Journal of Evaluation in Clinical Practice ISSN 1356-1294

EDITORIAL

Complexity and health professions education

Stewart Mennin PhD

jep_1502

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Professor Emeritus, Department of Cell Biology and Physiology, Assistant Dean Emeritus, Educational Development and Research, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA

Keywords complex systems, complexity, groups, health professions education, learning, medical education, work-based social theory

Correspondence Dr Stewart Mennin Department of Cell Biology and Physiology Educational Development and Research University of New Mexico School of Medicine Albuquerque, NM 87131 USA E-mail: smennin@gmail.com

Mennin Consulting & Associates Inc. http://www.menninconsulting.com Accepted for publication: 13 June 2010 doi:10.1111/j.1365-2753.2010.01502.x

Medical education should be informed by contemporary learning theories and concepts. Unfortunately, traditional medical education suffers from chronic fragmentation preferring reductionistic, instrumental explanations for complex phenomena. Complexity science and work-based social theory [1] offer an antidote to the fragmentation of health professions education; a different way to understand medical practice and the education process that is preparation for that practice. What is important in this work is to improve health professions education so that it provides and sustains practitioners capable of contributing creatively, skillfully and humanely to the health of people. How we organize and conduct ourselves in this endeavour depends to a great extent on our understanding of knowledge, knowing, learning, education and their variable expression in the clinic, community and classroom. As Bleakley writes, complexity challenges us to move from individualistic and social constructionist approaches to an examination of how meaning emerges from complex non-linear processes [1]. The present supplement speaks to these challenges. The contributing authors are disturbing in a generative way. They reject Newtonian certainty and linear Cartesian step-by-step cause and effect approaches to health professions education as limited and narrow. As described by Doll and Trueit, . . . we cannot, in a complex situation, reduce an effect to a cause. Causeeffect thinking comes into play only after we become aware of a situation and wonder what was the cause. In effect, we search backwards, trying to reduce an effect to its constituent cause(s). Such reduction produces a false understanding . . . [2] Complexity concepts and principles are well suited to the emergent, messy, nonlinear uncertainty of living systems nested one within the other where the relationship among things is more than the things themselves. Doll and Trueit trace the developmental trajectory of science and medicine as a prolegomenon to the emergence of complexity science in postmodern health professions education [2]. They provide an elegant overview of chaos and complexity and critique

