Supplementary Tables and Figures Fig1 suppl: Number of Publications/Year from 1995-2010
Supplementary Tables and Figures Fig 2-suppl: Distribution of Publications/Crafts Group
-
Supplementary Tables and Figures Tab 1 suppl: Number of Publications/Craft Group
Number of Publications/Crafts Group
General Medical Journal
Family Medicine
Alternative Medicine
Geriatrics
Drug & Alcohol
Anaesthetics
Cardiology
Dermatology
Emergency Medicine
Endocrinology
ENT
Gastoenterology
General Medical Journal
Genetics
Haematology
Immunology
Intensive Care
Nephrology
Neurology
O&G
Oncology
Ophthalmology
Paediatrics
Psychiatry
Rehabilitation
Respiratory
Rheumatology
Surgical
Urology
Basic Science
Physiology
Pathology
Pharmacology
Radiology
Epidemiology
Public Health
Health Services Research
Ethics
Education
Systems & Complexity
Allied Health
Nursing
Nutrition
Non-medical
733
40
47
90
39
50
286
57
16
140
98
80
838
363
186
304
57
55
855
182
442
94
205
606
95
30
50
122
37
925
400
450
905
275
32
161
92
167
24
319
165
331
57
Subtotal for Group
949
5248
2955
285
510
553
6691
Supplementary Tables and Figures Tab 2 suppl: Period before 1995
An alternative paradigm for diagnosis [is] based on cybernetics, ecology, and systems theory. This paradigm, termed
“ecosystemic epistemology,” suggests that diagnosis focus on knowing problematic situations in an ecological and
system way. … therapists … approach diagnosis in an ecological and systemic way. (Keeney, 1979)
The uniqueness and individuality of any person is further explained by the interactions between the various
components that make up the whole person … the synthesis of problem lists reduces what may be meaningful
clusters of problems … . Systems theory recognizes the existence of an organized whole with overlapping, interacting
systems. (Freer, 1980)
Understanding the role of the family in illness requires a transition from linear to system thinking. (Christie-Seely,
1981)
Changing Models. The Impact of Kuhn’s Theory on Medicine. 1st anomaly – many people who are ill do not have
disease which can be classified according to our conventional taxonomy. … 2nd anomaly – this contradicts the
doctorine of specific aetiology and the separation of mind and body. If diseases were discrete entities caused by
specific agents, we would expect disease to be evenly distributed in a given population shring the same
environment. Yet we know from studies … that disease is not evenly distributed. 25% of the population has 75% of
the illness. … 3rd anomaly – it has been known for a long time that in a controlled trial some patients respond to the
inert substance used for the controls (strikes at the received beliefs about therapy). … 4th anomaly – there is a
distinction between treatment and healing; that healing ultimately comes from within and is influenced by such
factors as the context of healing, the will to live, and the relationship between doctor and patient (or healer and
sufferer). (McWhinney, 1983)
This circularity of “diagnosis as treatment” and “treatment as diagnosis” occurs frequently in the clinical care of
patients, but is especially relevant when dealing with psychosocial or family problems. (Like et al, 1988)
The point about particulars is that their behavior cannot be explained or predicted solely by applying to them the
general laws of science. We cannot move an abstract knowledge of the laws to a prediction of the particular’s
behavior. Whether or not the law will apply to a particular will depend on its history and its context or environment.
… Clinical medicine itself has to apply these laws to a particular patient with a unique history. Clinical science has its
own abstractions, but they are low-level abstractions, not far removed from the concrete experiences of patients.
Our most important abstractions are diseases and syndromes, and even these are subject to great variation.
Experience is more important to a physician than theoretical knowledge because it provides the “acquaintance with
particulars” that is so important to clinical wisdom.
