The Complexity Science of Medicine Requires Freedom

In 1971 I was a first-year medical student, and I was struggling. We were studying Gross Anatomy and I just couldn’t seem to understand anything. At the time, a “regional approach” to anatomy was all the rage. We started dissecting the “posterior triangle of the neck” on our cadavers. Let me quote from a recent anatomy text:

The posterior neck triangle is a clinically relevant anatomic region that contains many important vascular and neural structures. The clinical aspect of the anatomy contained in the posterior neck triangle is useful for a wide variety of medical specialties, including anesthesiology, otolaryngology, physical medicine and rehabilitation, and others. Anatomic variations, as well as variations in nomenclature, exist among arteries and nerves in this region. This article will serve to mitigate ambiguity by providing alternative nomenclature when applicable…

Bounding a large anatomic region, the posterior neck triangle further divides into two smaller triangles by the inferior omohyoid muscle. These subdivisions include the occipital and subclavian triangles. The occipital triangle is bounded by the inferior belly of the omohyoid muscle, the trapezius muscle, and the sternocleidomastoid muscle. The subclavian triangle, sometimes referred to as the supraclavicular triangle, is bounded by the inferior belly of the omohyoid muscle, the clavicle, and the sternocleidomastoid muscle.

HUH???

I became hopelessly lost! I kept on asking from whence these muscles, nerves, blood vessels, and fascia originated and where they inserted! It just didn’t make any sense. WHAT did these things do? WHY were these structures there? With each passing day I became more and more confused. I realized I needed to somehow do something different in order to pass this course! Then I discovered Gray’s Anatomy and reached the turning point I needed.

The forerunner of Gray’s Anatomy was first published in London in 1858. Unlike the regional approach we were studying, it is organized as a systems approach to the subject. Things immediately clicked for me. Anatomy became one of my strongest subjects and remained so throughout my career. It formed the basis for my thesis for entry into the American Society of Ophthalmic Plastic and Reconstructive Surgery as well as numerous publications and presentations. It all happened because of a difference in perspective.

In 1979, the TV show Connections with James Burke began airing. The multidisciplinary approach to invention and innovation immediately captivated me. I realized that, just as in my experience with anatomy, I was a lumper and not a splitter. I was drawn to the verbs as much as to the nouns. Later, when I learned about network theory, I saw that I was more engrossed by the edges than the nodes. In Organizational Charts, I was drawn to the arrows and not the boxes.

Much has changed in medicine, and indeed in all of society. What was unthinkable now has become the norm. Although this could easily be a book-length discussion of the “connections” among all of this, I will only concentrate on sense-making of the titanic changes in medicine, healthcare, and “health” itself in the past few decades as we are reaching an inflection point that will determine the future manner of existence for all of us.

True to the formula of Burke in Connections, several disparate ideas were being formulated in the 20th century. Starting out distinct from each other, they finally collided to produce the problem all of us face in the catastrophe facing healthcare. 

The Postmodernist skepticism of the Grand Narrative was on the ascendancy. “Truth” became a fluid concept as it was seen as being based on individual experience. Against this backdrop, Critical Theory, especially as espoused by Herbert Marcuse and others of the Frankfurt School, took hold among the New Left and nascent leaders of education in this country. In this view, old ideas of logic and objective reality lost their prime importance.

Meanwhile, and seemingly paradoxically, investigations into quantum physics and nonlinear dynamical systems studies created newfound applications in such fields as economics. Brian Arthur developed his concept of Increasing Returns challenging classic thinking of the importance of negative feedback loops. A seminal meeting led to the founding of the Santa Fe Institute in 1984. This brought together investigators from multiple disciplines to investigate the workings of Complex Adaptive Systems. This flowering of Complexity Science created new understandings of the workings of the physical, social, economic, and biologic worlds.

In 1999, David Snowden developed what he termed the Cynefin Framework. This Welsh word is somewhat difficult to adequately translate but describes a point of view from which to make sense of the domains of Simple, Complicated, Complex, Chaotic, and Disordered. He and his coworkers described how these domains differed regarding such things as the relationships between the system and the agents within that system, cause and effect and response to problems within each of these domains. Reading this article was my own introduction to Complexity Science.

This helped me make sense out of the otherwise puzzling responses we had had in our attempts to apply the “scientific method” to some of the quality improvement projects in healthcare. They worked well in the “merely complicated” domain but fell flat when attempted to solve problems that were “truly complex”. These were the “Wicked Problems” described by Rittel and Webber in the 1970s.

Complexity Science provided the tools to apply action to the theories of Organizational Sciences I had learned from David Logan at the Marshall School of Business of the University of Southern California. Logan and his coauthors described the critical importance of Organizational Culture in determining Organizational Performance:

For the past decade, we have used agent-based modeling to visualize, in silico, the effectiveness of various interventions to maximize Organizational Performance. We define Organizational Culture as: The pattern of, and capacity for, constructive adaptation based on a shared history, core values, purpose and future seen through diversity of perspective.

Organizations are faced with continual stresses, external and internal. These stresses always produce a reaction…sometimes the reaction is no change. Adaptation can thus be seen as continual, but critical is whether or not it is constructive.

