Medicine's Unfinished Revolution. Part 1—The Case for Change: Systems Thinking and the Soul of Medicine

ABSTRACT

Medicine has historically progressed by addressing anomalies that its prevailing conceptual framework could not explain, subsequently expanding that framework to incorporate them. This essay, the first of two, contends that the current anomalies confronting medicine—chronic multimorbidity and suffering arising from the interactions between conditions and lived experiences—are fundamentally different. These challenges cannot be resolved by merely broadening a framework designed to isolate components, as they represent anomalies of interconnection and interdependence. What is needed is not an expanded biomedical frame, but an entirely new conceptual approach. Drawing on systems and complexity sciences, this essay differentiates four phenomena that medicine often conflates—health, illness, dis‐ease, and disease—and introduces the somato‐psycho‐socio‐semiotic (SPSS) model, which conceptualises health as a dynamic equilibrium rather than simply the absence of pathology. The consultation is redefined as the fundamental unit of care, and the health system is reconceptualised as a purpose‐driven organisation, described as a health care vortex, centred on the patient's experience of health. The argument is illustrated through the case of a single, representative patient and concludes by identifying unfinished work at three levels: the physician, medical education, and medicine's social license. A companion essay addresses the common objections to this argument.

1.

Medicine is a social science, and politics is nothing but medicine on a grand scale.

Rudolf Virchow (1848)

2. Medicine's History of Correction

Throughout its history, medicine has been shaped by individuals who challenged prevailing norms, often at personal and professional cost. Figures such as Hippocrates, Jenner, Semmelweis, Virchow, and Engel exemplify this pattern. Each recognised truths that their contemporaries either could not or would not acknowledge, faced consequences for their dissent, and were ultimately vindicated. David Maddison also fits this tradition, although his contributions focused on reforming medical education rather than clinical practice. He established a medical school structured around the actual burden of illness in the community, emphasising collaborative problem‐solving, integrating communication and social determinants of health as core clinical components, and selecting students based on both academic achievement and personal qualities. His significance within this lineage is further explored below.

In the framework articulated by Kuhn, each of these individuals confronted an anomaly—an observation or phenomenon that the prevailing medical paradigm could not explain [1]. For four of them, the existing framework was eventually able to adapt. Hippocrates recognised that disease had natural, rather than divine, causes; Jenner identified a protective relationship between two diseases before the underlying mechanism was understood; Semmelweis demonstrated that disease could be transmitted by the physician's own hands; and Virchow acknowledged that the origins of disease were as much social as biological. In each instance, the prevailing paradigm expanded to incorporate these insights: germ theory accommodated Semmelweis, immunology eventually explained Jenner, and public health partially addressed Virchow's observations. The medical framework persisted by enlarging its boundaries, and medical education evolved in parallel.

In the 1970s, Engel and Maddison represented a similar spirit of rebellion, yet the anomalies they identified could not be accommodated by the prevailing medical framework. Both advocated for a systemic perspective: Engel advanced the biopsychosocial model in clinical practice, explicitly drawing on systems theory, while Maddison reformed medical education to prepare physicians to treat the whole person. They recognised that the various aspects of a patient's life were interconnected in ways that the dominant paradigm failed to address. However, they lacked both the terminology and the conceptual framework to fully articulate or operationalise these insights, as systems sciences were only beginning to emerge and were not yet sufficiently developed for clinical or educational application. Although they could perceive the limitations of the existing paradigm, they remained constrained by it. Their intellectual efforts, however, began to challenge and erode these boundaries at the point where the prevailing framework could no longer contain the complexities they observed.

The phenomena that Engel and Maddison identified have, over subsequent decades, become increasingly evident: anomalies of interconnection and interdependence, such as chronic multimorbidity and suffering rooted in the relationships between conditions and life circumstances, cannot be addressed by simply expanding a reductionist framework. A paradigm designed to isolate components cannot be adapted to encompass phenomena that exist solely in the relationships among those components. In Kuhn's terms, this situation calls not for an expanded frame, but for a fundamentally new one. Systems and complexity sciences now provide this alternative. Rather than rejecting the biomedical method, these sciences clarify its limitations and extend its reach to include factors that the method, by design, cannot address: the context in which disease arises, the influence of that context on biological function, and the combined impact on health and illness experiences. Before advancing this argument, it is necessary to clarify two foundational concepts: the nature of complexity and the definition of a frame.