In human science, causality is not linear and unidirectional. A complex, self-organizing system does not respond to
change in a simple unidirectional manner. Reciprocal effects and feedback loops are circular, not linear processes. As
Gregory Bateson observed, when causal systems become circular, any event in the circle may be both the effect of a
previous event and the cause of a subsequent event anywhere in the circle. … Our greatest contribution to medicine,
however, may be in leading the way to a new method, a Geisteswissenschaften of medicine. (McWhinney, 1989)
Supplementary Tables and Figures Tab3 suppl: Period 1995 - 2000
In family medicine, it has been suggested that family physicians should look to chaos theory to help provide care to
individual patients who by their very nature are the multivariable, nonlinear, nonperiodic systems described by the
science of chaos. (Markham, 1995)
[General practice …]. 1. It is the only discipline to define itself in terms of relationships, especially the doctor-patient
relationship. The family doctor may become part of the complex of family relationships, and many of us share with
our patients the same community and habitat. … It gives general practice a quality of unexpectedness and flexibility
in adapting to change. 2 General practitioners tend t think in tems of individual patients rather than generalized
abstractions. We have difficulty thinking about diseases as separate from the people who ‘have’ them. 3. General
practice is based on an organismic rather than a mechanistic metaphor of biology. The metaphors we use in
medicine are ofter very revealing about the way we think. … Living organisms have properties possessed by no
machine: growth, regeneratin, healing, learning, self-organization and self-transcendence. … Organismic thinking is
multilevel and non-linear. … The transition from mechanistic to organismic thinking requires a radical change in our
notion of disease causation. … In self-organizing systems such as organisms, causation is non-linear. The multiple
feedback loops between organism and environment, and between all levels of the organism, require us to think in
causal networks, not straight lines. 4. General practice is the only major field which transcends the dualistic division
between mind and body. (McWhinney, 1996)
One effect of such and approach is the de-emphasis of disease labeling. By placing the names of conditions in
context, the disease label is seen as only part of the picture. … For most diseases the concept of a single cause is
inapplicable: medicine now accepts and uses the concept of mulifactorial causation. … Medicine can no longer
sustain a dualist stance. Mind and body are interacting sytems. Yet terms such as ‘functional’ and ‘orginic’ persist
and perpetuate the idea that mid and body are separate. … The mind of the observer and the observed
phenomenon cannot be separated. (Fabb, 1997)
…, the theories of ‘chaos’ and complexity suggest that much of the world is not linear and small changes can produce
dramatic transformation of an entire system. … For example, individuals are more than the sum of the multitude of
complex biochemical reactions taking place in their bodies, and social phenomenon cannot be fully explained in
terms of the individual actions of people. (Griffith & Byrne, 1998)
INTRODUCTION to applying systems and complexity sciences:
The data revealed 30 features of the practice that are important to consider in interventions and policy decisions;
however, it was clear that practices functioned as whole entities. As the analysis progressed, we saw that while it
was easier to separate these variables this way for organizational purposes, they were not truly independent; they
needed to be considered as being part of a complex system. (Crabtree et al., 1998)
Two statistical techniques that can help are cluster analysis and loglinear analysis repeated at the different time
points for the data. Cluster analysis provides a descriptive account of the system, and when repeated over time it
can reveal how the system changes. Loglinear analysis can tell us which variables or interaction of variables are
important in bringing about the observed changes. (Griffith & Byrne, 1998)
It is now clear why guidelines, CME, and standardized interventions often do not work as planned. Rationality and
knowledge for its own sake do not matter to complex adaptive systems except when they serve the attractors and
are consistent with the internal models. One size will not fit all. (Miller et al., 1998)
Family physicians prioritize a wide range of options for care, and provide of facilitate that care within an ongoing
relationship with the patient, the family, the health care system, and the community. The family practice approach
integrates provision of the entire range of health care, including (1) breadth of care that is not limited by the
patient’s age, the organ system of the patient’s problem, or the location at which care is provided; (2) depth of
knowledge of the patient, family, and community overtime as a critical context for the provision of care and for
choosing the timing and content of care; (3) bridging of the boundaries between health and illness, focusing on
enhancing the patient’s overall functional health status; and (4) guiding access to more narrowly focused care when
Supplementary Tables and Figures needed. … The discipline of family practice emerged in response to the continued need of patients for personal
physicians to provide patient-centered care by applying the advances in technical medicine brought about by
increased specialization. … Many of the problems of the current healthcare system are a result of the system’s
failure to provide the fundamental aspects of primary care. (Stange et al., 1998)
Supplementary Tables and Figures Tab 4 suppl: Period 200 – 2005
Our emerging understanding conceptualizes family practices as local professional complex adaptive systems. … Each
family practice is unique because of 5 features: 1. History and initial conditions, including and explicit or implicit
mission and the underlying priorities for the practice. 2. Particular agents and their unique styles and interests. 3.
