Complexity and Complexity and simplicity in simplicity in

healthcare: a vision healthcare: a vision of the futureof the future

Kamran Abbasi, acting editor Kamran Abbasi, acting editor BMJBMJ

What I will talk aboutWhat I will talk about

Where will medical research be Where will medical research be published in the future and how?published in the future and how?

What can paper journals and What can paper journals and traditional publishing houses offer?traditional publishing houses offer?

Do we know what clinicians want to Do we know what clinicians want to read?read?

Do journals affect practice?Do journals affect practice?

Doctors—be they clinicians Doctors—be they clinicians or journal editors—are in or journal editors—are in

the communication the communication business and the challenge business and the challenge

we face is how to create we face is how to create simplicity out of the simplicity out of the

complexity of information complexity of information available to us? available to us?

Does this mean we should Does this mean we should stand defeated by stand defeated by

complexity? complexity?

Far from it Far from it

Suppliers of information to Suppliers of information to doctors—and doctors doctors—and doctors

themselves when informing themselves when informing patients—must grapple with patients—must grapple with

complexity to deliver a complexity to deliver a message of such simplicity message of such simplicity that it aids decision making that it aids decision making

and prevents adverse and prevents adverse outcomesoutcomes

Both google and ipod are Both google and ipod are interfaces interfaces

(metaphorical gateways (metaphorical gateways through which humans through which humans

enter and navigate around enter and navigate around a technology)a technology)

Both are picture book Both are picture book examples of simplicity examples of simplicity concealing complexity concealing complexity

underneathunderneath

Everything should Everything should be made as simple be made as simple as possible, but not as possible, but not

simpler simpler

(Albert Einstein)(Albert Einstein)

Keep it simple. The Keep it simple. The healthiest buildings, healthiest buildings,

according to the ancient according to the ancient Chinese principles of Chinese principles of feng feng

shuishui, are those that have no , are those that have no clutter, because clutter, clutter, because clutter, which is complexity by which is complexity by

another name, deadens the another name, deadens the energy in a house energy in a house

(Economist)(Economist)

But is this some Einsteinian But is this some Einsteinian fantasy? fantasy?

How might simplicity defeat How might simplicity defeat complexity?complexity?

Research will be published Research will be published in international registers in international registers

and archives,and archives,probably not in journalsprobably not in journals

Predictions of Lord Kelvin, Predictions of Lord Kelvin, president of the Royal Society, president of the Royal Society,

1890-951890-95

Radio has no futureRadio has no future X rays will prove to be a hoaxX rays will prove to be a hoax Heavier than air flying machines Heavier than air flying machines

are impossibleare impossible

What are the drivers of a new form of What are the drivers of a new form of publishing?publishing?

Failures of the present systemFailures of the present system A vision of something betterA vision of something better MoneyMoney Balkanisation of the literatureBalkanisation of the literature SlownessSlowness Governments and consumersGovernments and consumers

A vision of something betterA vision of something better

““It's easy to say what would be the ideal It's easy to say what would be the ideal online resource for scholars and online resource for scholars and scientists: all papers in all fields, scientists: all papers in all fields, systematically interconnected, effortlessly systematically interconnected, effortlessly accessible and rationally navigable, from accessible and rationally navigable, from any researcher's desk, worldwide for any researcher's desk, worldwide for free.” free.”

Stevan HarnadStevan Harnad

A vision of something betterA vision of something better

““If you have an apple and I have an apple If you have an apple and I have an apple and if we exchange these apples then you and if we exchange these apples then you and I will still each have one apple. But if and I will still each have one apple. But if you have an idea and I have an idea and you have an idea and I have an idea and we exchange these ideas, then each of us we exchange these ideas, then each of us will have two ideas.” will have two ideas.”

George Bernard ShawGeorge Bernard Shaw

““You can resist the invasion You can resist the invasion of an army, but you cannot of an army, but you cannot

resist the invasion of an resist the invasion of an idea”idea”

Victor HugoVictor Hugo

People are no longer People are no longer divided by geography but by divided by geography but by

languagelanguage

Research will be Research will be made available made available

for free on for free on publicly publicly

accessible accessible databasesdatabasesOPEN ACCESSOPEN ACCESS

What I will talk aboutWhat I will talk about

Where will medical research be Where will medical research be published in the future and how?published in the future and how?