3. Two Concepts: Complexity and Frame

Discussions of complexity consistently emphasise two interrelated concepts: interconnectedness and interdependence. Interconnectedness refers to the joining of parts and their mutual influence. Interdependence, however, asserts that the behaviour of each part depends on the state of the others, making it impossible to vary or understand any part in isolation. Complexity emerges when simple elements organise into structured systems, enabling interactions that individual components cannot generate independently. As Russell Ackoff succinctly stated, the essential properties of a living system are properties of the whole, not of the individual parts; these properties arise from the interactions among the parts and are lost when the system is divided—either physically or conceptually—into isolated elements [2].

The implications for medicine are both direct and significant. Understanding a patient cannot be achieved solely by analysing individual components such as organs, biomarkers, or genes, because the patient, as a living and experiencing whole, possesses emergent properties absent from any single part. While these components are necessary for the patient's existence, they are insufficient to explain the totality of the patient's being. The interactions among these parts—how a person functions and experiences life—produce phenomena that cannot be uncovered by examining the parts in isolation.

The second foundational concept is the frame, as described by cognitive linguist George Lakoff: our thinking is constrained by the conceptual frames we use to interpret the world [3]. A frame directs attention to specific elements within its boundaries, while simultaneously obscuring what lies outside. Importantly, it is challenging to recognise or escape a frame without first becoming aware of its existence. However, a frame is not an impermeable barrier. Rather, it functions similarly to the boundary of a complex adaptive system: it delineates an inside and an outside, is sustained by the thought processes occurring within it, and persists as long as internal events continue to validate it. Each problem a frame successfully explains reinforces its unnoticed presence. These boundaries are not immutable; they can be redefined. Lakoff's concept of reframing and Kuhn's notion of a paradigm shift represent analogous processes at different scales: a small frame may be redrawn frequently as understanding evolves, while a paradigm—the broadest and most widely shared frame—changes infrequently, but reorganises the entire field when it does. Such a shift occurs when internal inconsistencies become unresolvable or when external realities can no longer be ignored. When the limitations of a frame can no longer be addressed by adjusting its boundaries, it collapses and is replaced by a new one.

These reformers, through their respective contributions, demonstrated the limitations of reductionism: the phenomena they identified existed only in the relationships among components and could not be discovered by examining parts in isolation. However, each corrective measure they introduced was eventually assimilated, and each expansion of the framework became the new reductionist boundary, subsequently accepted as the norm by those within it. The necessary transformation now is not another incremental expansion of a framework designed to isolate parts, but a fundamental shift to a paradigm capable of encompassing the person as a whole, including all biological, psychological, social, and existential interconnections.

4. A Category Error

In practice, the reductionist framework manifests as a methodological approach tailored to a specific class of problems: one pathogen, one disease, one target, one treatment. For such cases, this approach is not only sufficient but remarkably effective. Interventions such as penicillin, vaccines, and surgical procedures represent genuine achievements, and medicine appropriately celebrates them. However, the predominant challenges in contemporary medicine—chronic disease, multimorbidity, mental illness, and the consequences of poverty and aging—do not conform to this model. These are issues characterised by interconnection, feedback, emergence, and contextual factors, rather than single causes producing linear effects. Applying a method designed for the former category to the latter constitutes a category error. This error underlies the failures previously discussed: the existing framework cannot accommodate these complex problems because its methods were never intended to address them. It is important to recognise that this error is neither dramatic nor intentional; rather, it often manifests as care that adheres to guidelines yet fails to improve the patient's overall well‐being.

Consider a patient—call her Margaret. She is 67, with type 2 diabetes, mild heart failure, osteoarthritis of both knees, and 4 years of treatment for depression. She lives alone since her husband died. She sees five specialists and has accumulated 13 medications. By every clinical metric, each condition is expertly managed: her HbA1c is acceptable, her cardiac function stable, her mood scores within range. And yet her only complaint, when she sits down in the consulting room, is that she does not feel well—tired in a way sleep does not fix, no longer going to her book group, no energy to cook the Sunday family dinner, and unsure, some mornings, why she should get up at all.

Margaret's case is not atypical; in many ways, she represents the standard patient encountered in 21st‐century general practice. The prescription of 13 medications does not indicate a failure in prescribing, but rather reflects the logical outcome of repeatedly applying a single‐disease approach to a patient whose suffering arises from the interactions among multiple conditions and the interplay between these conditions and her broader life context. The critical question in her case is not ‘what is wrong with her?’ —a question already answered multiple times by various specialists—but rather, ‘what does living well mean for this individual, considering all aspects of her body, history, and environment?’