The pattern of nonlinear interactions among agents. 4. The local fitness landscape (i.e., the practice’s ecology niche)
and its particular expectations, community values, competitive issues, and ecology. 5. Regional and global influences,
such as larger health care systems, finances and regulations, and culture. (Miller et al,. 2001)
A ‘transformational leader’ drawing upon complexity insights recognizes the importance of the organization’s
socially constructed network where meaning often remains implicit, and understands the interplay between the
organization’s formal design structures and its informal self-generating networks. … In human systems,
preconditions for self-organization are: shared principles – systems align themselves around core values even if
system goals are not articulated, connectivity and feedback – self-organization emerges from non-linear processes
arising from feedback at a lovcal level; dialogue – this involves sensitivity to other perspectives and willingness to
change our mental models and paradigms; memory – without memory the system can do no better than mirror the
environment, as and system has a finite memory capacity, there must also be some form of selective forgetting;
interdependence – self-organization is driven by both competition and co-operation among system elements but
against a background of interdependence. (Kernick, 2003)
… set the stage for models of circular causality, which describes how a series of feedback loops sustain a specific
pattern of behavior over time. Complexity science is an attempt to understand these complex recursive and
emergent properties of systems and to find interrelated proximal causes that might be changes with the right set of
interventions (family support and medicatins for schizophrenia; depression seeing and cholesterol level reduction
after a heart attack). … [there is] the need to balance a circular model of causality with the need to make linear
approximations (especially in planning treatments) and the need to change the clinician’s stance from objective
detachment to refl ective participation, thus infusing care with greater warmth and caring. (Borrell-Carrio et al.,
2004)
… understanding and finding solutions to the complexities inherent in the workforce issue requires a systems
approach; simple linear approaches to ‘fixing’ a particular aspect are dangerous and invariably will lead to
unforeseen – usually detrimental – consequences. System approaches do not provide the one correct solution to a
problem; rather system approaches highlight the potential interactions one solution may have in a complex
environment. Building a multiple cause diagram provides a better understanding of these difficulties and forces
reflection on strategies and their likely consequences. (Sturmberg, 2004)
Supplementary Tables and Figures Tab 5 suppl: Period after 2005
Complexity theory has attracted considerable attention in recent years, … its themes of uncertainty and non-linearity
resonate deeply with the experience of working in general practice. Describing the consultation as a complex
adaptive system provides a coherent theoretical basis for understanding the consultation, which has so far been
lacking. (Innes et al., 2005)
In fact, nonlinear dynamics are often a sign of health. … patients with chronic stable disease who, after a minor
event, suddenly change their disease trajectory may be demonstrating sensitivity to initial conditions. … Attractors
limit the range of possible behaviors and thereby resist or limit changes in a patient’s course. (Katerndahl, 2005)
The consistency of the power law distribution across a wide range of consultation behavior suggests common
processes underlying the decision to consult among both high and low consulters. … Our data suggest that while
illness episode duration is distributed at an individual level, use of healthcare is not. Instead, the complex system,
comprising patients and their primary healthcare providers, itself strongly influences its own consultation rates.
(Love et al., 2004)
Healing was associated with themes of wholeness, narrative, and spirituality. Healing is an intensely personal,
subjective experience involving a reconciliation of the meaning an individual ascribes to distressing events with his or
her perception of wholeness as a person. (Egnew, 2005)
… builds a case for framing chronic pain within a complex adaptive systems (CAS) paradigm and explores how
paradox, one of the key features of a CAS, contributes to maintaining ‘chronicity’ in the system. A complexity science
paradigm can serve as a meta-framework, integrating theoretical models employed in chronic pain and reframing
dissent and conflict as positive generative forces for change. Interventions, based on complexity science principles,
can effect change in the highly interactive systems that constitute the chronic pain experience. (Brown, 2005)
… systems and complexity thinking – through an emphasis on understanding the relationships between all system
variables – synthesises the biomedical and the psychosocial elements of a patient’s illness and therefore
pragmatically reshapes clinical understanding, practice and outcomes. (Sturmberg, 2007)
…a systems and complexity view allows a simultaneous understanding of a phenomenon from different
perspectives, providing the opportunity to identify potentially different outcomes from a single action. (Sturmberg,
2007 – part2)
Generalists and specialists differ in the breadth of care provided and their level of differentiation. In addition, error
rates (a measure of complexity) are associated with, not only volume, but diversity, variability, and time limitations
as well. … complexity includes both cognitive complexity, which focuses on the content of information flowing, and
relational complexity, which focuses on the interactions by which the information flows between agents. Hence,
cognitive complexity is measured in counts, while relational complexity is measured in variability. (Katerndahl et al.,
2010)
Metaphorically the complexities of the ‘health care system’ can be compared to a vortex. All the elements making up
the ‘health care system’ exert their pressure onto the ‘health’ of the individual’s cells through their effects on the
person’s environment and their effects on the balance of his somato-psycho-socio-semiotic needs. Minor changes to
a single element within the system can have major, and often unforeseen, consequences on the whole system.
(Sturmberg & Martin, 2006)
General practice’s evolving roles and responsibilities require a multilevel approach that includes the individual
provider, group/team, the organization, and the environment, with recognition that even small changes in any one
of the four contexts will affect others, both across, and between all levels of the “health care system”. (Martin &
Sturmberg, 2006)