Table 2

Stepwise Adoption of Systems and Complexity Sciences Into General/Family Practice Research and Literature, by Adoption Period

Period and Key Complexity Science TheoriesCritical Assessment: Study Design and FocusWhat These Articles Added to Our Understanding
Before 1995413: general systems theory and cyberneticsDescriptive design47,913
The dynamic nature of the illness trajectory5
Teaching family dynamics in residency programs,6 using genograms to understand family dynamics,9 and illustrating chaotic system dynamics within families12
Ecosystemic description of the diagnosis4
The need for a paradigm shift7
Medicine as a human science deals with the nonlinear causality of illness and acknowledges the patient as a self-organizing system10
Culture as a meaning system influences health and illness, their meaning, and the response to treatment11
The need to integrate care for patients with cancer13
Research design8
Survey: first attempt to characterize work patterns of different specialties for specific conditions
Exploration of the philosophy of health and disease and the role of the physician in society
Holism as a key concept of general/family practice
Context matters
• The role of the family, n → 1, 1 → n, and n → n relationships
• Nonlinear dynamics determine the individual patient’s understanding and response to his illness
• Culture explains illness experience and therapeutic responses
Ecological dynamics of disease and disease management
Nonlinear dynamics of healing
The outcome of treatments affecting dynamic systems cannot be precisely predicted
1995–20001422: initial condition, self-organization, and emergenceDescriptive design1416,19,22
The need to teach chaos theory13
General practice defines itself by reflective multicausal relationship thinking and acting15
General practice deals with health and disease as multifactorial and interconnected personal states16
Understanding general practice through chaos and complexity theories19
Research design1721
Case study: response to diabetes care intervention17
Observational study: prevention in primary care practice18
Methodology study: the use of different statistical techniques, cluster analysis, and loglinear analysis19
Observational study: change in primary care practices20
Observational study: integrative nature of primary care consultation to meet patient need21
Defining the discipline of general/family practice
To understand the apparent randomness of outcomes in the natural world
Relationships matter
• The doctor-patient interaction, the particular circumstances of the patient, the organismic behavior of the body, the integration of mind and body
• Illness and healing result from network relationships
• The needs and benefits of ongoing therapeutic relationships
• The link between the patient’s illness and his community
• To facilitate practice change
Sudden changes in behaviors in relation to a change in circumstances (now known as cusp catastrophe)
• Patient self-management
• Consultation behaviors
General practices are complex adaptive systems whose stability arises from adherence to their attractor
Change requires awareness of and change in the attractor
Without general/family practice, the health system becomes dysfunctional
2000–20052329: dynamics in systemsDescriptive design2329
Applying complexity science principles to the function of medical practice23 and the understanding of the biopsychosocial model28
Family practices are local professional complex adaptive systems24
Understanding and managing in complex adaptive systems26
Constructing a complexity model of continuity of care and illustrating its veracity using previously published outcomes data27
Understanding the interconnected issues affecting the primary care workforce crisis29
The function of medical practice
Interdependence of its members
Emergent function arises from its historical context (initial condition)
Variability characterizes clinical practice
Small change can result in large outcomes and vice versa
Transformational leadership acknowledges the networked structure of the system and there interdependent interactions
Leaders maintain creative tension between cooperation and competition
Feedback loops show the patterns of interactions and outcomes in a complex adaptive system
Systems diagrams as a tool to seeing and appreciating interconnectedness and feedback
After 20053058: networksDescriptive design3032,3541,4347,4954,57,58
Healing is the process of reestablishing wholeness30,45,47,49
Consultation dynamics31,45,46 and outcomes32,46
Care team development, practice development, and dynamics35,57,58
Health systems and health system reform3638,43,44,50,5254
Toward an integrated understanding of health37,47,49 and disease41,43,45,47,49
Developing a safe health care environment39
Complexities of understanding and managing comorbidity40,4345
The generalist’s way of knowing51
Primary care paradox52
Research design33,34,42,48,55,56
Database analyses
• Patient consultation rates for general and specific conditions33
• Determining the complexity of primary care consultations56
Multimethod studies
• Reflective process to inform improvement in primary care practice34
• Clinical governance: toward a collaborative partnership approach55
Systematic review: dynamics of care planning42
Cross-sectional survey: uncertainty in primary care48
The application of systems theories to general/family practice activities
Interdependence and coevolution of patient and doctor in the healing relationship
Attractors limit the possible range of behaviors and resist or limit change in patient outcomes
Physiologic variability is a sign of health, loss of variability a sign of disease
Health and illness are personal dynamic states, influenced by context and variable over time, and the emergence of comorbidity
Patient consultation rates in general and for specific conditions follow power law distributions
Dynamic adaptive processes facilitate team care development
Understanding the structure and function of health systems as complex adaptive systems
Generalists understand that their knowledge base is cross-disciplinary, context sensitive, and emergent over time
Holism results in better quality, better health, greater equity, and lower cost for individuals and populations
Safety in health care is an emergent process within the dynamics of the health systems as a learning organization
System tools such as concepts maps and system diagrams facilitate an understanding of the patient’s illness and provide leverage points for care interventions
System dynamic approaches reduce the risk of making unforeseen mistakes
A holistic epistemology is associated with less stress reaction to uncertainty among primary care physicians