Systems and Complexity Thinking in the General Practice Literature: An Integrative, Historical Narrative Review

Pioneers of general practice from the fifties to the seventies of the last century saw themselves confronted with data they had not expected. In Austrian GP Robert N. Braun's (1) distribution of encounters' outcomes the highest ranking and least hardened 20% of all diagnoses paradoxically labeled 80% of all encounters. British Epidemiologist Archie Cochrane (2) found a skewed Gaussian distribution of intraocular pressure with glaucoma paradoxically occurring widely across the distribution even below the mean. British GP Marshall Marinker (3) experienced encounters he could not handle with the skills of his Balintian training but only cope with by hermeneutics of chaos borrowed from Foucault and Borges. These pioneers described implicitly and for the first time the complexity of general practice and it should last till the turn of the century that this complexity was made explicit.

Sturmberg et al. show us by the bibliometrical part of their review that the process of making complexity explicit is a self-referential one. The increasing flood of publications on complexity since the nineties of the last century has properties of an exponential or Pareto distribution - which is a strong marker of complexity itself. Therefore one would prefer to see this crucial graph within the article and not in the annex. By the narrative part of their review and the timelines graph the authors illustrate that first findings of complexity in general practice took place whilst the development of tools to handle complexity was done by other disciplines - e.g. Mandelbrot's chaos research - in the sixties. The timelines graph demonstrates complexity also as an "attractor". The founding of general practice's scientific societies coincided with the first and still implicit complexity findings in general practice and built an institutional matrix helpful to make general practice's complexity explicit. Systems philosopher Niklas Luhmann (4) early addressed to a major problem of complexity research by asking if reduction or respectful preservation is the apt approach. General practice's state of the art can be looked at in Sturmberg's et al (5) actual handbook. The vast majority of its articles has a hermeneutical describing approach, only a minority has a reducing or sensu strictu mathematical one.

This article tracks down systems and complexity thinking in general practice to its implicit very beginnings. This year's first international congress on the item (held in Washington DC) will look forward questioning how to deal with it explicitly. "Exploration or explanation?" seems to link up again with the two possible modes of approach already discussed by Luhmann.

References
1.Braun RN. Die gezielte Diagnostik in der Praxis. Stuttgart: Schattauer Verlag, 1957 (p168).
2.Cochrane AL, Blythe M. One Man's Medicine. 2nd ed. Cardiff: Cardiff University Press, 2009 (p197-202).
3.Marinker M. Sirens, Stray Dogs an the Narrative of Hilda Thompson. In: Greenhalgh T, Hurwitz B (ed). Narrative based Medicine. London: BMJ Books, 1998 (p 103-109).
4.Luhmann N. Social systems. Stanford: Stanford University Press, 1995.
5.Sturmberg JP, Martin CM. Handbook of Systems and Complexity in Health. New York, NY: Springer 2013.

Competing interests: Research in general practice's epidemiology under aspects of complexity and risk.