Publicação
Managing Complexity in Healthcare: Complexity science principles and the paradigm-shift in managing healthcare dualities: The medical education and patient’s involvement challenges
| Resumo: | This dissertation is about the need to embrace paradigm-shifting in medical education from the prevalent Newtonian model to the emerging Complexity science. Although described for more than two decades in the literature, complexity science remains superficially known by the healthcare community. The dominance of the rationalistic paradigm is still very strong due to several reasons: (a) learning and knowledge practices still follow essentially knowledge-asprediction (versus knowledge-as-understanding adequate for unpredictable situations), (b) formal curriculum usually ignores any other discipline or knowledge external to clinical and basic expertise (i.e., epistemological narrowing), (c) medical schools teach health as the machine metaphor and illness as the result of the malfunction of its parts, and (d) linear mental models drive professionals to break down clinical care into specialized operations (e.g., define strict procedures for each situation). Furthermore, the reductionist way of organizing care and delivery makes almost impossible for nonmedicals to understand operations, and high differentiation. Finally, healthcare is different from all other complex services as health outcomes depend on patient’s adherence. Thus, patient-doctor relationship is vital and needs to be protected. Alternative paradigm of complexity science suggests that health and illness result from complex and adaptive interplay between different components of the whole system (i.e., biopsychosocial), leading to clinical decisions based on holistic approaches that embraces unpredictability (i.e., rigid advice become obsolete) and recognizes emerging forces of the whole system (e.g., intuition, experience). Three studies were conducted based on a real-world problem introduced by a Portuguese medical school, namely to understand the evolving needs of medical education and the emerging future areas regarding patients (e.g., chronical) and systems (e.g., complexity), to obtain a broad understanding of the challenges these professionals face in the 21st century. First study looked to explore participants experiences during care and delivery aiming to identify patterns of how doctors and patients cope with competing needs, realworld complexities and conflicting demands. It followed Grounded Theory (GT) and the three coding stages (open, axial, selective) looking to catch the interplay between 99 stakeholders (13 FG). The emerging patterns obtained through induction where then iv compared against theory, revealed diverse, interrelated, paradoxical problems doctors face daily in Portuguese health institutions. Challenges were represented by nine themes followed by four aggregate dimensions organized in two pairs of dualities that composed a paradoxical model in line with the complexity paradigm logic: (1) medical proximity versus (2) expertise vigilance, and (3) holism and diversity versus (4) clinical and integrated structure. Dimensions illustrate practice dichotomies and their interdependencies. The model can provide medical education with a better understanding and importance of adopting complexity thinking to guide their activities. Furthermore, it is an insightful tool for future doctors to reflect about experiences, complex practices and positions regarding each pair of dualities, identify balances or imbalances between patterns of behaviours, and desirable or undesirable outcomes. This study contributed to highlight the ontological nature of healthcare. The second study is a mix method study combining thematic analysis (TA) and narratives organized by temporality and plot to explore the experiences of participants (13 FG, two clusters: IMSS and EMSS, representing different “worlds”) during patientdoctor relationship. Participant’s engagement experiences were study at this dyadic relationship, patient’s roles (e.g., active, passive) and provider’s roles (e.g., B2C, A2A) in the light of the Service-dominant Logic (SDL). SDL view was compared with Relationship-centered care (RCC) and value cocreation concept was used in the patientdoctor relationship empirical field. SDL advances RCC regarding patient’s role who need to be recognized as resource integrator (active). It is when doctors offer care solutions and patients integrated those in their own profile of resources that health benefit can be cocreated. Such was revealed by narratives arranged by plot and temporality. Stories during patient-doctor relationships were compared: a) in the past and present times the IMSS highlighted doctor’s paternalistic-power roles and patient’s passive roles, and b) during future temporality more active and equating-roles were whished. This study has practical implications for medical education: a) RCC is important to be included (e.g., communication, interpersonal