http://bmj.com/cgi/content/full/324/7330/171

 

BMJ 2002;324:171 ( 19 January )

Letters

Complexity science

    Let them eat complexity: the emperor's new toolkit
    New approaches to evaluation of treatments are needed

Let them eat complexity: the emperor's new toolkit

EDITORPlsek and Greenhalgh's example of complexity in health care is absurd.¹ Do they really encourage us to believe that, if only Dr Simon had some grounding in complexity theory, she would have been able to understand why getting rid of lunch time upsets her colleagues? We do not have to appeal to the science of complex adaptive systems, chaos theory, catastrophe theory, Einstein's general theory of relativity, quantum mechanics, or even Freudian psychoanalysis to appreciate the distress of Dr Simon's hungry staff.

Although Plsek and Greenhalgh's aim may have been to make some fairly abstract science more accessible, the result is misleading and potentially harmful. The series does not articulate honestly the background to the emerging study of complex adaptive systems by switching repeatedly between misapplied metaphor and empirically grounded science. I suppose contemporary NHS managerialism has to have its own body of knowledge and set of techniques to bolster a sense of expertise, but it could do better than borrow from the wilder shores of the popular business section of the airport bookstore.

Greenhalgh's series continues the tradition of misusing scientific concepts by confusing technical terms (for example, non-linear, attractor pattern) with "homey" everyday ideas (for example, hidden needs and motivations), in the manner described by Sokal and Bricmont.² This misuse of mathematical metaphor is hardly an original treatment and was regularly promulgated among business management organisations in the United States for at least a decade. Late and a bit stale, it is beginning to appear regularly in the BMJ.³ The antirationalist outcome has more in common with 19th century romanticism than the sophisticated, postmodern thinking that proponents imagine they practiseserving political and careerist, rather than scientific, ends. There are useful applications of chaos theory (an established subset of the more speculative complexity theory) in the clinical sciences: the analysis of cardiac electrical rhythms; electroencephalography in epilepsy; sugar concentrations in diabetes patients; the behaviour of waiting lists; and so on. Unfortunately these ideas may be swamped by the intellectual snake oil of "complexity theory as metaphor," easily identified by the absence of mathematical modelling, which I fear we can expect to see spattered, expensively, across massed ranks of flip charts by healthcare administration faddists in the United Kingdom.

Plsek and Greenhalgh seem to authorise a means by which uncomfortable situations (for example, tension caused by poorly managed services) may be dismissed as spooky natural phenomena over which to stroke one's china handy conceptual toolkit for the credulous healthcare manager on an inadequate budget.

Ian Reid, professor of psychiatry. 
University of Dundee, Dundee DD1 9SY

1.	Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ 2001; 323: 625-628[Full Text]. (15 September.)
2.	Sokal A, Bricmont J. Intellectual impostures. London: Profile Books, 1998.
3.	Kelley MA, Tucci JM. Bridging the quality chasm. BMJ 2001; 323: 61-62[Full Text]. (1 July.)

New approaches to evaluation of treatments are needed

EDITORI enjoyed the fresh look at the world of medicine provided by the four articles on complexity science,¹ but I am not sure that swapping the old rules for the mathematics of complexity theory are right. Maybe the rules of complex systems are simpler and more fundamental than we think. In his seminal work The Tao of Physics Capra identifies six things that should govern scientific thinking²:

• Knowledge of the structure does not predict function
• Process is primary and determines structure
• The observer is part of the whole system
• There are no fundamental equations
• All descriptions are approximations
• Cooperation not dominance should prevail.

These paradigms can be applied to the world of medicine² and have provided me with a different perspective in my clinical practice. I suspect that they are applicable to all other specialties; if they are not then Capra's paradigms are flawed.

I was sorry that the articles in the series did not address the issue of research. When I applied Capra's paradigms to research into chronic pain³ I was able to understand why it is so difficult to undertake. Classical approaches to clinical trials (randomised controlled trials, for example) fail when one is trying to assess the effects of drugs with complex neurochemical effects in patients whose pains are a complex of biological, psychological, social, and spiritual elements. A look through the leading pain journals shows the rarity of classical clinical trials. Yet chronic pain afflicts about 1 person in 12.

In complexity lies the reason why it is so difficult to evaluate the effects of interferon beta or cannabinoids in multiple sclerosis. Clinical trial methodology does not overcome the problem of complexity in patients. We need new approaches to the evaluation of treatments that not only move away from the analytical reductionist approach but also remain rigorous and acceptable.

William Notcutt, consultant anaesthetist. 
James Paget Hospital, Great Yarmouth NR31 6LA willy@tucton.demon.co.uk

1.	Complexity science. BMJ 2001; 323: 625-628[Full Text], 685-8, 746-9, 799-803.
2.	Capra F. Tao of physics. 3rd ed. London: Flamingo, 1992.
3.	Notcutt WG. The tao of pain. Pain Reviews 1998; 5: 203-215.

© BMJ 2002

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EDUCATION AND DEBATE
Complexity science: The challenge of complexity in health care.

Paul E Plsek and Trisha Greenhalgh
BMJ 2001 323: 625-628. [Full text]  

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