The research methodologies commonly employed in medicine exacerbate this issue. These methods are designed to determine whether a specific intervention produces a particular outcome, not to explore how multiple elements interact over time within a given context to generate observed phenomena. The randomised controlled trial, regarded as the gold standard in medicine, is intentionally structured to eliminate contextual variables and isolate the effect of the intervention [4, 5]. While this design is advantageous for certain types of problems, it is inadequate for cases like Margaret's. Factors such as loneliness, loss of purpose, and complex medication interactions cannot be randomised away or fully captured by such trials. According to Ashby's law of requisite variety, complex problems require responses that are equally complex—only variety can absorb variety [6]. Therefore, the solution is not to dismiss biomedical or population‐level evidence, but to reject evidence that has been stripped of its broader systemic context.

5. On the Nature of Health

If the biomedical framework is insufficient to address Margaret's needs, the solution is not to discard it, but to broaden the definition of health and explicitly identify what the narrower framework omits. The ambiguity begins with the term ‘health’ itself, which is often used as if its meaning were universally agreed upon. In reality, this is not the case, and such confusion can lead to clinical harm. What is commonly referred to as a ‘health problem’ actually encompasses at least four distinct phenomena—health, illness, dis‐ease, and disease—each requiring a different type of clinical attention.

Historically, the concept of health—derived from the Old English hal, meaning whole—has been regarded as an experiential state of wholeness. Philosophers from Plato to Kant, as well as the World Health Organisation's Ottawa Charter, have all the lived experience of balance and coherence as central to health [7, 8, 9]. However, modern biomedicine has increasingly marginalised this perspective by objectifying disease and extending this objectification to encompass the entire range of human experience. This process has led to the categorisation of illness, dis‐ease, and even ordinary life challenges as diseases. By medicalising life itself, health has become structurally invisible: health budgets are effectively disease budgets, health ministers function as disease ministers, and phenomena that cannot be classified as pathology are rendered non‐existent within the system.

A systemic model of health is required—one that regards the individual not as a collection of organ systems, but as an integrated and dynamic entity whose health arises from the interplay among biological, psychological, social, and meaning‐making dimensions. The somato‐psycho‐socio‐semiotic (SPSS) model conceptualises health as a dynamic equilibrium among four domains. The somatic domain includes genetic, microbial, and physiological factors influencing biological function. The psychological domain encompasses mental well‐being and the internal life that modulates biological processes. The social domain involves relationships, employment, housing, and the broader infrastructure in which a person lives. The semiotic domain, responsible for sense‐making, includes the values, understanding, and orientation that enable an individual to integrate experiences across all other domains [7, 8].

Within this model, health is conceptualised not as a static state, but as a basin of attraction—a dynamic centre of gravity to which an individual is drawn when all four domains are in balance. Illness and dis‐ease represent deviations from this centre, resulting from disturbances in one or more domains. Changes in any single domain can have cascading effects across the others.

Re‐examining Margaret's situation through this framework reveals that her somatic domain is expertly managed—she is under the care of five specialists, takes 13 medications, and her treatment meets all clinical guidelines. However, her social domain has diminished significantly since her husband's death: she no longer participates in her book group, hosts Sunday dinners, or has companionship at home. Her psychological domain continues to be affected by 4 years of depression, which persists despite mood scores that appear within normal limits. Her semiotic domain—the means by which she finds meaning in her life—has also deteriorated. From a biomedical perspective, her care appears flawless; from a holistic perspective, it is profoundly lacking. As Peter Drucker observed, Margaret's care was executed correctly in terms of disease management, but it was not the appropriate care for her overall well‐being [10]. Restoring her health will require addressing her social, psychological, and sense‐making domains, potentially in conjunction with a reduction in her medication regimen. Ideally, she would have a clinician who prioritises understanding what would make her mornings meaningful, recognises her grief as a legitimate diagnosis, reduces her medications to a more manageable number, and ultimately helps her regain a sense of wellness for the first time since her husband's passing.

6. What Health Care Is

If health is understood as a dynamic equilibrium among four interacting domains, rather than simply the absence of disease, then health care must extend beyond the management of disease after its onset. Addressing disease without attending to the underlying social, psychological, and semiotic factors that contribute to its development is, at best, incomplete and, at worst, counterproductive, as these unaddressed conditions will continue to generate illness. Margaret's regimen of 13 medications exemplifies this issue: the system manages outputs while neglecting the inputs that drive health outcomes [9, 11].

