas and complexity thinking.

Professionals in Quadrant 2 are those who may not have a complete or even partial understanding of complex systems, but using intuition perhaps developed through experience, act as if they do. They demonstrate complexity thinking in their actions, despite a lack of explicit knowledge of complexity. This is an acceptable method to manage healthcare but could be improved and possibly made more effective through deliberate actions developed using more explicit knowledge of systems thinking and complexity and the management techniques coming from the research in this field.

Those in Quadrant 3 have neither knowledge of systems and complexity thinking nor do they exhibit a tendency to instinctively act in a manner that is consistent with systems thinking. Given their lack of education or awareness of complexity, there is at least the potential for them to learn and subsequently develop a complexity mindset. It is possible that they will become quick adaptors of complexity thinking. It is likely that the majority of healthcare professionals fall somewhere in or near Quadrant 3.

Medical professionals in Quadrant 4 are those who have been trained in complexity science but for a variety of reasons choose not to embrace systems and complexity thinking. They pose the most troubling, as well as the most challenging, hurdle to complexity implementation. While the number of healthcare professionals who fall into Quadrant 4 is likely small, the reasons for their reluctance to act with complexity thinking need to be analyzed.

It should be noted that the framework can also be applied to the multiple levels of the healthcare profession. It can be applied at the frontline medical practitioner, at the healthcare administrative level and at the politician level. While it is more nuanced, the framework can be especially useful when thinking about complexity acceptance at the public level or the cultural level. The central building blocks of complexity (agents, who can interact, and who can adapt) is particularly strong at the social or cultural level. Again, the diverse global experience of COVID-19 was a dramatic illustration of this.

Challenges of complexity acceptance in healthcare

There are common challenges of complexity acceptance in a variety of professions. These include education, tradition, and culture of many professions.

The first common issue limiting the adaption of complexity techniques is the commingling of terms complicated and complex. To all but a systems practitioner, the terms complicated and complex are fungible. Indeed, even dictionaries assume that the terms are synonyms. However, in systems science, complicated and complex systems are very distinct, with very distinct properties, characteristics, and techniques for management.

In healthcare, this commingling of the terms exists at almost all levels from medical practitioners, researchers, administrators, consultants, policy-makers, and, perhaps most significantly, in the general public. Even when a group is aware that the situation is complex, they often do not have the communal knowledge to appreciate the difference, and thus when a specific issue is labelled “complex,” it is often implicitly understood by most to be “complicated.” This leads to demands for complicated type solutions, which are often the worst or at best very ineffective methods of management for complexity. This is an issue not only of education but also of communication and attitude or cultural norms.

The most common challenge is that of embedded complicated thinking. Traditional education has focused on knowledge as the basis of a profession. Complexity management changes the dialogue away from knowledge to flexibility and adaptability. This presents a challenge to healthcare traditions. ¹⁴

The embeddedness of knowledge is a special part of the culture of medicine and particularly practitioners and in the mind of the general public. Medical school education focuses heavily on educational assessments and standardized test scores. Licencing exams enhance the knowledge ethos. Medical dramas, a television staple, continually embed the image of doctor as savant, while the news and social media trumpets medical science and pharmaceutical breakthroughs. This public perception may be reinforcing practitioner’s perceived need to respond with a complicated mindset.

The science of medicine has benefited greatly from complicated thinking. It is the complicated thinking of traditional science that has produced great leaps forward of knowledge in diagnosis, treatment, and management of disease and medical maladies. It can be argued that complicated thinking should remain at the forefront of first-line medical care. However, when healthcare as a whole is taken into account, complicated thinking alone is insufficient. Furthermore, the success of complicated thinking limits the ability of complexity of thinking and management to gain the attention it deserves.

This leads to another common issue, namely, formal education. Education about complexity appears to be almost totally lacking. ¹⁵ Although complexity and systems thinking as a field of study has been in existence for over 50 years, the field itself has not caught on beyond certain subsectors of biology, computer science, economics, and mathematics. Knowledge of complexity in the general public is especially weak.

There is a corresponding lack of knowledge in the medical profession. There is only a weak presence of complexity in educational programs as well as in the literature and research on medical education. ¹⁶ An informal analysis of educational programs in Canadian medical schools showed an almost complete lack of education on complexity or systems thinking. An additional informal survey of medical professionals showed an almost similar total lack of knowledge of systems and complexity. It is reasonable to assume that this educational gap extends to healthcare administration programs as well.