skills, humanizing) but is the SDL view that advances patients and professional’s roles (A2A versus B2C), and b) patient needs to be viewed as operant resources by doctors, who in turn only offer part of the inputs to cocreate health benefit. It also draws management implications: a) managers need to support and protect this relationship, and b) recognize the unfinished nature of the relationship that needs v feedback from patients to doctors and vice-versa to adjust and make sense of situations. In sum, study highlights the need to recognized the idiosyncrasy of each case operating during patient-doctor relationship in accordance with the praxeology of applied disciplines such as medicine (versus homogenous and general rules). The third study is a qualitative content analysis (QCA) using an unconstrained matrix based on two medical education frameworks addressing medical education reform, the CanMEDS (2025; 2015) and the Health Systems Science (HSS), respectively grounded on CAS and on system thinking (i.e., systems-theory), to identify the emerging future areas and if systems and complexity thinking is identified as core by a Portuguese sample. This study contributes for the literature in the medical education field through an extensive review of the systems-theory (i.e., systems theory, complexity theory) and the advances brought by the complexity science, the clarification of their multidisciplinary roots, concepts and basic assumptions. It also draws implications to medical education (e.g., curriculum) through the identification of future areas, and to management (e.g., doctors, managers, others) by highlighting the need to maintain the organizations in the complexity zone (i.e., “edge of chaos”, “loosely coupled”) developing a structure not too tight nor too flexible, in order to deal with uncertainty, unpredictability and with the emergence of new patterns and behaviours, allowing for agents, processes, systems changing, adaptation and co-evolution. Thus, the third study contributes for the explanation of the epistemology of the complexity science paradigm, more specifically, its assumptions and premises. Considering it all, the present research thesis and the three studies aim to contribute and advance the paradigm of complexity science in the healthcare field and in the area of medical education. |
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| Autores principais: | Lopes, Catarina Martins |
| Assunto: | Health behavior Analysis of Education Higher Education Production Management Diversity |
| Ano: | 2025 |
| País: | Portugal |
| Tipo de documento: | tese de doutoramento |
| Tipo de acesso: | acesso aberto |
| Instituição associada: | Universidade de Lisboa |
| Idioma: | inglês |
| Origem: | Repositório da Universidade de Lisboa |
| Resumo: | This dissertation is about the need to embrace paradigm-shifting in medical education from the prevalent Newtonian model to the emerging Complexity science. Although described for more than two decades in the literature, complexity science remains superficially known by the healthcare community. The dominance of the rationalistic paradigm is still very strong due to several reasons: (a) learning and knowledge practices still follow essentially knowledge-asprediction (versus knowledge-as-understanding adequate for unpredictable situations), (b) formal curriculum usually ignores any other discipline or knowledge external to clinical and basic expertise (i.e., epistemological narrowing), (c) medical schools teach health as the machine metaphor and illness as the result of the malfunction of its parts, and (d) linear mental models drive professionals to break down clinical care into specialized operations (e.g., define strict procedures for each situation). Furthermore, the reductionist way of organizing care and delivery makes almost impossible for nonmedicals to understand operations, and high differentiation. Finally, healthcare is different from all other complex services as health outcomes depend on patient’s adherence. Thus, patient-doctor relationship is vital and needs to be protected. Alternative paradigm of complexity science suggests that health and illness result from complex and adaptive interplay between different components of the whole system (i.e., biopsychosocial), leading to clinical decisions based on holistic approaches that embraces unpredictability (i.e., rigid advice become obsolete) and recognizes emerging forces of the whole system (e.g., intuition, experience). Three studies were conducted based on a real-world problem introduced by a Portuguese medical school, namely to understand the evolving needs of medical education and the emerging future areas regarding patients (e.g., chronical) and systems (e.g., complexity), to obtain a broad understanding of the challenges these professionals face in the 21st century. First study looked to explore participants experiences during care and delivery aiming to identify patterns of how doctors and