what they see as the excessive reliance of the scientic method on static representational models. Educators, in all elds, need to rethink not only the model used but the very concept of model [2]. They prefer the dynamic, ambiguous interplay of complex events that draws more on metaphor than on model. Where models provide a single representation metaphor provides alternative ways of understanding that depend on unique conditions of each situation and the participants and objects involved. Ambiguity is necessarily embraced as a fundamental aspect of complex systems, of the messyness of lived experience rather than as something to be eliminated or controlled. Similarly, difference and diversity are sources of energy and information rather than something to be reduced. Doll and Trueit tell a provocative story about Gregory Batesons work with schizophrenics in a mental hospital that stimulates us to rethink the idea of normal [2]. For them, normal is relational with varying degrees of stability embedded in the web of life understood as transformative change. To think complexly is to adopt a relational, a system(s) view. That is to look at any event or entity in terms, not of itself, but of its relations [2]. Relationshipcentred care, described by Suchman [3], is an elegant application of this concept to the doctor patient relationship, which needs to be extended to the teacherstudent relationship (relationship-centred teaching). A good teacher does more than communicate with others, he communes with them, he is reborn in the relation of Being-in [2]. Education as transformation is a recurring theme throughout this supplement. Complex systems learn and complexity research is the study of learning systems. Davis and Sumara, writing from the perspective of mathematics education and complexity, intrigue and entreat health professions educators to rethink the pragmatics of teaching [4]. They argue that in a complex teaching, learning environment every moment is a potential teachable or pedagogical moment lled with constellations of possible phenomena. For them, education is among the most complex of human enterprises, arising in the nexus of individual interest, social need, disciplinary
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diversity, cultural self-perpetuation, and humanitys efforts to situate itself in the more-than-human world. Oriented by this realization, the insights offered by hard complexity research do more than inform education; they transform education [4]. A complexity view of faculty development becomes one of pedagogical possibilities for participation in collective engagement. For these authors, knowledge (knowing) is an evolving changing domain that continuously is adapted and adapts, that cannot be reduced to simple components. Davis and Samara speak about redundancy in a system as necessary for coherence in communication and complex collectivity [4]. An integrated curriculum is one that pays attention to the relationship between variable iteration and redundancy. . . . learning and teaching are not about telling or instructing about optimal practices, but a much more attentive and tentative rhetoric of listening, participating, and engaging [4]. Bleakley expands the dimensionality of learning in complex settings such as the clinic to include the team and the objects it uses, as more than the individual [1]. He brings forth the intimate relationship between social learning theories and complexity in the rich context of clinical care and medical education. The history of western medicine is congruent with the rise of individualism and modernism. We are in a post-modern phase that is still unfolding. Social learning theories, compatible with complexity science, provide a way to understand and deal with non-linear, complex, dynamic systems (living systems) that are synergetic with current trends towards inter- and trans-professionalism, shared tolerance, ambiguity, relationship-centred care, teaching and distributed cognition related to the workplace [1]. Social learning theories, described by Bleakley, . . . stress the importance of both context (learning is situated) and process (learning is dynamic). Where traditional learning theories focus upon what is learned or accumulated by an individual and how that is retained and reproduced, social learning theories focus upon processes of collaboration, means of access to distributed knowledge, how knowledge acquires legitimacy and meaning, knowledge production rather than reproduction, socialization as a process of learning and identity construction as a learning outcome [1]. Work-based learning describes, . . . how knowledge is a product of interactions between actants (artifacts: instruments, materials and symbols) and actors (practitioners), where material and cultural worlds are given equal status. Such interactions produce networks that provide temporary stability for knowledge in which knowing is enmeshed. Knowledge is not then in persons but is an effect of relations or interactions within networks, engaging both the material world (artifacts) and persons [1]. In the post-modern (complex) world, the status of knowledge is transformed from a noun to a verb existing in a dynamical relational form. Education is political. Bleakley moves the thinking about learning from privatized knowledge to shared knowledge realized democratically or collaboratively; from connectionist and retrospective (analysis of events as if static and private), to dynamicist and prospective (synthesis of events as moving through time and becoming public) [1].Both Bleakley [1] and Arrow and House [5] see health teams as collective, emergent intelligence. Complexity and social activity theory orient us to the work of the environment shaping activity rather than the cognition of practitioners dictating events [1]. The clinical team is an open dissipative system adjusting and regulating itself through reection and feedback, organi836

zational roles, rules and protocols. Ideas such as these ideas are glaringly absent from mainstream medical education. The authors in this supplement frame learning as a process in which a systems emergent properties are adaptive, demonstrating a constant altering of structure in response to emergent experience. The unit of analysis becomes the team, the group and the interaction among multiple agents. This is a fundamental transition in how health professionals conceive of themselves at work. According to Bleakley, A situated learning or communities of practice model describes learning not as sedimentation of knowledge but as cultural participation. Learners gain entry into a community of practice as a form of identity construction through legitimation of role that is also a means of gaining temporary stability within a dynamic system [1]. The complexity perspective that Arrow and House bring to the study of group dynamics is unique and opens a deeper understanding of how we should consider the educational approach to training for and working as effective members of health teams. Groups of clinical practitioners are complex adaptive systems and variations and differences among clinical teams and groups can promote and or block effective group coordination [5]. Arrow and House describe two different sets of multidisciplinary learning groups; one dealing with operating room teams learning minimally invasive cardiac surgery and the other dealing with mental health treatment. They distinguish between teams, task forces, and crews from the perspective of self-organizing complex adaptive systems [5]. Effective individual, group and organizational learning in the health professions exists in a complex state that becomes an effective resource for learning when attention is focused on the dynamics of differentiation, integration and organizational context. Arrow and House emphasize the need for deep diversity in groups where knowledge, skills and abilities are distributed across multiple perspectives and experiences, i.e. . . . people who can think differently, do things differently and bring different approaches to bear in processing information [5]. By itself, diversity does not necessarily lead to improved group interaction. Differences are integrated as an emergent property of self-organization [6]. High levels of group problem solving are related to self-organization and the role of coaching and how organizational structure to promotes adaptive learning. The determination of competence in the workplace and other quasi-authentic health practice and education settings requires sampling from many interconnected factors. Sturmberg and Hinchy contend that . . . competence/capability is a complex concept the performance of a specic task, regardless of the mode of assessment, depends on the ability to integrate discrete knowledge, skills and attitudes in a specic clinical situation [7]. These authors explore the underlying assumptions of borderline competence [7]. They propose a criterion-referenced standard setting approach that denes a borderline zone of competence, rather than a single cut point and offer a cusp catastrophe model approach to differentiating competent from non-competent candidates. From their perspective, . . . borderline no longer refers to a single score that delineates competency, but instead a range of scores over which competency judgments are indeterminate [7]. They present a specic approach to determining the range of a borderline performance and examine closely the concept of borderline performance being a band along an ability continuum from clear incompetence to clear competence [7]. Sturmberg and

