Complexity Theory and Family Practice Complex Consultations and

Complexity Theory and Family Practice: Complex Consultations and the “Edge of Chaos” Andrew Innes Frances Griffiths Peter Campion

Complex Adaptive Systems “A collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents. ” Plsek. P, Greenhalgh T. The challenge of complexity in health care. BMJ 2001; 323: 625 -628.

Clinical Interactions through a Complexity Lens Clinical consultations are seen as complex processes where meaning emerges often unpredictably from the interaction between the clinician and the patient. The role of the clinician therefore becomes that of an enquiring participant who seeks to influence change in a patients condition.

Research Questions n n Does Complexity Theory help us to understand consultations in general practice? Do doctors and patients view consultations in a way that is consistent with understanding them as a complex system?

Method n n n Qualitative focus group study with general practitioner (4) and patient groups (4) Focus groups included a brief presentation introducing Complexity followed by focus group discussion. Analysis used a constant comparative technique supported by n. VIVO.

Findings n n n Attractors “Edge of Chaos” Complexity filtering

Attractors in the consultation Computers: One of the interesting things about computers is they are non chaotic. They do tend to force you into, into a very structured role; em or they behave in a very structured way, in a pretty non-chaotic way. General practitioner (Group D 3)

Continuity of Care ST I think the comfort zone is continuity to both parties but I think there is a danger of complacency isn’t there and I think that sometimes it is useful to have actually seen another doctor sometimes they can pick up things you may have missed. SF The fresh look at things ST Yes or just checked, it’s sort of like a cross check sometimes… General Practitioner (Group D 2)

A personal clinical approach L Well we did have a partner who I think definitely fell into that category and I used to quite often be the second opinion because they were just not happy, you know, that such and such was you know, that was going. Err he was very keen on manipulating necks and it seems just about every problem could get down to having your… PD Neck manipulated. L …neck manipulated, you know. And you would have people coming in, you know, with erm, you know, sort of saying “Well, he manipulated my neck and really that wasn’t what I was in about something else”, you know. General Practitioners (Group D 3)

Diagnosis I’m always open for new ideas but I just get the impression that sometimes if someone has made a diagnosis, not just doctors but anything, that then other people are quite sort of reluctant to, without really strong information, others are quite reluctant to go against that. Patient (Group P 1)

The “Edge of Chaos” Pull yourself together man!

Patient Actions I called the doctor back saying he’s not right, you know and the doctor came stomping in, obviously annoyed to high heaven that I had called him back. Why isn’t he out of bed? , why are the curtains closed, why isn’t he up and doing things? , he should be fit. I said there is something wrong, this is not my husband, he doesn’t stay in bed, he doesn’t do this and he just didn’t listen, he just completely dismissed it out of hand, and said “well these things take time he has just got a headache”, it’s a virus, it’ll take time. Well I’ve had viruses, but I know myself after 4 days if it’s not shifting there is something wrong, and I don’t know what snapped but I actually rang the doctors and demanded a second opinion and within half an hour the doctor was back on the phone saying that he’d got an appointment at Hull Royal and I was to take Paul straight down to this particular ward. Patient (Group P 1)

Doctor Actions There was one in the British Medical Journal, the BMJ which I used to have on my wall about a bloke who came in and moaned every week for years about this chronic low back pain and finally the Doctor just couldn’t stand it so he just took a newspaper out and read the newspaper, and finally the patient shut up. He rolled it up, whacked him on the head and said, “Pull yourself together man!” And the patient walked out, and the, the Doctor expected the police to come shortly afterwards. A couple of weeks later he came back and said “Thank you very much. I have finally pulled myself together”. General Practitioner (Group D 3)

Nature of the Clinical Problem ST Well - I went along to the methadone talk last week and I’m thinking I haven’t got many methadone clients – I’ve had 2 this week and both of them I have taken an element of risk in the consultation to do with the prescription and there is, erh, yes there is risk with a certain element with you know the client group. If you don’t prescribe them I shall be off doing this or that. DR Such as? M What sort of risk did you take? ST Erm, risk of, ermm, loss of trust from the patient, erm risk of them harming themselves or somebody else mainly. Risk of going off the usual rules, erm those three areas mainly. General Practitioner (Group 3)

“Complexity Filtering” PM …we all know, em because we have been doing it for a good few years now, we all know that interaction is anything but simple… TM Mm. PM …between the Dr and the patient. It is multifaceted and whatever else you want to, you know, there are many other terms you can use. And there are lots of directions you can head off, lots of things get thrown out, little bits you’ll pick up, sometimes you’ll leave them for another day, sometimes they just get lost won’t they? General Practitioner (D 3)

Proxy Assessments PH … It’s very difficult to get a handle on anybody you haven’t seen the first time round. I don’t know if you find that experience… PH when your registrar says to you MH Yeah. PH “I’ve got this patient which has this and this”. Actually getting a proper handle on them third party is very, very difficult. General Practitioner (D 3)

“Stripped down” Consultations PD … I just accept that different role. You’re out of hours TM Mm. PD role is err actually fairly simple. It is much more simple medicine TM Mm. PD than what you are trying to do and, and you don’t need so much information. You basically need to know, does the patient need to be in hospital? Do you need to give them something now?

Conclusions n n n Complexity Theory does seem to offer a useful framework for the analysis of consultations. Doctors and patients do discuss their experience of consultations in ways that are in tune with complexity thinking. Positive and negative influences of consultation “attractors” can be identified. The “Edge of Chaos” is a risky but potentially creative zone in which consultations can take place. Complexity filtering is a central task of the consultation Analysis of consultations within a complexity framework is of practical use to doctors and those who teach doctors to consult

Contact details: a. d. i@btinternet. com