Complexity, Uncertainty and Mess as the Links Between Science and the Humanities in Health care

Abstract

In medical school I was taught the mantra of history, examination, diagnosis and treatment. Each was supposed to follow the other in a rational and linear sequence with a single diagnosis suggesting appropriate treatment. Yet in practice, it is almost never like this. A single patient has hypertension—so far so good—but she also has bronchiectasis after many years of smoking. She has just been diagnosed with cancer of the oesophagus. She has a daughter with severe learning difficulties and she is fearful, not only for herself but also about what will happen to her child. She is married and the relationship is difficult. Her sister has lung cancer and is already very ill. The sister’s children have problems and children of their own and this is only the beginning of a story which has become richer and richer the longer I have known this patient and her family. It is a story with multiple components each of which interacts with the others unpredictably. Each of the components has a history which affects the interaction and each has the capacity to affect my patient’s blood pressure and to support or undermine the treatment that I am prescribing for her. Seeing this situation as a complex adaptive system is much more useful than trying to stick to the medical school mantra because sensitivity, intuition, commitment and a pragmatic preparedness to muddle through then become as important as a sound grasp of biomedical knowledge.

The core of this chapter was first written as a keynote presentation to the Annual Conference of the Royal New Zealand College of General Practitioners in Wellington in 2004 (with permission from NZFP)