What can paper journals and What can paper journals and traditional publishing houses offer?traditional publishing houses offer?

Do we know what clinicians want to Do we know what clinicians want to read?read?

Do journals affect practice?Do journals affect practice?

Benefits of publishing in Benefits of publishing in the BMJthe BMJ

Full text articles available freeFull text articles available free Wide international exposure in print and on Wide international exposure in print and on

webweb Media exposureMedia exposure High impact factor >7High impact factor >7 Fast track peer review and publicationFast track peer review and publication High quality reviewing and technical editingHigh quality reviewing and technical editing Indexed by Medline and Current ContentIndexed by Medline and Current Content Authors retain copyright, share reprint Authors retain copyright, share reprint

revenuerevenue

Should a journal/newspaper Should a journal/newspaper be more like a computer be more like a computer screen (something the screen (something the

Times compact tries to do), Times compact tries to do), and use visual prompts to and use visual prompts to guide people around the guide people around the

“screen”?“screen”?

(Robert Thomson) (Robert Thomson)

The internet has changed The internet has changed newspapers’ role in society. newspapers’ role in society. Newspapers compete with Newspapers compete with the internet but also find the internet but also find

ways to complement itways to complement it

(Robert Thomson)(Robert Thomson)

Newspapers can’t compete Newspapers can’t compete with the web and tv for with the web and tv for

breaking news, but they can breaking news, but they can for viewsfor views

(Simon Kelner)(Simon Kelner)

Technology has made life Technology has made life more complexmore complex

(Chris Caposella, head of (Chris Caposella, head of Microsoft’s desktop Microsoft’s desktop

applications)applications)

People read journals in People read journals in different ways in print and different ways in print and different ways on the webdifferent ways on the web

What I will talk aboutWhat I will talk about

Where will medical research be Where will medical research be published in the future and how?published in the future and how?

What can paper journals and What can paper journals and traditional publishing houses offer?traditional publishing houses offer?

Do we know what clinicians want to Do we know what clinicians want to read?read?

Do journals affect practice?Do journals affect practice?

Words used by 41 doctors to describe Words used by 41 doctors to describe their information supplytheir information supply

Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible ImpossibleImpossible Impossible

Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming OverwhelmingOverwhelming Overwhelming

Difficult Difficult Difficult Difficult Difficult Difficult DifficultDifficult

Daunting Daunting DauntingDaunting Daunting Daunting Pissed offPissed off ChokedChoked DepressedDepressed DespairingDespairing WorrisomeWorrisome

SaturationSaturation VastVast HelpHelp ExhaustedExhausted FrustratedFrustrated Time consumingTime consuming DreadfulDreadful AwesomeAwesome StruggleStruggle MindbogglingMindboggling UnrealisticUnrealistic StressStress Challenging Challenging Challenging Challenging

ChallengingChallenging ExcitedExcited Vital importanceVital importance

Conclusions of studies of doctors’ Conclusions of studies of doctors’ information needs during information needs during

consultationsconsultations

Information needs do arise regularly when doctors see Information needs do arise regularly when doctors see patients (about two questions per consultation)patients (about two questions per consultation)

Questions are most likely to be about treatment, Questions are most likely to be about treatment, particularly drugsparticularly drugs

Questions are often complex and multidimensionalQuestions are often complex and multidimensional The need for information is often much more than a The need for information is often much more than a

question about medical knowledgequestion about medical knowledge Doctors are looking for guidance, psychological Doctors are looking for guidance, psychological

support, affirmation, commiseration, sympathy, support, affirmation, commiseration, sympathy, judgement, and feedback judgement, and feedback

Conclusions of studies of doctors’ Conclusions of studies of doctors’ information needs during information needs during

consultationsconsultations Most of the questions generated in Most of the questions generated in

consultations go unansweredconsultations go unanswered Doctors are most likely to seek answers Doctors are most likely to seek answers

to their questions from other doctorsto their questions from other doctors Most of the questions can be answeredMost of the questions can be answered

—but it is time consuming and —but it is time consuming and expensive to do soexpensive to do so

Doctors seem to be overwhelmed by Doctors seem to be overwhelmed by the information provided for themthe information provided for them

The information paradox: Muir The information paradox: Muir GrayGray

Doctors are overwhelmed with Doctors are overwhelmed with information yet cannot find the information yet cannot find the information they needinformation they need

Information paradoxInformation paradox

““Water, water, Water, water, everywhereeverywhere

Nor any drop to Nor any drop to drink”drink”

The Rime of the The Rime of the Ancient MarinerAncient Mariner

What I will talk aboutWhat I will talk about

Where will medical research be Where will medical research be published in the future and how?published in the future and how?