The influence of social factors on biological processes is not merely metaphorical; it is grounded in physiology. The death of Margaret's husband did not directly harm her heart or alter her HbA1c levels, but it profoundly disrupted her social domain, diminished her psychological resilience, and undermined her sense of meaning, with subsequent biological consequences. Prolonged social and psychological stress activates the hypothalamic‐pituitary‐adrenal (HPA) axis and the sympathetic nervous system, converting lived experience into inflammatory responses that impact organ function, cellular regulation, and gene expression. While the genome establishes the boundaries of biological potential, it does not function as a static programme independent of environmental influences. Lived experience—including the quality of relationships, material security, and the presence or absence of meaning—continuously shapes gene expression and modulates the body's stress and immune responses. The biological and social domains are not separate entities that occasionally interact; rather, they are mutually constitutive and operate in a continuous feedback loop. Consequently, interventions targeting only the biological substrate will not achieve health if the sustaining conditions are absent [9, 11].

This understanding has direct implications for the delivery of care. The consultation—the interaction between patient and clinician—constitutes the fundamental unit of health care. It is within this context that a comprehensive understanding of the individual is developed, and trust is established over time. The traditional distinction between ‘soft’ and ‘hard’ science becomes irrelevant here: the therapeutic relationship is simultaneously a human connection and a clinically valuable resource, and these aspects are inseparable. This relationship fosters the conditions necessary for healing and gradually builds tacit knowledge of the patient that cannot be communicated through referral letters, electronic records, or brief specialist encounters. This rationale underpinned Maddison's Newcastle curriculum, which regarded communication skills as essential clinical competencies and continuity of care as a necessity rather than a logistical convenience. Nevertheless, the scope of what can be achieved within any consultation is shaped not only by the clinician, but also by the structural design of the health system in which the consultation occurs.

7. What a Health System Is For

All purpose‐driven organisations require a clearly defined focal point that guides the activities of every level within the structure. Health systems are no exception, although their focal point is particularly complex: it is not a product, profit margin, or performance metric, but rather the patient's personal experience of health. The corresponding organisational model—the health care vortex—aligns every layer of the system around this central objective [12]. Historically, however, this focus has shifted. The ascendancy of germ theory redirected attention from the experience of health to the management of disease, and, as often occurs with effective frameworks, this shift became invisible, no longer recognised as a particular perspective.

A health system can be conceptualised as a multi‐layered organisation with the patient's experience of health at its core. Each layer—from national policy and institutional design to individual clinical encounters—must align its activities with this central purpose, and information must circulate bidirectionally. Top‐down, higher levels provide guidance and constraints that direct the work of lower levels, ensuring that care delivery remains connected to the system's overarching goal. Bottom‐up, feedback from the point of care enables these constraints to be adjusted in response to real‐world conditions, maintaining the system's adaptability. When a shared sense of purpose is maintained across all layers, the system functions as a coherent whole. However, if any layer prioritises a secondary objective—such as efficiency, throughput, or budget constraints—over the system's core purpose, the ability to achieve that purpose is compromised at every level [12, 13, 14].

These implications are tangible. When higher organisational levels prioritise secondary objectives—such as reducing community health services to meet budget targets or emphasising throughput over therapeutic continuity—the resulting effects cascade downward, undermining the conditions necessary for effective care and ultimately diminishing the patient's ability to maintain or restore health. Conversely, even the most skilled and continuous clinical relationships cannot compensate for deficiencies in fundamental social determinants such as safe housing, adequate income, or a supportive social environment. The constraints established by higher levels dictate what is achievable at lower levels. Therefore, the system's core purpose must be consistently upheld at every organisational tier (Figure 1).

Figure 1.

The complex adaptive nature of health, visualised through the SPSS‐Model and the health vortex model. (A) The domains of the somato‐psycho‐socio‐semiotic (SPSS) model of health; (B) the dynamics of various health states; (C) the principles of the health vortex model; (D) the health vortex model in detail showing the interconnected and interdependent functional layers of health.