But even that is not simple to ascertain! In Complex Adaptive Systems, the predictability horizon is very, very short. What may seem to be advantageous in the short term results in disaster when seen in a larger perspective. Here is where understanding the work of Elinor Ostrom is absolutely necessary to see the net effect of all of these underlying principles on both healthcare and the larger picture of health itself.

Other authors have seen healthcare as a Common Pool Resource and urged application of Ostrom’s concepts in Governing the Commons. These concepts include 10 variables:

1. The size of resource system – a moderate territorial size is most conducive to self-organization.
2. The productivity of system – self-organization is less likely to work if a resource is either overabundant or already exhausted.
3. The predictability of system dynamics – for example, some fishery systems approach mathematical chaos, making self-organization infeasible. (sic)
4. Resource unit mobility – self-organization becomes more difficult with mobile rather than stationary units, e.g., in a river versus a lake.
5. The number of users – transaction costs can be higher with larger groups, but such groups can also mobilize more resources. The net effect depends on other variables and on the tasks undertaken.
6. Leadership – high skills and an established track record amongst leaders aids self-organization.
7. Norms and social capital – in terms of shared moral and ethical standards.
8. Knowledge of the socio-ecological system – more if better.
9. The importance of resources to users – where the resources is vital, self-organization becomes easier.
10. Collective choice rules – which can lower transaction costs.

and these 8 principles:

1. Define clear group boundaries.
2. Match rules governing use of common goods to local needs and conditions.
3. Ensure that those affected by the rules can participate in modifying the rules.
4. Make sure the rule-making rights of community members are respected by outside authorities.
5. Develop a system, carried out by community members, for monitoring members’ behavior.
6. Use graduated sanctions for rule violators.
7. Provide accessible, low-cost means for dispute resolution.
8. Build responsibility for governing the common resource in nested tiers from the lowest level up to the entire interconnected system.

If healthcare (and all of health itself) is viewed as a Common Pool Resource and a truly Complex Adaptive System, the methodology of Ostrom has a high likelihood of producing the necessary constructive adaptation to the internal and external stresses seen in healthcare today. However, the erosion of objective truth and logic in our Postmodernist world, united with the primacy of ideology over ethics in Critical Theory set the backdrop for an inflection point in the early spring of 2020. 

The interaction of the system and the agents was heavily tipped towards the system. The influence of Big Pharma, Big Tech, and Big Politics on healthcare delivery, research, and education was all but complete. The delivery of care was largely corporatized or in the hands of huge academic systems. Individual professionals had very little of the key elements of autonomy, mastery, and purpose described by Dan Pink as critical for motivation.

More primary care providers were drawn to “concierge practice” to regain some of those elements. In my own area of Oculofacial Surgery, the best and brightest were opting to limit their practice to aesthetics. 

The necessary cooperation between stakeholders described by Ostrom to effectively govern a Common Pool Resource was poisoned. Under the Cynefin Framework, what was in reality a Complex System operating under emergent order was pushed into a merely Complicated System with imposed order. Medicine, and arguably all of healthcare and health itself, became an overfished fishery. Burnout was inevitable and only a matter of time.

We were warned of possible problems with this concentration of power outside of the hands of actual caregivers by Baffy and co-authors in a seminal article appearing in the American Journal of Medicine in August 2019:

Since the use of complex digital tools and rapidly growing electronic databases require advanced computing skills, internet based mega-companies such as Google, Amazon, Facebook and Apple may become interested in spearheading further transformation and outcompete current stakeholders in scholarly communication and develop more user-friendly tools. Such developments could potentially lead to a few large entities controlling the gateways to scientific knowledge, a sobering thought.

Indeed, Covid was seized upon as the catalyst for the “Great Reset” with the subtitle, “In every crisis there is an opportunity.” It was rather astounding that this project could be developed so soon after the emergence of Covid. Critics were roundly accused of “conspiracy theory” and spreading “misinformation…”

Things didn’t exactly turn out as hoped by Klaus Schwab. The unpredictability of a truly Complex Adaptive System, even under an attempt to beat it into imposed order, popped up. Courageous dissenters refused to go along with what they knew were wrong dictates. Healthcare professionals, first responders, and members of the military and clergy refused to comply and were vocal about it, despite intense pressure and personal and professional costs. In particular, The Great Barrington Declaration was impossible to ignore.

Influential commentators, some of them members of the elite, made cogent arguments utilizing the new medium of Substack. These flourished much like the pamphlets and handbills of prior underground dissent.

As I write this, medicine is still “In the Wilderness,” but I can see a brightening horizon. We still need to formulate a counter to the nihilism of Postmodernism and Critical Theory. We still need to re-establish free speech and intellectual freedom in healthcare delivery and education. We still need to raise truth above ideology. But I now think that is a possibility.

And someday, we will look at those words of Winston Churchill describing the critical role played by the RAF in 1940 to those equally courageous individuals who fought against equally daunting odds 80 years later:

Never in the field of human conflict was so much owed by so many to so few.