John C. Peirce, MD, MA, MS
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Peirce J.; Understanding Medical Systems. Ann Intern Med. 1998;129:753-754. doi: 10.7326/0003-4819-129-9-199811010-00034
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Published: Ann Intern Med. 1998;129(9):753-754.
TO THE EDITOR:
Nolan  argues the importance, if not necessity, of understanding medical systems for improving health care. However, he fails to mention a key characteristic of a successful system, that of learning and adapting to environmental change through innovation. These attributes are essential if we are to achieve our purposes (his principle 1) of reducing waste, error, and unneeded variation and improving outcomes of care. This is at the core of complex adaptive systems based on chaos and complexity theory [2, 3]. I like viewing our system of medical care as a biological system rather than as a machine, the industrial model for organizations and systems. Because biological systems become more complex through the ebb and flow of differentiation and integration, we can see fragmentation and piecemeal care as an unintended consequence (Nolan's principle 3) of specialization (differentiation) for which we have yet to establish effective integrating activities. The emergence (a central attribute of complex adaptive systems) of family practice and emergency medicine in the 1970s came about not because new biomedical knowledge needed to be put to use but because these two specialties better integrated care for two populations of people.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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