Complexity in Family Medicine

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Complexity in Family Medicine What does this
have to do with your residency?

• Cathy MacLean
• September, 2010

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"Vision is the art of seeing the invisible."

• Jonathon Swift

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Comparison of Two Historical Models of Medicine
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Traditional Biomedical Model

• Reductionist focus on the broken part and fix
  it
• The body as a machine - correct the faulty
  mechanism
• Linear causation, single causes, either/or
  thinking
• Mind-body distinction
• Focus on diseases as entities separate from the
  person
• Emphasis on traditional basic sciences
• Strive for certainty
• Physicians need to remain objective,
  detached physician as clinical
  scientist  

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Whole Person Model

• Systemic approach address the big picture the
  whole patient context
• The body as an organism
• Complex causation e.g. complexity theory
  both/and thinking
• Integration of mind-body
• Focus on the person their experience
• Integration of behavioural sciences humanities
  with the biological population sciences
• Accept the inevitability of uncertainty
• Physicians need to be involved use their
  subjectivity emotional intelligence
• Physician as healer

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Complexity

• Simple dealing with the known like following a
  recipe
• Complicated going from unknown to the known
  like launching a rocket
• Complexity dealing with the unknowable
  raising a child
• Where do you think we fit?

Brenda Zimmerman CIHR Primary Care Summit 2010
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The Complex Chronic Care/ Multiple
Morbidity Person Focused Care

• The Complicated
• Acute Care/Single Disease
• Disease Focused Care

Often all causes can be identified and
measured Diagnosis and prognosis are often
accurate Specific therapy or treatment is often
available disease management Technological
intervention is usually effective cure is likely
with return to normal health Profession is
knowledgeable while patient/family is
inexperienced
Multivariate cause, changing over
time Diagnosis is uncertain and prognosis
obscure Indecisive technologies therapies with
adversities person life management No cure,
pervasive uncertainty coaching self care over
time is needed to improve health Profession
patient/family must be reciprocally knowledgeable
to improve health
From Dr. Zimmermans presentation CIHR Primary
Care Summit, 2010/ Halstead Holman, MD (Stanford)
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BC Study Findings

• found that the more higher-care-needs (DM and
  CHF) patients were attached to a primary care
  practice, the lower the costs were for the
  overall healthcare system (for the total of
  medical services, hospital services and drugs)
  These findings support the general literature on
  the benefits of primary care and continuity of
  care.

Marcus J. Hollander, Helena Kadlec, Ramsay Hamdi
and Angela Tessaro. Increasing Value for Money
in the Canadian Healthcare System New Findings
on the Contribution of Primary Care Services,
Healthcare Quarterly, 2009.
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Barbara Starfield

• First contact accessibility
• Longitudinality/relationship patient
• focused care over time
• Comprehensiveness of care/ service
• Availability of service
• Coordination/continuity of records
• Family centeredness
• Community orientation
• Cultural competence

http//www.jhsph.edu/pcpc/pca_tools.html
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What does this have to do with your residency?
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The Future of Family Medicine In Canada

• The patients medical home concept
• Attachment and relationship
• Interprofessional team based skills
• IT including EMRs and e consults
• Alternative funding models
• Patient self management
• Accountability and evaluation
• CDM, managing complexity

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Family physicians are the masters of complexity.

• Remember this as you go through your residency.
• Embrace patient centered care the importance of
  relationship continuity and comprehensive
  practice
• Be conscious of the role of complexity ie when
  applying CPGs appreciate it is not as simple as
  it looks.
• Recognize the basis of your value and develop
  your skills in managing the complex.

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Thanks!cmaclean_at_ucalgary.ca