Margaret's predicament exemplifies the consequences of a displaced focal point within the health system. The system fails her because it is structured around disease outcomes rather than health experiences, prioritises throughput over relationships, and addresses institutional needs instead of individual needs. The gradual and largely unnoticed shift of the system's centre will not reverse spontaneously, and future generations of patients cannot afford to wait for such a change. Evidence from organisational change and health‐system reform consistently indicates that restoring the focal point—from disease management to the patient's experience of health—requires the deliberate and collective recommitment of all stakeholders, including clinicians, patients, institutions, funders, and governments. This is not merely a technical challenge; it is fundamentally a political and moral issue [15].

8. The Unfinished Work

The central argument is straightforward: systems and complexity thinking do not supplant the strengths of conventional medicine, but rather provide the scientific framework that reveals why these strengths are insufficient on their own and identifies what additional elements are necessary for a comprehensive approach. This framework, which was absent in earlier reform efforts, highlights the need to address unfinished work simultaneously at three distinct levels.

At the level of the physician—the clinician working directly with patients like Margaret—the imperative is to adopt a broader perspective. This does not entail abandoning biomedical tools for managing conditions such as diabetes, heart failure, or depression, but rather integrating these tools within a more comprehensive understanding of the patient's life. The focus should shift from managing discrete conditions to addressing the entirety of the patient's lived experience. Success is measured not solely by clinical indicators such as HbA1c, but by the patient's ability to find meaning and motivation in daily life. Systems thinking provides the scientific rationale for this holistic commitment. Patients like Margaret require clinicians capable of addressing both physical and existential dimensions of health.

At the level of medical education—the focus of Maddison's reforms—the objective is to prepare graduates for the realities of patients like Margaret, rather than for an idealised patient envisioned by traditional curricula. This requires integrating the study of complexity alongside biochemistry, recognising uncertainty as an inherent aspect of clinical practice, and treating continuity of care as essential rather than optional. It also involves selecting students who view uncertainty as an opportunity for growth, and resisting the trend toward increasing specialisation as the sole response to complexity. This is not merely a theoretical concern. Two decades ago, a shift from a discipline‐based curriculum to a longitudinal, patient‐centred approach was implemented, in which students followed a ‘longitudinal patient’ across various care settings—self‐care, general practice, specialist care, hospital, and community—learning about the person rather than the department, and encountering the SPSS domains as practical realities. Students thrived under this model. However, significant challenges remained at higher organisational levels, such as changing specialist attitudes toward teaching and aligning assessment systems that continued to prioritise factual recall. While point‐of‐care innovations were effective, they were constrained by systemic factors beyond the control of individual educators—the organisational vortex at a higher level [16].

At the level of medicine's social license—where the discussion becomes explicitly political, as it did for Virchow and Maddison—the challenge is particularly formidable. The focal point of the health system has shifted away from serving the patient's experience of health toward prioritising disease outcomes, throughput metrics, and institutional objectives. Restoring the original focus necessitates the collective recommitment previously described, which in turn requires significant political courage. This is exemplified by Virchow, who characterised medicine as a social science and faced professional consequences for his stance [17], and highlights the need for medical education to treat such political engagement as essential rather than optional.

9. Conclusion

Ultimately, each of the reformers in this tradition was vindicated, yet all left their work incomplete. The conceptual framework they lacked is now available. Systems and complexity sciences are consistent with the principles that motivated their dissent: openness to new ideas, explicit articulation of insights derived from careful enquiry, and the promotion of genuine choice. These sciences provide a coherent understanding of health, health care, and the purpose of health systems, as well as an explanation for why misdefining any of these elements consistently results in patients like Margaret—those who are expertly managed yet remain unwell.

However, even the most compelling arguments for change do not implement themselves. Such proposals inevitably encounter resistance, often manifesting as predictable objections: demands for randomised trial evidence, requests for cost‐effectiveness metrics, accusations of rebranding holism, concerns about criticism of specialists, or fears of abandoning scientific rigour. These objections vary in substance; some warrant thoughtful responses, while others lose relevance when considered outside the prevailing conceptual frame. Differentiating between these types of objections—and responding without perpetuating the same defensive reflexes that once marginalised reformers—is the focus of the companion essay. The fundamental questions—what is the purpose of medicine, and what qualities should its practitioners possess—remain unresolved and pressing. Systems and complexity sciences do not provide definitive answers, but they offer a framework precise enough to guide both enquiry and action.

Funding

The author has nothing to report.

Ethics Statement

This research did not require IRB approval because it is not human subject research.

Conflicts of Interest

The author declares no conflicts of interest.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.