Clinical evaluation: constructing a new model for post-normal medicine

The converging paradigms of holism and complexity: An exploration of naturopathic clinical case management using complexity science principles

RATIONALE

Traditional whole systems of medicine, such as naturopathy, are founded upon holism; a philosophical paradigm consistent with contemporary complexity science. Naturopathic case management is predicated upon the understanding of an intimately interconnected internal physiological and external context of the human organism-potentially indicating a worldview aligned with a complexity perspective. In this study we investigate naturopathic clinical reasoning using a complexity lens with the aim of ascertaining the extent of correspondence between the two.

METHOD

Mind maps depicting case presentations were sought from Australian degree qualified naturopaths. A network mapping was undertaken, which was then analysed in accordance with a complexity science framework using exploratory data analysis and network analysis processes and tools.

RESULTS

Naturopathic case schematics, in the form of mind maps (n = 70), were collected, network mapped, and analysed. A total of 739 unique elements and 2724 links were identified across the network. Integral elements across the network were: stress, fatigue, general anxiety, systemic inflammation, gut dysbiosis, and diet. A modularity algorithm detected 11 communities, the primary ones of these representing the nervous system and mood; the gastrointestinal tract, liver, and nutrition; immune function and the immune system; and diet and nutrients.

CONCLUSIONS

Naturopathic case management is holistic and based on a perspective of an integrated physiology and external context of the human organism. The traditional concept of holism, when subjected to a complexity lens, leads to the emergence of a contemporary holistic paradigm cognisant of the human organism being a complex system. The application of complexity science to investigate naturopathic case management as employed in this study, demonstrates that it is possible to investigate traditional philosophies and principles in a scientific and critical manner. A complexity science research approach may offer a suitable scientific paradigm to develop our understanding of traditional whole systems of medicine.

Taxonomy for complexity theory in the context of maternity care

BACKGROUND

The linear focus of 'normal science' is unable to adequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking.

OBJECTIVE

This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care.

METHOD

A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy.

FINDINGS

The final taxonomy for complexity theory included and defined 11 components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them.

Introducing case management for people with dementia in primary care: a mixed-methods study

BACKGROUND

Case management may be a feasible solution to the problem of service fragmentation for people with dementia.

AIM

To adapt a US model of primary care-based case management for people with dementia and test it in general practice.

DESIGN AND SETTING

Mixed-methodology case studies of case management implementation in four general practices: one rural, one inner-city, and two urban practices. Practice nurses undertook the case manager role in the rural and inner-city practices, and were allocated one session per week for case management by their practices. A seconded social worker worked full time for the two urban practices.

METHOD

Participants were community-dwelling patients with dementia who were living at home with a family carer, and who were not receiving specialist care coordination. Case study methods included analysis of case loads and interviews with patients, carers, local NHS and other stakeholders, and case managers. Measures included numbers of patients with dementia and their carers, number of unmet needs identified, and actions taken to meet needs. Case manager records were compared with findings from interviews with patients and carers, and with other stakeholders.

RESULTS

The number of eligible patients was smaller than expected. No practice achieved its recruitment target. Researchers identified more unmet needs than case managers. The practice nurse case managers reported lack of time and found research documentation burdensome. Patients and carers were positive about case management as a first point of contact with the practice, as a 'safety net', and for creating a one-to-one therapeutic relationship.

CONCLUSION

Further investigation is required before case management for people with dementia and their carers can be implemented in primary care.

Thinking through health capacity development for Fragile States

The purpose of this paper is to consider capacity development for healthcare in Fragile States and its roles, for example, in securing civil and political stability, as well as improved health, within the various contexts prevailing in fragile settings across the world. As a precursor to this, however, it is important to understand how, in rapidly changing environments, the role and contribution of different donors will have an impact in different ways. This paper sets out to interpret these issues, and what becomes apparent is the need to develop an understanding of the value base of donors, which we demonstrate through the development of a value-based framework. This highlights the separate motivations and choices made by donors, but what is apparent is that all remain within the positivist perspective perhaps for reasons of accountability and transparency. However, the emergence of new interpretations drawing on systems thinking, and followed by complexity theory more recently, in understanding contexts, suggests that the favouring of any one of these perspective can be counterproductive, without a consideration of the contexts in which they occur. In seeking an explanation of these environmental contexts, which also address the perspectives in use, we suggest the use of wider multi-ontology sense-making framework such as Cynefin. Through this approach, analytical insights can be given into the interpretation, decision and intervention processes available in these different and often changing environments, thus enabling greater coherence between donor values and recipient contexts.

