Dear Chris

Sorry that you could not come to Tufton yesterday. I hope you had an
interesting/challenging/enjoyable day interacting with the sick (and
worried well) of Upper Nithsdale and with the wider environment. I have a
couple of comments on your reply to Andrew.

I think perhaps we are overdoing the complicated vs complex division.
Surely this is useful to make a point to illustrate the differences, but
can things really be categorised so neatly. Is there not a continuum, with
complicated - rigid and predictable at one end and truly complex - "no
holds barred as far as interaction goes" at the other. Sure, consultations
and decision making ARE complex and therefore you will see emergence,
feedback loops etc, but do we have prove it everytime, by performing power
calculations and looking for fractals which can be mathematically verified
in every case and apply the label "C"omplex adaptive system.

Even if there might be a simple "non-complex" answer to apparent paradoxes,
should we not discuss and explore them before jumping to the "obvious"
conclusion. I am not sure of the appropriateness of the "Reid" test. He
seemed to suggest that there was no place for complexity theory in
exploring the health sciences - full stop. Applying the Reid test would
perhaps mean - "don't even think about complexity in case you are drawn
into a mire of pseudoscience". I'm for one am not quite ready to wind up
this list or the Tufton group.

Yours complexedly

Dan


On 13 March 2002 02:44, Chris Burton [SMTP:[log in to unmask]] wrote:
> Andrew
>
> interesting but not sure they pass the Reid test(*)
>
> Self management plans are complex, as in complicated or multi-factorial,
but have we any evidence that they are Complex with a capital C? This may
be a bog ordinary reductionist "absence of evidence" rather than "evidence
of absence" situation. Did you mean no evidence of effect from step up ICS
or evidence of no effect? If it's simply no ( or after critical analysis
unconvincing) evidence then all you are doing is observing a proxy measure.
>
> The variable response to meds doesn't really require complexity either
does it? Hungin's work on the reassurance effect of normal endoscopy makes
it reasonable that 15mg lansoprazole + reassurance beats 30mg +
uncertainty. Again there's a reductionist explanation - you can even allow
it to be couched in terms of non-linear movement between attractors in
symptom space ( "I get a bit of indigestion but hey.." and " I'm getting a
lot of heartburn these days") but no proof of Complexity.
>
> * the Reid test I propose is that a suggestion gets treated to the same
sort of assault as Prof Reid from Dundee gave the BMJ series on complexity
- basically that a scientific ideas has been taken for too far a walk such
that the credibility gap between its current position and where it started
tends to infinity.
>
> Just thought I'd be provocative before you all go tuftoning together
tomorrow and I end up seeing patients.
>
> Chris
> --
> Chris Burton, [log in to unmask] on 13/03/2002
>
>
> On Tue, 12 Mar 2002 17:35:23 -0000, Andrew & Norma Innes wrote:
> >Better late than never!
> >Could I contribute 2 simple accounts of complexity  in action to our
> >co-operative enquiry?
> >
> >
> >
> >1.       At a recent meeting I was talking  to Ron Neville from the
> >Tayside Centre for Asthma about the paradox that centres  on the use
> >of inhaled corticosteroids (ICS) in deteriorating asthma. In short
> >there is no evidence that increasing the dose of ICS in worsening
> >asthma is  effective but there is evidence that the use of self-
> >directed management plans  works in reducing asthma exacerbations
> >and A&E attendances. The central act  of self-management plans is of
> >course to increase ICS in response to  deteriorating asthma.
> >
> >Self-management plans are of course a complex  intervention!
> >
> >
> >
> >2.       Katherine is a 45 year old with a  history of dyspepsia
> >characterised by marked heartburn. She is not helped by lansoprazole
> >(a powerful acid suppressing drug) at a dose of 30mg daily given by
> >one of my partners and was therefore referred for upper
> >gastrointestinal  endoscopy. The result of the endoscopy was to show
> >modest oesophagitis and the  specialist recommended treatment with
> >lansoprazole at the lower dose of 15mg.  Katherine picked up her
> >prescription from the surgery and was disappointed to note that not
> >only was the medication offered the same but also the dose was
> >lower. Sceptical that it would make any difference she nevertheless
> >took the  treatment and came to see me for review. Her symptoms were
> >abolished much to her  surprise!             The response here is
> >beyond placebo as treatment was started with the expectation that it
> >would not work.   What is going on?
> >
>