What can paper journals and What can paper journals and traditional publishing houses offer?traditional publishing houses offer?

Do we know what clinicians want to Do we know what clinicians want to read?read?

Do journals affect practice?Do journals affect practice?

Evidence based policy Evidence based policy making sets the context in making sets the context in

which evidence based which evidence based clinical practice can take clinical practice can take

placeplace(Muir Gray)(Muir Gray)

Would it be better to stop Would it be better to stop talking about EBM and talking about EBM and

instead talk about evidence instead talk about evidence informed practice?informed practice?

NICE guidance is NICE guidance is implemented variably, implemented variably,

suggests a national studysuggests a national study

BMJ 2004;329:999-1003BMJ 2004;329:999-1003

Factors that favour Factors that favour implementation are: strong implementation are: strong

professional support, professional support, convincing evidence base, convincing evidence base,

no more costs, no more costs, implementation tracking, implementation tracking,

and professionals not and professionals not isolatedisolated

Evidence based guidelines Evidence based guidelines or collectively constructed or collectively constructed

“mindlines”?“mindlines”?

BMJ 2004;329:1013-16BMJ 2004;329:1013-16

Clinicians: informed by Clinicians: informed by brief reading but mainly by brief reading but mainly by own and their colleagues’ own and their colleagues’

experience, their experience, their interactions with each interactions with each other and with opinion other and with opinion leaders, patients, and leaders, patients, and

pharmaceutical pharmaceutical representativesrepresentatives

An insoluble paradox exists An insoluble paradox exists between the desire for between the desire for

consistent evidence based consistent evidence based guidelines and the unique guidelines and the unique

requirements of an requirements of an individual patientindividual patient

Decision makers are often Decision makers are often forced to provide a forced to provide a definitive answer in definitive answer in conditions of high conditions of high

uncertainty, and unthinking uncertainty, and unthinking adherence to guidelines adherence to guidelines

and protocols can be and protocols can be harmfulharmful

Decision support systems Decision support systems are one attempt to impose are one attempt to impose simplicity upon complexity, simplicity upon complexity,

providing clinicians with providing clinicians with concise, evidence based, up concise, evidence based, up

to date, and—crucially—to date, and—crucially—individualised informationindividualised information

A B C D E FA B C D E FG H I J K LG H I J K L

M N O P Q RM N O P Q R S T U V W X S T U V W X

Y Z Y Z

A B C D E FA B C D E FG H I J K LG H I J K L

M N O P Q RM N O P Q R S T U V W X S T U V W X

Y Z Y Z

0 1 1 0 1 1 0 0 0 0 1 0 0 1 1 0 1 1 0 1 1 0 0 0 0 1 0 0 1 1 1 1 0 11 1 0 1

All of this, of course, raises All of this, of course, raises serious questions about the serious questions about the existence of journals, once existence of journals, once rated by the inscrutability rated by the inscrutability of their language and the of their language and the

complexity of their subject complexity of their subject matter matter

Those that survive the Those that survive the downturns in advertising downturns in advertising

revenue, subscriptions, and revenue, subscriptions, and the threat of open access the threat of open access

publishing will be the ones publishing will be the ones that, in the words of that, in the words of

Einstein, make everything Einstein, make everything as simple as possible, but as simple as possible, but

not simpler not simpler

They will be more readable They will be more readable to compete with other to compete with other entertainment media entertainment media

And the print and And the print and electronic versions, in their electronic versions, in their

different ways, will be different ways, will be metaphoric gateways metaphoric gateways

through which humans through which humans enter and navigate around enter and navigate around

Simplicity concealing layer Simplicity concealing layer upon layer of complexityupon layer of complexity

In our information rich and In our information rich and highly complex world, those highly complex world, those

suppliers of information, suppliers of information, and doctors, who succeed and doctors, who succeed will be the ones who make will be the ones who make simple sense of our messy simple sense of our messy world while capturing its world while capturing its

fuzzinessfuzziness