Complexity in Primary Care: Understanding Its ValuePDF
ACP J Club. 2007 Nov-Dec;147:A11. doi:10.7326/ACPJC-2007-147-3-A11
Sweeney K. Complexity in Primary Care: Understanding Its Value. Oxon: Radcliffe Publishing Ltd; 2006. This book can be obtained from www.radcliffe-oxford.com for $45.
Is evidence-based medicine (EBM) the only type of knowledge that clinicians use (or need to use) during patient consultations? A more likely situation is that we use several different explanatory models or “ways of knowing” as the frameworks in which we see patients in day-to-day clinical practice. This book tries to make sense of these different “ways of knowing” and introduces a new model based on complexity theory. The premise of Kieran Sweeney's book, Complexity in Primary Care: Understanding Its Value, is that complexity theory can provide clinicians with a way of understanding clinical care. If, like me, you had never heard of complexity theory, this book provides an excellent introduction to the topic and how it relates particularly to the application of EBM in clinical practice, with a focus on primary care.
The clinical vignette in Chapter 1 will be familiar to most primary care clinicians—where the EBM consultation with a patient gets diverted because of a particular narrative. The EBM focus is rapidly replaced by the patient's individual narrative, and the 2 jostle for importance.
Chapter 2 provides an excellent overview of the origins of the current scientific basis of clinical medicine. This model is based on reducing disease states to their constituent parts; it assumes that the whole is the sum of those parts and that it progresses in a linear way. In Chapter 3, Dr. Sweeney summarizes the well-known criticisms of EBM and poses the question of whether there is a danger in regarding the EBM model as the pinnacle of the explanatory models of clinical practice. Chapter 4 describes the development of qualitative research methods and the emergence of the naturalistic model, and Chapter 5 introduces the historical development of complexity.
In Chapter 6, the book aims to develop an understanding of chaos and complexity. The chapter presents several examples of how the principles of complexity theory have been applied to research in health care organization and clinical settings. The author proposes a new approach to clinical research in which conventional quantitative and qualitative research methods are examined at a second “interpretive” level for patterns in the data to detect features of complex systems. As Dr. Sweeney explains, an interaction and change over time are common threads in both organization of health care systems and individual doctor–patient relationships. To illustrate how this might work, Chapter 7 provides examples of data analysis using complexity principles. Techniques are used to examine 4 papers, including ones on decision-making and implementation of evidence in practice, to explore particularly the doctor–patient relationship. How likely is it that using the principles of complexity will make me a better doctor or produce a better health care system?
Finally, Dr Sweeney proposes in Chapter 8 that the 3 “ways of knowing”—EBM, naturalistic models, and now complexity theory—offer complementary ways of making sense of individual clinical narratives and that doctors use them all.
I found this to be an enlightening book, one that introduced me to a whole new way of thinking about clinical practice and the way that EBM fits into it. Some parts of the book are heavy-going, and the examples of the new research critique were not completely convincing. However, clinicians, EBM teachers, and researchers would gain from reading this book. It goes some way to explain why EBM in itself may not be sufficient for the myriad aspects of providing care to patients either as individual persons or in health systems. This is not new; however, Kieran Sweeney offers important insight into a whole new paradigm that may explain why this may be.
Matthew J. Thompson, MBChB, MPH
Department of Primary Health Care, University of Oxford
Oxford, England, UK