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Complexity and medical education

Hinchy argue that a complexity-based concept of borderline competence reects a zone in which the relationship between clinical signicance and performance difculty exist. . . . the pass/fail decision should be conceptualized as occurring in a threedimensional framework the axes being performance, clinical signicance and required skills mix. Plotting a candidates observed performance in relation to clinical signicance and required skills mix results in the emergence of his/her competency plane [7]. Medical education and medical practice are highly relational endeavours that depend on authenticity and iterative variability of experience embedded in continuous feedback and reection. The present supplement raises the awareness of the nature of the collaborative relationship between teaching and learning and of curriculum as linkages in a decentralized self-similar nested network of human knowing [4]. The authors urge us to pay more attention to metaphor, associations and relationships and to see learning as a co-participation, emergence and co-evolutionary process rather than one of individual achievement and accountability [4]. The perspective of complexity science adds signicantly to our understanding of the lived experience of health professions education. There are new ideas and new terminology. A brief glossary of complexity is provided to help readers navigate an unfamiliar landscape [8]. It will take time for complexity science to gain pedagogical traction with busy medical practitioners, educators and researchers. It is a major conceptual shift especially for educational research which has borrowed and imported its theories from other academic areas [4]. Davis and Sumara argue that . . . complexity theory might be properly construed as a theory of education, oriented as it is to better understanding the co-implicated dynamics of many over-lapping, interlacing, and nested systems [4]. It

remains to be seen how complexity science and health professions education will co-evolve.

Acknowledgement
The author thanks Dr Regina Petroni Mennin for clarifying and rening this work.

References
1. Bleakley, A. (2010) Blunting occams razor: aligning medical education with studies of complexity. Journal of Evaluation in Clinical Practice, 16, 849855. 2. Doll, W. E. Jr & Trueit, D. (2010) Complexity and the health care professions. Journal of Evaluation in Clinical Practice, 16, 841 848. 3. Suchman, A. L. (2006) A new theoretical foundation for relationshipcentred care: complex responsive processes of relating. Journal of General Internal Medicine, 21, S40S44. 4. Davis, B. & Sumara, D. (2010) If things were simple . . .: complexity in education. Journal of Evaluation in Clinical Practice, 16, 856 860. 5. Arrow, H. & Henry, K. B. (2010) Using complexity to promote group learning in health care. Journal of Evaluation in Clinical Practice, 16, 861866. 6. Mennin, S. (2010) Self-organisation, integration and curriculum in the complex world of medical education. Medical Education, 44, 20 30. 7. Sturmberg, J. P. & Hinchy, J. (2010) Borderline competence from a complexity perspective: conceptualization and implementation for certifying examinations. Journal of Evaluation in Clinical Practice, 16, 867872. 8. Mennin, S. (2010) Complexity and health professions education: a basic glossary. Journal of Evaluation in Clinical Practice, 16, 838840.

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