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The complexity
beyond guidelines
17 January 2006
There’s always a BUT
and we need to look
for it.
•A single correct answer
•Guideline initiated by diagnosis
•How-to versus whether- to
•The urge to simplify
Doctors and patients as
widgets
- one should not take it for granted that the patient longs for what others consider
perfect health.
Sarah Moss.
Signs for Lost Children, 2015.
This misrepresentation of
medical science as the solid,
simple, Newtonian certainty of engineering, rather than the
fluid, complex, Einsteinian doubt of biology, has misled not only the public, but the profession itself.
Julian Tudor Hart A New Kind of Doctor, 1988.
To be blunt, if one has a very thick skin, the
problems one confronts
become technical, and not the complex ones of
human relations.
Antonovsky A. Complexity, conflict, chaos, coherence, coercion and civility. Soc Sci Med 1993; 37: 969-981.
•A single correct answer
•Guideline initiated by diagnosis
•How-to versus whether- to
•The urge to simplify
…that complex,
fragmentary, doubt- provoking
knowledge which we call truth.
George Eliot The Mill on the Floss, 1860
At such moments
[diagnosis] doubt is smothered and
certainty is being manufactured.
Annemarie Mol The Body Multiple, 2002
… how to live with doubt? It isn't easy. But somehow we must
come to terms with the fact that we live in an undetermined
world, where doubt can always be raised. Somehow we must learn
to understand how it is that, given this possibility, we can still act.
Annemarie Mol The Body Multiple, 2002
To act with confidence while simultaneously
remaining uncertain is a paradox that epitomizes expert practice.
JS Ilgen et al. Comfort with uncertainty Advances in Health Sciences Education https://doi.org/10.1007/s10459-018-9859-5
Our definition of confidence is likely to change if we move
away from a goal of ‘getting a
diagnosis right’ towards ‘taking a reasonable next step while
attending to and anticipating
varied responses to management plans.’ JS Ilgen et al. Comfort with uncertainty
Advances in Health Sciences Education https://doi.org/10.1007/s10459-018-9859-5
… the need for clinicians to continuously
reconstruct and redefine their understanding of
the problem, even as
they are trying to solve it
JS Ilgen et al. Comfort with uncertainty Advances in Health Sciences Education https://doi.org/10.1007/s10459-018-9859-5
Doing good does not follow on finding out
about it, but is a matter of, indeed, doing. Of
trying, tinkering,
struggling, failing, and
trying again.
Annemarie Mol The Body Multiple, 2002•A simple correct answer
•Guideline initiated by diagnosis
•How-to versus whether- to
•The urge to simplify
how-to guidelines
whether-to guidelines
Robert McNutt and Nortin M. Hadler How Clinical Guidelines Can Fail Both Doctors and Patients Guest Blog, Scientific American Blog Network, November 22, 2013
•A single correct answer
•Guideline initiated by diagnosis
•How-to versus whether- to
•The urge to simplify
mess
versus
difficulty
Repairing a car that has broken down, deciding the next move in a game of chess and finding the error in a set of accounts are difficulties.
They may be difficult; but as problems they are bounded, and individuals will know when
they have found a solution. But devising policies to reduce crime or to increase the performance of the NHS is a mess; there is rarely agreement about where the problem actually lies or where improvements can best be made, and it is subject to high levels of
uncertainty. Jake Chapman
System failure. Why governments must learn to think differently.
Demos, 2002.
The existence of significantly different perspectives on a
problem is a key characteristic of a mess, one that is difficult to
incorporate in a linear, rational model of decision or policy
making.
Jake Chapman System failure. Why governments must learn to think differently.
Demos, 2002.
This misrepresentation of
medical science as the solid,
simple, Newtonian certainty of engineering, rather than the
fluid, complex, Einsteinian doubt of biology, has misled not only the public, but the profession itself.
Julian Tudor Hart A New Kind of Doctor, 1988.
Uncertainty and doubt make us
safer
We all recognize certain injuries that almost invariably cause suffering: the death or suffering of loved ones,
powerlessness, helplessness,
hopelessness, torture, the loss of a life’s work, deep betrayal, physical agony,
isolation, homelessness, memory failure, and unremitting fear. Each touches
features common to us all, yet each
contains features that must be defined in terms of a specific person at a specific
time. Eric Cassell
The Nature of Suffering and the goals of medicine, 1991
