Practice Jazz: Understanding Variation in Family Practices Using Complexity Science

Sensemaking may be enhanced by considering the 4 ways of knowing health and health care,⁵¹ which include understanding: (1) the clinician; (2) the patient, family, and community; (3) systems; and (4) scientific evidence about disease and treatment. Judgments about the variation can be made within each way of knowing. Desirable variation due to clinician factors should build on each clinician’s unique skills and values, and compensate for or improve weaknesses. Local adaptation of objective evidence and the development of unique approaches to meeting the needs of patients in their personal and local context represent potentially desirable sources of variation. Evidence-based medicine provides a basis for reducing variation on the basis of scientific knowledge developed from studies of groups of individuals. Systems that integrate scientific evidence with the unique needs of patients, families, and communities and the specific talents of clinicians represent an opportunity for interventions that both reduce variation from known effective health care approaches and increase variability that personalizes care. Complexity science can help us to look for the inter-relationships among these different ways of knowing and to recognize what is not knowable or controllable. Yet, complexity science represents only a partial answer to efforts to integrate these diverse perspectives. There is a need for additional theoretical work to develop approaches that both include and transcend current ways of thinking.^52,53

Family practices are systems co-evolving within fitness landscapes where there is a continual need for sensemaking and improvisation. This is particularly true during the current period of rapid change and co-evolution of practices with a rapidly changing health care system. Excessive standardization with the goal of trying to maximize each part is as potentially problematic⁵¹ as variation from scientific evidence. Like a healthy body, a healthy practice represents a balance of the generalizable and the particular. The result is tension between the local, the regulatory, and the universal—and between patient, professional, societal, and ecological expectations. We believe the principles of complexity science explain why linear quality improvement interventions (one disease at a time) often have limited effect and poor transportability.^{15,16,19,54-56} These principles may also explain why countries with a higher proportion of primary care services have better population health status^36,57,58 despite the repeated observation that specialists do better at following disease guidelines and improving disease specific outcomes.^59-61 It is never just about the specific; it is about the specific in relation to the whole, and the whole is always more than the sum of the specifics. Good primary care serves all members of the community well with the resources available. Further application of complexity science to understand these paradoxes will require more quality longitudinal data in multiple practices and broad integrative measures of the process and outcomes of care.^51,62

Conclusions

Family physicians are told to implement guidelines, to diagnose and treat in specific ways, and to eliminate variation in practice. Our study using complexity science suggests that this is only part of the story. Family practices are systems that self-organize, reveal emergent behavior, and co-evolve. Successful practices are those that minimize errors, make good sense of what is happening, and effectively improvise to make good practice jazz. Seeking to eliminate error by dampening all variation through the imposition of excessive standardization and external controls is unlikely to be sustainably effective and is likely to have long-term negative consequences. We encourage all family practice staff members to become knowledgeable of practice guidelines and evidence-based practice; these are some of the core skills of good patient care.⁶³ Using these core skills to implement flexible, locally meaningful systems may reduce error. Also, efforts to change and improve future practice are best served by focusing on improving care as a whole and on developing the skills of reflective practice and relationship-centered care.⁵¹ We encourage policymakers to acknowledge the potential benefits of some kinds of variation and to support its healthy evolution.

Acknowledgments

The data used in our paper came from studies supported by a grant (1RO1 HS08776) from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and grants from the National Cancer Institute (1RO1 CA60862 and 2RO1 CA60862). A A grant from the Center for Research in Family Practice and Primary Care, Cleveland, New Brunswick, Allentown, and San Antonio, supported communications, analyses, and writing. We are grateful to the practices participating in the research on which our paper was based.