National Alliance for Physician Competence Discovery Workshop

Context

  • Keynote: Bob Lindberg, a practicing physician in Connecticut, then gave a talk about how his practice has transformed after applying the principles of complexity theory in his way of thinking and approaching his work.
  • Conversation: The group then engaged in a brief conversation about what they heard.

Keynote Address

Bob Lindberg

Thank you for inviting me.

I'm happy to be here to talk to you. When I was thinking about what to share it reminded me of a meeting I attended in Philadelphia back in 2000. I was intrigued by a number of things I heard at that meeting.

Afterwards I found it interesting to read about stories written by doctors and that helped me understand the terms being used and after that I could read other people.

I'm an internal medicine doctor and I've been interacting with my system for the last 21 years. I don't know that what I do should be a template for others but I want to share some stories with you.

I'll give you the bottom line before we begin.

The power of complexity science - the killer application - is the terms, the vocabulary that it gives you.

The power of complexity science - the killer application - is the terms, the vocabulary that it gives you. Science is a descriptive language and helps us make sense of the world. If we live in a complex world dealing with complex problems you want a language that helps you understand that.

Complexity has given me some good images. Before that conference in Philadelphia I was using a lot of engineering terms. An example of this is a chart I looked at last week.

Reading a chart from before that conference read a lot like this. Her chief complaint was shortness of breadth and constant fatigue, GI complaints and weight loss. At this visit I told her that she had lung disease. I did some other tests to show there were no other problems. No thyroid, no diabetes, no anemia, no heart disease, and colon normality. I also sent her for a cat scan and a CT of the chest. Her cat scan was normal.

She asked me why am I tired and what's going to happen? I said we should send you to a pulmonologist.

Bob
The way I approached this was an engineering system with a cause and affect and also a way of managing her problem. I felt obligated to answer questions about the future as well.

Then I went to that conference - and I saw that things were a system of inter-connected agents and I learned the difference between an engineered system and an evolved system. An engineered system is predictable.

An evolved system is something that you cannot break down to its parts and you have to understand the behavior of the whole. Complex evolved systems - like a weather system - the components change with the interactions. When the wind blows the temperature changes and that changes the winds. There is back and forth. It is hard to predict and hard to manage.

A complex adaptive system learns and evolves and adopts over time. It has a connection to the past, the present and the future - unlike the engineered system.

I started to think about my practice because I had a new situation to deal with. A couple of years before that conference the local hospital wanted to manage my practice and it sounded good to me. But it was a flop - it didn't work and the hospital knew it. The patients didn't like it either. So the hospital came to me and said I needed to go back to managing my own practice.

What we ended up with when the hospital came in was unhappy people. They provided an office manager and a policy manual this thick.

When I left the conference I remember saying to myself: simple rules, simple rules, simple rules. This is something that came from the conference. Complex systems have complex interactions and the components make the behavior hard to understand

After attending that conference I decided to throw out the employee manual and developed three simple rules.

After attending that conference I decided to throw out the employee manual and developed three simple rules. The first rule is to treat everyone the way we want to be treated. The second was to make more money then we spend. The third rule was there are no other rules.

We've had no turn over since then. I started to think more about these things and to pay attention to different things. A good theory helps you know where to look and where not to look. Complexity science starts to focus your attention on the interconnections and interaction of the components.

In the new way I started paying a lot of attention to the interactions and nurtured those interactions and understood that you don't get in the way of what happens naturally.

There are things that happen naturally. Structure, function or meaning - might happen whether you want it to or not.

People in my office know how to do things better then I do. Why should I tell them how to do that? Not to have titles and a hierarchy - there is no time to look at the employee manual to figure things out. Things are always happening and things are emerging that are unexpected.

You need a flexible, nimble organization to handle these things on the fly. The question is, "How to make your organization more flexible, adaptive and nimble?"

Emergence is the arising of new unexpected patterns or processes in a self-organizing system. I began to think about how I was talking to my patients. I began to adopt a non-linear conversation or a walk in the park conversation. Traditional conversation is to rule out certain things - it's an interrogation. In a primary care practice things are nebulous and you need to have a creative conversation and have a relationship that is very therapeutic. It's natural to have a conversation rather than an interrogation.

The world we live in is an image in our brain and we make a mistake when we think we live in the same world as everyone else. The details are fleshed in by what is happening to us at the time.

My interrogation system wasn't tapping into the patient's images. My simple rule is to say what is on the top of my head (with few exceptions). The patient picks up on that and replies in kind. It's a very surprisingly efficient conversation and arrives at a solution and uncovers the hidden agendas and concerns. It's a rich conversation.

I don't use it in all situations. If someone has a broken leg then they want to be out of pain. But for something like chronic pain or back pain or just about 90% of what you do in primary care lends itself to this kind of conversation.

If I had used this emergent conversation with the patient I mentioned earlier I would have arrived at a solution and understood her situation sooner.