patients cope with competing needs, realworld complexities and conflicting demands. It followed Grounded Theory (GT) and the three coding stages (open, axial, selective) looking to catch the interplay between 99 stakeholders (13 FG). The emerging patterns obtained through induction where then iv compared against theory, revealed diverse, interrelated, paradoxical problems doctors face daily in Portuguese health institutions. Challenges were represented by nine themes followed by four aggregate dimensions organized in two pairs of dualities that composed a paradoxical model in line with the complexity paradigm logic: (1) medical proximity versus (2) expertise vigilance, and (3) holism and diversity versus (4) clinical and integrated structure. Dimensions illustrate practice dichotomies and their interdependencies. The model can provide medical education with a better understanding and importance of adopting complexity thinking to guide their activities. Furthermore, it is an insightful tool for future doctors to reflect about experiences, complex practices and positions regarding each pair of dualities, identify balances or imbalances between patterns of behaviours, and desirable or undesirable outcomes. This study contributed to highlight the ontological nature of healthcare. The second study is a mix method study combining thematic analysis (TA) and narratives organized by temporality and plot to explore the experiences of participants (13 FG, two clusters: IMSS and EMSS, representing different “worlds”) during patientdoctor relationship. Participant’s engagement experiences were study at this dyadic relationship, patient’s roles (e.g., active, passive) and provider’s roles (e.g., B2C, A2A) in the light of the Service-dominant Logic (SDL). SDL view was compared with Relationship-centered care (RCC) and value cocreation concept was used in the patientdoctor relationship empirical field. SDL advances RCC regarding patient’s role who need to be recognized as resource integrator (active). It is when doctors offer care solutions and patients integrated those in their own profile of resources that health benefit can be cocreated. Such was revealed by narratives arranged by plot and temporality. Stories during patient-doctor relationships were compared: a) in the past and present times the IMSS highlighted doctor’s paternalistic-power roles and patient’s passive roles, and b) during future temporality more active and equating-roles were whished. This study has practical implications for medical education: a) RCC is important to be included (e.g., communication, interpersonal skills, humanizing) but is the SDL view that advances patients and professional’s roles (A2A versus B2C), and b) patient needs to be viewed as operant resources by doctors, who in turn only offer part of the inputs to cocreate health benefit. It also draws management implications: a) managers need to support and protect this relationship, and b) recognize the unfinished nature of the relationship that needs v feedback from patients to doctors and vice-versa to adjust and make sense of situations. In sum, study highlights the need to recognized the idiosyncrasy of each case operating during patient-doctor relationship in accordance with the praxeology of applied disciplines such as medicine (versus homogenous and general rules). The third study is a qualitative content analysis (QCA) using an unconstrained matrix based on two medical education frameworks addressing medical education reform, the CanMEDS (2025; 2015) and the Health Systems Science (HSS), respectively grounded on CAS and on system thinking (i.e., systems-theory), to identify the emerging future areas and if systems and complexity thinking is identified as core by a Portuguese sample. This study contributes for the literature in the medical education field through an extensive review of the systems-theory (i.e., systems theory, complexity theory) and the advances brought by the complexity science, the clarification of their multidisciplinary roots, concepts and basic assumptions. It also draws implications to medical education (e.g., curriculum) through the identification of future areas, and to management (e.g., doctors, managers, others) by highlighting the need to maintain the organizations in the complexity zone (i.e., “edge of chaos”, “loosely coupled”) developing a structure not too tight nor too flexible, in order to deal with uncertainty, unpredictability and with the emergence of new patterns and behaviours, allowing for agents, processes, systems changing, adaptation and co-evolution. Thus, the third study contributes for the explanation of the epistemology of the complexity science paradigm, more specifically, its assumptions and premises. Considering it all, the present research thesis and the three studies aim to contribute and advance the paradigm of complexity science in the healthcare field and in the area of medical education. |
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