Table 2.

Stepwise Adoption of Systems and Complexity Sciences Into General/Family Practice Research and Literature, by Adoption Period

Period and Key Complexity Science Theories	Critical Assessment: Study Design and Focus	What These Articles Added to Our Understanding
Before 19954–13: general systems theory and cybernetics	Descriptive design4–7,9–13 The dynamic nature of the illness trajectory5 Teaching family dynamics in residency programs,6 using genograms to understand family dynamics,9 and illustrating chaotic system dynamics within families12 Ecosystemic description of the diagnosis4 The need for a paradigm shift7 Medicine as a human science deals with the nonlinear causality of illness and acknowledges the patient as a self-organizing system10 Culture as a meaning system influences health and illness, their meaning, and the response to treatment11 The need to integrate care for patients with cancer13 Research design8 Survey: first attempt to characterize work patterns of different specialties for specific conditions	Exploration of the philosophy of health and disease and the role of the physician in society Holism as a key concept of general/family practice Context matters • The role of the family, n → 1, 1 → n, and n → n relationships • Nonlinear dynamics determine the individual patient’s understanding and response to his illness • Culture explains illness experience and therapeutic responses Ecological dynamics of disease and disease management Nonlinear dynamics of healing The outcome of treatments affecting dynamic systems cannot be precisely predicted
1995–200014–22: initial condition, self-organization, and emergence	Descriptive design14–16,19,22 The need to teach chaos theory13 General practice defines itself by reflective multicausal relationship thinking and acting15 General practice deals with health and disease as multifactorial and interconnected personal states16 Understanding general practice through chaos and complexity theories19 Research design17–21 Case study: response to diabetes care intervention17 Observational study: prevention in primary care practice18 Methodology study: the use of different statistical techniques, cluster analysis, and loglinear analysis19 Observational study: change in primary care practices20 Observational study: integrative nature of primary care consultation to meet patient need21	Defining the discipline of general/family practice To understand the apparent randomness of outcomes in the natural world Relationships matter • The doctor-patient interaction, the particular circumstances of the patient, the organismic behavior of the body, the integration of mind and body • Illness and healing result from network relationships • The needs and benefits of ongoing therapeutic relationships • The link between the patient’s illness and his community • To facilitate practice change Sudden changes in behaviors in relation to a change in circumstances (now known as cusp catastrophe) • Patient self-management • Consultation behaviors General practices are complex adaptive systems whose stability arises from adherence to their attractor Change requires awareness of and change in the attractor Without general/family practice, the health system becomes dysfunctional
2000–200523–29: dynamics in systems	Descriptive design23–29 Applying complexity science principles to the function of medical practice23 and the understanding of the biopsychosocial model28 Family practices are local professional complex adaptive systems24 Understanding and managing in complex adaptive systems26 Constructing a complexity model of continuity of care and illustrating its veracity using previously published outcomes data27 Understanding the interconnected issues affecting the primary care workforce crisis29	The function of medical practice Interdependence of its members Emergent function arises from its historical context (initial condition) Variability characterizes clinical practice Small change can result in large outcomes and vice versa Transformational leadership acknowledges the networked structure of the system and there interdependent interactions Leaders maintain creative tension between cooperation and competition Feedback loops show the patterns of interactions and outcomes in a complex adaptive system Systems diagrams as a tool to seeing and appreciating interconnectedness and feedback
After 200530–58: networks	Descriptive design30–32,35–41,43–47,49–54,57,58 Healing is the process of reestablishing wholeness30,45,47,49 Consultation dynamics31,45,46 and outcomes32,46 Care team development, practice development, and dynamics35,57,58 Health systems and health system reform36–38,43,44,50,52–54 Toward an integrated understanding of health37,47,49 and disease41,43,45,47,49 Developing a safe health care environment39 Complexities of understanding and managing comorbidity40,43–45 The generalist’s way of knowing51 Primary care paradox52 Research design33,34,42,48,55,56 Database analyses • Patient consultation rates for general and specific conditions33 • Determining the complexity of primary care consultations56 Multimethod studies • Reflective process to inform improvement in primary care practice34 • Clinical governance: toward a collaborative partnership approach55 Systematic review: dynamics of care planning42 Cross-sectional survey: uncertainty in primary care48	The application of systems theories to general/family practice activities Interdependence and coevolution of patient and doctor in the healing relationship Attractors limit the possible range of behaviors and resist or limit change in patient outcomes Physiologic variability is a sign of health, loss of variability a sign of disease Health and illness are personal dynamic states, influenced by context and variable over time, and the emergence of comorbidity Patient consultation rates in general and for specific conditions follow power law distributions Dynamic adaptive processes facilitate team care development Understanding the structure and function of health systems as complex adaptive systems Generalists understand that their knowledge base is cross-disciplinary, context sensitive, and emergent over time Holism results in better quality, better health, greater equity, and lower cost for individuals and populations Safety in health care is an emergent process within the dynamics of the health systems as a learning organization System tools such as concepts maps and system diagrams facilitate an understanding of the patient’s illness and provide leverage points for care interventions System dynamic approaches reduce the risk of making unforeseen mistakes A holistic epistemology is associated with less stress reaction to uncertainty among primary care physicians