"Why clinicians hold the key to fixing health care's complexity problem"

I once wrote a post with the title, "A jumbo jet is complicated, but mayonnaise is complex..." with the point that there is an important difference between complicated and complex.  Mary Uhl-Bien and Michael Arena came up with the concept in one of their articles ("Complexity leadership: Enabling people and organizations for adaptability"), stating, "… a jumbo jet is complicated but mayonnaise is complex. When you add parts to a jumbo jet they make a bigger entity but the original components do not change–a wheel is still a wheel, a window is a window, and steel always remains steel. When you mix the ingredients in mayonnaise (eggs, oil, lemon juice), however, the ingredients are fundamentally changed, and you can never get the original elements back. In complexity terms, the system is not decomposable back to its original parts…"

As Alex Di Miceli explains in a blog post on Medium ("Complex or complicated?"), complex systems are emergent, meaning that the whole is always greater than the sum of its parts.  Like the mayonnaise, you can't break complex systems down into their individual components easily and figure out how they work together.  Complicated systems are not emergent, so you can break these systems down into their individual components rather easily and see how they fit and interact together.  He writes further:

"A car engine is complicated, traffic is complex."

"Building a skyscraper is complicated. The functioning of cities is complex."

"Coding software is complicated. Launching a software startup is complex."

The differences between complex and complicated is similar to the difference between Newtonian physics and quantum physics (see my post, "Like clockwork?" for more on this point).   Classical physics, often called Newtonian physics is based upon Sir Isaac Newton's three universal laws of motion and emphasizes the linear, cause-and-effect nature of the world around us.  To every action there is an equal and opposite counteraction.  Output is proportional to input.  The overall system is a sum of its individual component parts.  Under this paradigm, we should be able to both predict and understand exactly what happens in a system by breaking it down into its individual components.  The laws of the universe should work like clockwork.  Quantum physics, however, is completely different.  Rather than the machine-like, clockwork universe of Newton, we appreciate that the world is quite complex (rather than complicated).  It is non-linear and emergent.  We could never fully understand or appreciate how exactly a system works just by understanding its individual components.

Alejandro Quiroga and Thomas Lee recently wrote an article for NEJM Catalyst, "Why clinicians hold the key to fixing health care's complexity problem".  They suggest (and I tend to agree with them on this point) that clinicians are ideally suited to a world of complexity, because that is exactly what they deal with on a daily basis.  They write, "The decision-making processes honed by clinicians in medical school and residency, which emphasize teamwork, hypothesis-testing, and rapid adaptation, are better suited to complex problems than the processes typically taught in business and health administration programs, and organizations can benefit from harnessing their clinicians' skills to address complex operational problems."

Drs. Quiroga and Lee also suggest that the current state of U.S. health care is a paradox, in that "systems are managed as single, predictable machines, even though they frequently face complex, unpredictable problems."  Hospitals and health systems employ a vast army (their exact word) of physicians and nurses who are used to working in a non-linear quantum universe!  And yet, over the last couple of decades health care organizations have created operating systems based upon the business and/or manufacturing industry, with a focus on Lean/Six Sigma, the Toyota Production System, standardization, dashboards, checklists, huddles, etc.  While these changes have made our operating systems better, they have fallen short of the results observed outside of health care.  A major reason for these lower-than-expected results are that they work well in a complicated world, but they don't work as well in a complex one, like health care.

They suggest that physicians and nurses are trained to lead in the complex world of health care.  They write, "If clinicians want a more agile system, then they have to engage with how it works, not just how it feels.  That means stepping into strategy, governance, and operational design with the same adaptive, emergent mindset they use at the bedside.  Administrators must allow clinicians to step into those realms, and move from controlling to enabling, from predicting to learning, and from perfect plans to rapid, iterative pilots."

It's a great article written by two very well-respected leaders in health care.  Dr. Quiroga is currently the President and CEO of Children's Mercy in Kansas City, while Dr. Lee is the Chief Medical Officer at Press Gainey Associates, Inc.  They end their article by recommending that leaders at every level (even non-clinician leaders) can start by:

1. Creating adaptive space for experimentation, in addition to standard operational systems

2. Learning to pivot and paying attention to emergence

3. Flattening hierarchy to increase information flow, ensuring leaders have access to the information being learned on the front line

4. Nurturing social capital as core infrastructure

5. Leading with curiosity and humility, knowing that without a doubt, we don't know it all.