#KeyLIMEPodcast 223: Chaos networks complexity and other shiny words

The co-hosts take a look at complexity science as they review a paper that attempts to describe patterns of use of complexity principles and considers, in Jon’s words: does complexity science address the oxymoron of bringing order to a system that (by definition) is unpredictable?  Listen here.


KeyLIME Session 223

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Cristancho et al.,What is the state of complexity science in medical education research? Med Educ. 2019 Jan;53(1):95-104.


Jon Sherbino (@sherbino)


During my internship in global health, nearly two decades ago, medicine seemed far less complex than my typical, current day.  Perhaps it was because I had only five antimicrobials available to me and only two diagnostic modalities (a blood smear that I examined myself and an x-ray).  More likely, the perception of a “simpler time” was a function of my own inexperience and dyscompetence.  However, anecdotally, it seems to me that year-on-year the practice of medicine becomes more complex as technology advances, health systems groan to carry a load they were never designed for, and patient needs, complex physiology and the environment intersect in jarring ways.

Complexity is the buzz word, the God term, the sound bite, uttered at the start of every strategic planning meeting I’ve attended in the past year.  Can you not feel the static in the system?

Complexity science and the study of complex, adaptive systems have been in existence for a long time, but are generally regarded as entering academic discourse in the mid 20th century (think general system theory and cybernetics).  One’s take on complexity science is influenced by the discipline of the scholar with one framework arguing for algorithmic (where computational representation of an environment is desired), deterministic (where nesting of elements and the associated feedback loops represent the environment) and aggregate (where the deterministic elements are acknowledged as less predictive and learning and dynamic change in the environment is considered) approaches.  In other words, does complexity science address the oxymoron of bringing order to a system that (by definition) is unpredictable with outcomes that cannot be reliably repeated.


…to describe the patterns of use of complexity principles and to consider the consequences of those patterns for our ability to advance scholarly conversations about ‘complex’ phenomena in our field.”

Key Points on the Methods

Using a series of review papers to map highly cited manuscripts on complexity science in the health sciences, a quasi-systematic search of the medical education literature, including 3 highly cited journals and 2 open access journals, was conducted.  46 papers ranging from 2000-2017 were included.  None of the typical synthesis checklist items were explicitly described. Only papers with a theoretical underpinning of complexity were included.

Key Outcomes

Principles such as fuzzy boundaries, adaptation, non-linearity, unpredictability, and self organisation, allow for the representation of illness as “dynamic interactions within and between multiple systems” and not the simple failure of a single organ. These ideas re frame an organization as relationships between many parts and not isolated parts within a common leadership structure.  Finally, in education complexity reinforces the acquisition of competencies that allow for adaptation, when knowledge is constantly changing.

Interprofessionalism, life long learning, change management and social responsibility are specific themes that emerge from attention of complexity science in health professions education.

In health professions scholarship, this review identifies four key themes:

1. complexity is defined in various and non-explicit ways
a. colloquial definitions
b. minimal elaboration of theory
2. within a single study multiple (and conflicting) approaches to complexity are used as a type     of ‘unconscious variety’.
a. failure to recognize or incorporate legitimate disciplinary perspectives on complexity
b. inappropriate scope creep from precise frameworks
3. the type of complexity science used is typically implied rather than strictly defined
4. primary citations to support complexity science are infrequent

Key Conclusions

The authors conclude…

“Do medical education scholars understand that there are multiple legitimate orientations to complexity science, deriving from distinct disciplinary origins, drawing on different metaphors and serving distinct purposes? If we do not understand this, a cascade of potential consequences awaits. We may assume that complexity science is singular in that there is only one way to do it. This assumption may cause us to perceive our way as the ‘right’ way and to disregard other approaches as illegitimate. However, this perception of illegitimacy may limit our ability to enter into productive dialogue about our complexity science-inspired research.”

Spare Keys – other take home points for clinician educators

This paper includes a great infographic mapping various approaches and ideas relevant to complexity science.  The meta is not lost on me.  This visual representation really makes a complex idea less linear and more accessible.

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