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Caring Is Complex: And It Always Has Been.

The health care system has been described as one of the most complex industries in modern society. The confluence of rapidly evolving technology, ever shifting payment structures, expanding teams, and dynamic relationships between providers and consumers have further complicated the landscape of what we refer to as health care.

First, what is complexity? Complexity is a recent buzzword in health care circles, but what is really meant by this concept? Glouberman and Zimmerman (2002) eloquently broke down the simple, complicated, and complex in metaphors that relate each category to baking, rocket science, and parenting. (See Table 1 below.) Extrapolating these metaphors to health care provide clues to identify when we're working with complexity.

The simple realm is made for health care that involves using an evidence base with agreed upon solutions, providing fairly certain and predictable results. Simple problems in health care abound-these are the visits that fit well into 15-min appointments, brief documentation, and straightforward problem-solving. For example, diagnosing and treating strep throat is a simple health problem that fits with a simple solution. The diagnostic process and application of the medical model of thinking does not, in itself, require a relationship. Test for the bacteria, treat it if found, and rheumatic heart disease will be prevented (which is the actual reason strep throat is treated). Simple.

Complicated problems require the application of greater expertise, often combining the skills of many professionals working as a team to produce the desired result. A patient who presents with major depressive disorder is an example. The medical provider works with the behavioral health clinician to correctly diagnose; the medical provider chooses the most appropriate pharmaceutical agent, and the behavioral provider selects the most appropriate counseling intervention. With practice, repetition, and team learning, the process described can become more successful in collaboration. Working in the realm of the complicated, however, still depends on the medical model in making a diagnosis and providing an agreed-upon treatment modality, even when there are multiple team members. Though it is done for and with a patient, the a priori nature of the evidence applied is done somewhat externally to the patient, attempting to separate subject and object. The thinking that combines the best evidence of both pharmaceutical treatment of depression and counseling modality is necessary but insufficient for optimal care. It's complicated.

Complex problems, on the other hand, are unpredictable. There is no algorithm that guarantees certain results for complex problems. This uncertainty draws little utility from equations, linear approaches, or reductionist thinking. Although separating the parts from the whole are effective strategies for simple and complicated problems, this approach may actually hinder solving complex problems by not appreciating the relationships inherit in the system.

Complex problems exist within the systems they originate from, and they influence the system they inhabit. Sense-making can only occur therefore in relation to the system and is achieved through examination and understanding of the relationships between parts, not the parts alone. Complexity exists because of, and for, relationships. In this way, it is relationships that separate the complex from the simple and complicated.

Family systems theory is one example of an applied complexity approach to problem solving. Understanding the patient within the context of their family unit, their community ecosystem, and self-identified relationships better allows for the levers for change to be pulled in effort to nudge the system (patient) to emerge differently. Taking the complicated example above, it is only through consideration of the best evidence base and how it would apply to the individual, and their context, that optimal care can be realized. Success with one system or patient is no guarantee of success with the next similarly presenting situation due to this need for individualization of the evidence base. Optimal care therefore exists in the relationship between provider and patient in understanding the individual's context, as well as in the relationship between the evidence base and its applicability to the individual patient within their context. It's complex!

In health care we often strive for the one right answer, the correct diagnosis, the correct plan ... the simple solution. When this is possible, it is elegant, rewarding, and satisfying. To the extent that simple solutions work, they drive quick and easy success within the medical model. It is easy to see why they are so favored. We owe many medical breakthroughs of our modern era to the application of the simple--for example, less people die from pneumonia than 75 years ago. In this sense, the success of the medical model has contributed to health care's current level of complexity--more patients live with chronic diseases and are living longer. More people live with mental illness. We have intensified our relationship with disease by permitting so many to live longer with them, while accumulating more of them. The simple and complicated solutions in our health care system will likely continue to perpetuate this process, but is it what patients and providers are really seeking?

As the health care landscape becomes more complex, this simple approach, routed in the medical model, may no longer serve as the best medicine. When the health care team cannot "fix," how do we continue to care? The answer is complex, or rather, complexity science and systems thinking, and it is the foundation of how the medical and behavioral fields originated--caring for another, through a relationship.

Einstein once said, "Everything must be made as simple as possible, but not one bit simpler." If the health care system continues to value and push oversimplified solutions to complex problems, we sacrifice context. We lose connection to the very system we seek to influence. We put at risk the very value Collaborative Family Healthcare Association (CFHA) was founded on--relationship.

As CFHA celebrated its 20th annual conference as a change organization, we came together in Rochester, NY to reflect on two decades of work, innovation, and, above all, relationships--relationships with each other, with the communities we serve, and the health care systems we seek to improve. As Family, Systems, and Health pushes forward the field by taking on translational research, CFHA will as well. It has been CFHA's willingness to acknowledge complexity, through its emphasis on systems, that has distinguished this organization. We strive to improve ourselves, by coming together as a membership, learning from one another, pushing each other to emerge as individuals, to improve the care we provide. I look forward over the next 2 years to delve into the fray with you all. To explore together and discover your approach to the complex problems we face. What we do is not rocket science; it's far more complex!

Received January 28. 2019

Accepted January 29, 2019

Andrew S. Valeras, DO, MPH

Concord Hospital Family Health Center, Concord, New Hampshire

Correspondence concerning this article should be addressed to Andrew S. Valeras, DO, MPH, New Hampshire Dartmouth Family Medicine Residency, Concord Hospital Family Health Center, 250 Pleasant Street, Concord NH, 03301. E-mail:
Table 1
Simple, Complicated and Complex Problems

Following a recipe       Sending a rocket to the   Raising a child

The recipe is            Formulae are critical     Formulae have a
essential                andnecessary              limited application
Recipes are              Sending one rocket        Raising one child
tested to                increases assurance       provides experience
assure easy              that the next will be     but no assurance of
replication              OK                        success with the next
No particular            High levels of expertise  Expertise can
expertise is             in a variety of fields    contribute but is
required. But            are necessary for         neither necessary nor
cooking expertise        success                   sufficient to assure
increases                                          success
success rate
Recipes produce          Rockets are similar       Every child is unique
standardized             in critical ways          andmust be understood
products                                           as an individual
The best recipes         There is a high           Uncertainty of
give good                degree of certainty       outcome remains
results every            of outcome
Optimistic approach to   Optimistic approach       Optimistic approach
problem possible         to problem possible       to problem possible

Note. Reprinted from Glouberman, S., & Zimmerman, B. (2002).
Complicated and complex systems: What would successful reform of
Medicare look like? (Commission on the Future of Health Care in Canada:
Discussion Paper No. 8. 8.). Ottawa, Canada: Communication on the
Future of Health Care in Canada. This table is a copy of an official
work that is published by the Government of Canada and that the
reproduction has not been produced in affiliation with, or with the
endorsement of the Government of Canada.
COPYRIGHT 2019 American Psychological Association, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Valeras, Andrew S.
Publication:Families, Systems & Health
Article Type:Report
Date:Mar 1, 2019
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