The limits of reductionism in medicine: could systems biology offer an alternative?

In the first of a two part series, Ahn and colleagues discuss the reductionist approach pervading medicine and explain how a systems approach (as advocated by systems biology) may complement reductionism.

Service providers' reflections on the affective domain and its influence on decision-making about treatments for chronic pain

OBJECTIVES

This study sought to explore why service providers, working within the complex area of chronic pain, do not believe that the affective domain influences their decision-making about treatments.

METHODS

These results were extrapolated from a larger multistage study based on a series of iterative postal questionnaires. Stage 1 of the large study identified, via postal survey, what treatment components service providers identified as 'important'. In stage 2, a constructivist framework was used to develop an iterative Delphi questionnaire to explore service providers' rationale for these choices. Stage 3 also employed a Delphi process and asked participants to reflect on their previous comments. Stages 2 and 3 used postal questionnaires and summary reports from preceding rounds for background information.

RESULTS

Most service providers clearly felt that 'affect' and 'self-image' had little influence on their decision-making compared to 'coherence' and 'purposiveness'. This report presents the findings of the Stage 3 questionnaire, in which participants were asked to reflect and comment on this low level of endorsement for the influence of affect and self-image. Seven themes emerged from the coded data: professionalism, self-protection, affect and experience, lack of reflective skills, ethos of altruism, lack of understanding, and model of practice. Analysis of these themes indicates a tension between what service providers feel they should do and what they actually do.

DISCUSSION

Service providers felt that affect and self-image had little influence on their decision-making. However, there is growing evidence in the literature to suggest that it is not possible, or preferable, to divorce emotion from the clinical encounter. Chronic illnesses are complex systems that do not respond optimally to linear problem-solving. Access to a wide range of information, including the affective domain, is important for effective decision-making.

Perspectives on emerging zoonotic disease research and capacity building in Canada

Zoonoses are fundamental determinants of community health. Preventing, identifying and managing these infections must be a central public health focus. Most current zoonoses research focuses on the interface of the pathogen and the clinically ill person, emphasizing microbial detection, mechanisms of pathogenicity and clinical intervention strategies, rather than examining the causes of emergence, persistence and spread of new zoonoses. There are gaps in the understanding of the animal determinants of emergence and the capacity to train highly qualified individuals; these are major obstacles to preventing new disease threats. The ability to predict the emergence of zoonoses and their resulting public health and societal impacts are hindered when insufficient effort is devoted to understanding zoonotic disease epidemiology, and when zoonoses are not examined in a manner that yields fundamental insight into their origin and spread.EMERGING INFECTIOUS DISEASE RESEARCH SHOULD REST ON FOUR PILLARS: enhanced communications across disciplinary and agency boundaries; the assessment and development of surveillance and disease detection tools; the examination of linkages between animal health determinants of human health outcomes; and finally, cross-disciplinary training and research. A national strategy to predict, prevent and manage emerging diseases must have a prominent and explicit role for veterinary and biological researchers. An integrated health approach would provide decision makers with a firmer foundation from which to build evidence-based disease prevention and control plans that involve complex human/animal/environmental systems, and would serve as the foundation to train and support the new cadre of individuals ultimately needed to maintain and apply research capacity in this area.

The doctor, his patient, and the computerized evidence-based guideline

This paper explores some of the issues raised by the finding in a randomized controlled trial (RCT) that general practitioners (GPs) taking part failed to use a computerized evidence-based guideline, nor did it have any impact on patient outcomes. GPs are expected to 'make an initial decision on every problem [patients] may present' and to address psychological and social problems in addition to biomedical ones. The computerized guideline imposed an external, largely biomedical, agenda that superseded the patient's. This disrupted the normal pattern of GP consultations and it was therefore ignored. Guidelines for any particular disease are effective if backed up by a detailed programme of education and audit. However, the large number of different conditions seen in general practice means that it is impractical to have such programmes for more than a small fraction of the clinical workload. The reductionist assumptions underlying the construction of evidence-based guidelines from systematic reviews lead to inflexible recommendations on the management of disease. Anthropologists and sociologists make an important distinction between scientifically defined diseases and the culturally constructed experience of illness. Because GPs deal with patients suffering illness that may or may not result from disease, disease-centred guidelines often conflict with their needs and wishes. The development of evidence-based medicine (EBM) was intended as a tool to help doctors make sense of evidence in the context of individual patients' problems. Few GPs are skilled in it, and it has been appropriated by powerful expert groups such as guidelines developers and the pharmaceutical industry. It is suggested that more understanding of EBM by GPs leads to better informed decision making by them and their patients.