Several years ago, at a venerable New York hotel, I attended a meeting that has made a lasting impression on my thinking. The purpose of the event was to bring together academic physicians of all levels for two days of lectures, dinners, and talk. On the first afternoon, we had breakout sessions to discuss topics of major, even pretentious-sounding, importance: the future of clinical research, the health of the Third World, the genetic revolution. The breakout groups comprised everyone from a post-doc to a professor and featured an eclectic mix of sub-specialties, all sitting around tables in darkened meeting rooms that were oppressively overheated.
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Explore This IssueMay 2007
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The breakout groups were charged with reducing our deliberations into a key concept to guide future clinical or basic research, policymaking, or even a personal career choice. Although the groups focused on different subjects and had amazingly diverse memberships, we all came back with the same word. That key word was (drum roll, please) complexity.
You may find it ironic that complexity could be a simplifying concept but the unanimity of its selection shows how complicated medicine has become.
As Simple as Complexity
Everything about modern medicine is complicated. I love adjectives, so I suggest the following other descriptors of our current state: multifaceted, convoluted, intertwined, interdependent, interdigitated, intricate, thorny, and downright confusing. Nothing in research is simple anymore. Clinical trials can number 50,000 patients and—with mathematic and statistical analyses worthy of astrophysics—provide evidence for 1.1 relative risk of an adverse event that occurs in one in a thousand subjects. Genetic studies are similarly baroque, involving hundreds of SNPs distributed unevenly in the population but, in certain alignments (or phases of the moon), produce a suggestion that genes do matter after all. Microarray analyses are even worse because, in reality, each data point comprises myriad others.
Clinical medicine can be similarly dizzying in its practice. Each decision involves a measured and deliberate weighing of risks and benefits, which must be explained in a comprehensible way to the patient even though the physician might be clueless about the right choice. The problem is that the risks and benefits are often uncertain, shifting, or imprecise. While, as professionals, we pride ourselves for being evidence based, often the evidence simply does not exist.
Our breakout groups were correct. Complexity governs our work as physicians and providers.
No More Easy Decisions
As noted in “Sniff 101 and Other Lessons” (April 2007, pg. 6), I recently attended on general medicine and was amazed by the complexity of the medical problems I saw and the tortuous thought process necessary to devise even the most basic diagnostic or therapeutic plan. Modern medicine is now like a chess game; we have to plan for many moves in advance knowing that our opponent, sickness, is cagey, mean, and unpredictable. How do you play chess against a madman, knowing that erratic moves can beat even the cleverest strategy?