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Can we import improvements from industry to healthcare?

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1039 (Published 21 March 2019) Cite this as: BMJ 2019;364:l1039

Re: Can we import improvements from industry to healthcare?

I want to thank Kevin Stewart and Carl Macrae for bringing up the question of complexity in "learning set ups" from different fields (aviation is a linear field subjected to the simplest form of law of physics). Indeed the issue is "[...] more complex that we think".

In the book "Handbook of Systems and Complexity in Health" editors Joachim P. Sturmberg and Carmel M. Martin [1] at page 1 explains the differences between simple and complex views in science (table 1.1 at page 2) and make the demarcation complicated / complexity phenomenon in figure 1.1 at page 2 (aviation and birthday parties respectively). It seems more "hard" to make planes fly but if you analyse 10000 flies and 10000 birthday parties I will put my money betting for more "harm" in birthday parties events because emerging properties and unpredictability (there is no "law of children" to look at).

Victor Montory in his book [2] makes a qualitative distinction in these two fields. In page 19 says "[...] my colleague brought up the pilot with an unexpected twist, "Victor, what we need is the experience that reliable airlines offer their passengers. Do you care who the pilot is when you board a plane?"". When he took their usual Minneapolis-Boston flight in one occasion the anonymous voice announced to the other passengers and him that they will have a chance to meet the pilot. "[...] He had shared some polite laughs with a few who cracked a joke or made a casual remark. After some pleasantries, I asked him, "Did any of the passengers catch your attention?" He slowed his pace and looked at me briefly, "No, not really. At the end of the day they are all a blur"".

Ironically Iván Illich tried to prevent us about accepting "happily" the successes of other fields in their "Alternatives" essay [3]. He said that administrative function were adopted by the religious congregations (eclipsing the clerk "original" functions) and "[...] maybe we will learn by this way that the principles of enterprises management are not applicable to the Christ's body" (my translation from Spanish to English). He followed remarking that the Christ's vicar is not a C.E.O. in a business society neither a byzantine monarch. That clerical technocracy is more fare away from the Gospel that sacerdotal aristocracy. If we think about Mark Jamoulle's term "quaternary prevention" [4] it is not a coincidence that he references Illich as one of their sources of inspiration (among Balint, Eco and McWhinney) [5].

In BMJ if we search the term "Aviation" it gives us (searched 11:25 of April 15 2019) 2,311 results from Jan 1840 to Apr 2019 [6]. The editorial of Kevin Stewart and Carl Macrae put some context to the security analogy raised so many times in a cheered way I would say. Thanks for writing it. Nassim said in his book Antifragile that "cats are not washing machines" [7] (living organisms adapt to stress and they can benefit from them. He says in his book that you "use and lose" your washing machine. But about your muscles the issue is "use them OR lose them"). Of course we can learn punctual characteristics from linear and simple systems (aviation). But we must remember (as the authors of this editorial point out) that healthcare is a complex, dynamic and adaptative system. With emergent properties. And we need models that can fit there [8].

I want to end quoting Joachim P. Stumberg work [9] "[...] —contradictions viewed through the lens of interconnectedness are “as yet not fully understood” phenomena. They require exploration, not condemnation to coerce patients and doctors alike into conformity and uniformity. Contradictions are an opportunity to learn and gain new insights—in practice, it makes for difficult conversations, and it requires time. Both are scarce commodities in the hamster wheel environment of disease management with its tight constraints based on economic rationalist doctrine".
Pilots can be constrained by top-down approaches (some "stability autopilot system" added to the plane without their knowledge) [10]. Guidelines and vertical protocols (among other things) can enlarge our technological somnambulism [11] and daily feel as a healthcare professionals that we are in an automatic pilot [12]. Let's hope critical analysis like this editorial help us not to crash the "healthcare service plane" seeing only AFTER the accident the risk of doing analogies from non-complex fields to complex fields. Factum stultus cognoscit.

References:
[1]: Handbook of Systems and Complexity in Health (Editors: Sturmberg, Joachim P, Martin, Carmel). Springer. 2014
[2]: Montori, Victor M. Why We Revolt: a Patient Revolution for Careful and Kind Care. The Patient Revolution, 2017
[3]: [Obras Reunidas De Ivan Illich(Vol.I) editorial F.C.E. 2006 revisión de Balentina Borremans y Javier Sicilia). "Alternativas" page 71 section "Eclipse del clérigo"] Spanish language book
[4]: Jamoulle M, Roland M, Bae JM, Heleno B, Visentin G, Gusso G, Godycki-Cwirko M, Pizzanelli M, Ouvrard P, La Vallev R, Gomes F, Widmer D, Bernstein J, Marino M, Lima Wagner H, Rossi I. [Ethical, pedagogical, socio-political and anthropological implications of quaternary prevention]. Rev Med Brux. 2018;39(4):383-393
[5]: https://orbi.uliege.be/bitstream/2268/226522/4/AMUB__en_201809009_final.pdf (page 6 of 33)
[6]: https://www.bmj.com/search/advanced/aviation
[7]: Taleb, Nassim Nicholas. Antifragile: Things That Gain from Disorder. Random House, 2014.
[8]: Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, Greaves F, Harper L, Hawe P, Moore L, Petticrew M, Rehfuess E, Shiell A, Thomas J, White M. The need for a complex systems model of evidence for public health. Lancet. 2017 Dec 9;390(10112):2602-2604
[9]: Sturmberg JP. Evidence-based medicine-Not a panacea for the problems of a
complex adaptive world. J Eval Clin Pract. 2019 Mar 19
[10]: https://www.nytimes.com/2019/03/19/podcasts/the-daily/boeing-737-max-eth...
[11]: https://en.wikipedia.org/wiki/Technological_somnambulism
[12]: http://jan.ucc.nau.edu/~jsa3/hum355/readings/ellul.htm

Competing interests: No competing interests

15 April 2019
Marc C. Escarré
Dietitian
Baixada Sant Miquel nº2