Equilibrium is death in bio-chemistry. I would have thought she needs energy and oxygen to burn fuel efficiently. She was being confined to her home. Complexity science helps you understand time and what has evolved over time. We need sun exposure to maintain the body clocks inside us. Without that exposure to the sun every day you get jet lagged. I would encourage this lady to get outside and get some sun.

Exercise is a way of forcing the overall system to talk to each other. The answer to chronic broken parts is to try to enhance the overall system health. It's helpful to the component that is broken to enhance the overall system. There is also a social component. We need our social relationships.

She had bowel problems and sleep problems. That is an issue of rhythms. The body is an interconnected set of oscillators. If they are in tune with each other they stay healthy. If there is a problem with the flow of information - one way evolution does that is because of oscillators. The vocal chords sends out vibrations to your ears and information is transmitted without degradation across distance, and different mediums.

That kind of dynamic is going on everywhere. I would not have looked at this kind of thing without understanding complexity science.

A loss of rhythmic things is degradation of harmonic modulations across all the oscillators. The system is getting degradation.

My new roll is someone that is participating in the self-organizing patterns of meaning and behavior with my patients. Good flow of information and story telling. Empathy, sympathy - evolved systems rather then engineered systems.

I'd like to close with a quote that attracted my attention originally. It's by James Goodwin.

Chaos theory (Complexity Science) does not attack the established findings of traditional science; it simply points out the limitations of a linear, reductionist approach in our attempt to describe natural phenomena. The great gift of Complexity Science to the practice of medicine has been the simple but profound negative statement: traditional medicine cannot predict complex systems. People are complex systems. We spent the last century of scientific medicine studying primarily what we could measure. This is understandable. However to value and teach only those aspects of medicine that we can study and measure is indefensible. Complexity science disabuses us of the notion that with better methodologies and understanding we will master complex phenomenon. It gives us the concepts and vocabulary to articulate the fact that much of the practice of medicine is outside the realm of modernist reductionist model of science... The Physician labors in a sea of uncertainty, but our vocabulary - the product of scientific medicine - communicates a degree of determinism that doesn't exist. We can use the conceptual framework of Complexity Science to teach our students valid ways of analyzing complex systems that do not promise total understanding or predictability. When complete understanding is abandoned as a goal, the traditional tasks of the physician - listening, witnessing, relieving suffering - will no longer be relegated to a small corner of medicine, the so called art of medicine, but will be returned to the core of medical practice and medical education. James Goodwin JAMA 11/97

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Conversation

Q: I would be interested in a comparison in the function of your office before and after in terms of being adaptable.

A: I frequently hear about other doctors from my patients. They may transfer to me and say a doctor is a great doctor but their office is a mess. It doesn't matter how good you are and what you know. If you don't have flexibility and adaptability you are dead. I can't say I mapped out how to be more flexible. A good flow of information is critical. Computers as well as humans. Trust. Lot of conversations. Lots of lunches. The interconnections are key. Those interconnections were discouraged before. That is very in-efficient.

Q: The comments you made evokes some thoughts about eastern medicine.

A: I don't know much about eastern science. I think it's about understanding the collective behavior of the whole. Eastern philosophy has been way ahead of us. The age we are going to is beyond reductionism towards understanding the collective behavior of the whole. How do they stay orderly with no one in charge? The body is changing and there is an orderliness to it. It's a connection to getting away from thinking about us as being un-attached to the rest of the world but we embody the past as well. You can't divorce yourself from the community and the weather and your family. These are systems that are both connected and embedded in other systems.

Q: That made me think about networks. You have a node and a network. How do people know each other? Someone did some research that people are 6 degrees from anyone else. There are not that many steps from one part of the system to another part of the system.

Q: Can you share a few thoughts about the breakdown of complexity and aging?

A: There is a lot of provocative research about thinking of aging as a loss of healthy complexity. In a healthy system there are a lot of connections and redundant connections and a lot of information flowing. There is a loss of components and a lot less interactions and less complex organisms as you get older. Parkinson's disease is an example.

There are mathematicians that have taken the vibrations of the hand of a person with Parkinson's and seen that there is less information flowing and a loss of complex system interaction.

How do you check the health of the overall system? You can put a piece of gum in a patients mouth and ask them to walk.

You can check their heart rate and see that it is always varying up and down. It's constantly changing. It's at the heart of everything and all that interaction causes variability. There is data that shows that during disease or aging the heart rate variability diminishes. It's a loss of normal complexity.

You can measure that and look at the pattern. You can look at heart rate data plotted over time. How do you look at the whole system and see if the whole system is healthy?

I am not suggesting you abandon your roll and look for problems or stop doing diagnostic tests that are appropriate. You need a foot in both worlds. I am still a tester but some times that emergent conversation focuses on where the patient's concerns are and that might bring out some information that helps decide what to do.

Q: It's like listening between the lines.

A: Listening is therapeutic. It's story telling and I've learned not to interrupt those stories. I remember their stories and that fosters that relationship. What I can give them is a relationship that is therapeutic.

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