Practice Jazz: Understanding Variation in Family Practices Using Complexity Science
Much variation exists in family practices. There is also much that is constant and deeply resistant to change.
Complex adaptive systems are like a family reunion; they are dynamic-bounded webs of diverse agents interacting nonlinearly.28 Dynamic refers to the continual presence of multiple interactions and their accompanying surprises, challenges, and responses, both within the system and between the system (eg, practices) and its environment. Bounded refers to the defining purpose or intent of the system (eg, to deliver health care to local patients). The metaphor of a web characterizes the multiple interconnections of the system. The agents in practices include clinicians, office staff, and patients, and can also include pharmaceutical representatives, health care system administrators, and others. Agents have the capacity to exchange information, learn, and adjust their behavior. No individual agent can ever know or understand everything that is occurring. The nonlinear relationships among the agents are the result of ongoing feedback loops and mean that small changes can lead to large effects and big changes can lead to small effects. For example, the introduction of a small medical record stamp to identify smokers in one practice leads to a dramatic increase in smoking counseling, while a major quality improvement program in another practice results in minimal change.
What makes an organization “professional” is the application of specialized values and expertise to address difficult problems and uncertainty. These values and skills are acquired through specialized training and are created by the larger social context.29 It is the socially defined professional values and expertise of the family physician that are applied in their daily activities. A co-evolving professional world of the health system and payer manager is increasingly interacting with the physician professional value system.
Each family practice is unique because of 5 features:
- History and initial conditions,including any explicit or implicit mission and the underlying priorities for the practice.
- Particular agents and their unique styles and interests.
- The pattern of nonlinear interactions among agents.
- The local fitness landscape(ie, the practice’s ecological niche) and its particular expectations, community values, competitive issues, and ecology.
- Regional and global influences, such as larger health care systems, finances and regulations, and culture.
The local fitness landscape, a complexity science term from evolutionary biology, specifically refers to the local terrain and all the many complex adaptive systems, from microbes to organizations, that seek their own purpose and niche within that terrain. Biological evolution and technological evolution are processes attempting to optimize systems riddled with conflicting constraints.30 Each family practice must evolve by attempting to optimize the entire package of services it delivers. This evolution must account for all the other competing and cooperating health care services and local resources, such as economic conditions, availability of insurance types, and the particular local disease and illness epidemiology.
How all of these factors manifest in a particular family practice at any given time and over time can be understood using 3 complexity science properties: self-organization, emergence, and co-evolution. Self-organization refers to the spontaneous development of structures and forms of behavior in systems characterized by multiple feedback loops and nonlinear dynamics. These structures are a function of the patterns of relationships among agents. Everything changes in response to and as a result of everything else, with each complex adaptive system seeking a better position in its local fitness landscape—a niche where it can prosper and survive.31 In this setting of ongoing co-evolution, both competition and collaboration become strategies for workable solutions. As the agents of any complex adaptive system interact, novelty and surprise continuously emerge in unpredictable ways. For example, a new successful approach to scheduling is introduced by an unassuming receptionist. This emergence creates a system that is greater than the sum of its parts; it is what cannot be understood through a reductionist (one problem at a time) examination of the practice.32
A particular family practice is the unique self-organized system that emerges when particular physicians and staff (agents) come together in particular ways with particular goals, preferences, and priorities (initial conditions) within a particular community setting (local fitness landscape) given specific regional and global influences. At any future point, this practice is the unique self-organized system that has emerged through co-evolution with all the other systems in the local fitness landscape.
The result is much variation between and within family practices. Practices have much in common, however, because of their common goal of seeing patients to assist them with their everyday health problems in a shared cultural and historical context. From that perspective, variation in family practices is inevitable and a powerful source of creative possibility, value, and good clinical practice. Practices use 2 strategies for successfully enhancing that creativity: sensemaking and improvisation. Sensemaking is a social activity that requires interaction among agents.33,34 People must come to have some notion of “Who am I,” “Why am I here,” and “What is going on around me?” Improvisation is a strategy for dealing with surprise in complex adaptive systems. Improvisation can be described as intuition guiding action in a spontaneous way.35 Intuition is not a random guess at what to do, but the result of using high levels of expertise to act in the moment.27,36