Complexity and systems thinking are specifically mentioned in the CANMEDS guide for education. ¹⁷ Whether this listing of complexity is again being commingled with “complicated” or is just being ignored, or is still being considered for implementation in medical education is difficult to ascertain at this point. It is quite possible that the embeddedness of complicated thinking in medicine is “crowding out” the ability of medical students to embrace complexity.

Although science is rightly the bedrock of medical education, it should not comprise the full extent of what passes for medical knowledge. Some progress has been made in this area with the realization that qualities such as empathy are an important characteristic of medical professionals. Empathy is just the tip of the iceberg though with managing complexity in patient care.

Suggestions for complexity acceptance and further analysis

The first key for successful acceptance of complexity is education. While education is needed at all levels and for all agents of healthcare, the most practical place to start is medical school and healthcare administration programs. It is not enough to just educate. The education must be reinforced through testing, and through allowing complexity ideas to be tried.

Various calls for introduction of systems and complexity thinking into healthcare have been put forward. The embeddedness of complicated thinking, as already noted, provides a serious challenge. It is likely only through specific testing of complexity ideas that students will begin to take the study of systems seriously and begin to appreciate its application to healthcare.

It has been noted that systems learning amongst medical students “can be viewed as ‘broccoli’—students may recognize that it is good for them in the long term, but it may not be palatable in the moment.” ¹⁸ Given the emphasis on traditional medical knowledge and licencing requirements, this attitude is understandable.

One of the non-intuitive characteristics of complexity management is that the best practices are generally self-organized rather than top-down solutions. Education of the main agents in the healthcare system has a significant probability of creating self-organizing management techniques, and in turn, inspiring more research which may act as a catalyst for innovation and change. The collective, socially organized wisdom of medical practitioners who are free to think in complexity terms will likely produce breakthrough methods of practice and management once freed from the straitjacket of a sole dependence on a complicated paradigm.

A second implementation imperative is to change the attitude of “solving” problems in healthcare. Complex problems cannot be solved—they can only be managed. It cannot be overstated the need to think in terms of “manage, not solve.” The challenge of implementing this mindset will take time. The success of the traditional complicated science in medicine has created great progress is healthcare, but this success has created the image that healthcare issues can be solved. This is simply not true for complex issues. It requires not only education and a change in mindset, but also tremendous amounts of humility. This is a paradigm shift in attitude, and paradigm shifts often take time to be accepted. Again, the scalability of complexity requires that this “manage, not solve” attitude and its associated humility be recognized and practiced across the spectrum of agents. Not an easy challenge to overcome and one that will only take place over time as attitudes change and awareness of a complexity approach becomes recognized.

Education is of course related to changing attitudes. Once professionals understand the basics of complexity, the attitudes and willingness to embrace complexity may become much greater. Even a most basic identification of complexity may allow practitioners the freedom from tradition to think and act differently. The greater the mass of professionals recognizing complexity in systems leads to higher probabilities of complexity strategies for management to be tried. If nothing else, a recognition of the traits of complex systems would help to lower the stress and frustration of dealing with a healthcare system that seems to be increasingly broken. Acceptance and the willingness to embrace complexity will ultimately be a generational change. As one commentator put it, “adopting complexity thinking in healthcare systems requires actors to work against many of the deeply engrained structural and social norms that prevail.” ¹⁹

Concluding considerations

Complexity does not supplant complicated thinking. Ironically, the success of complicated thinking is itself a potential catalyst for change. The rise of digitization, Artificial Intelligence (AI), personal healthcare devices, and robots have the potential to displace many of the simple and complicated tasks of healthcare. ²⁰ As one academic commentator stated, “the most disruptable industry in the world, …(by AI) …, is hands down, healthcare.” ²¹ If practitioners do get displaced by technology for the more complicated tasks they do, it increases the focus on the complex issues which by necessity need management by human interaction.

Healthcare has long been dominated by complicated thinking. A wide variety of researchers, practitioners, and commentators have explored the potential for the addition of complexity thinking to improve not only medical care, but also health systems outcomes. The acceptance of complexity and systems thinking into healthcare seems to be lagging its potential. The challenges of accepting complexity thinking into healthcare are themselves complex in nature. Acceptance of complexity into healthcare will only be accomplished through increased knowledge of systems thinking and complexity along with the willingness to embrace complexity and systems thinking.

ORCID iD

Richard Nason https://orcid.org/0009-0001-7105-9742