False Dichotomies of Health Care - Part 2: One Size Fits All

Reductionism vs Complexity

Definitions

In Part 1 of false dichotomies, we consider widely divergent studies on the nature of Life. Each provides a different view of reality, somewhat like the way MRI “slices” are oriented in different planes to give different 2-dimensional images of a 3-dimensional organ, like a brain.

The brain is complicated - something highly intricate with many interconnected structures and systems. Life is complex (whether individual organisms, populations or whole ecosystems) - something with many complicated and inter-connected systems, but which are inconsistently inter-related and even self-configuring. A brain works in complicated but specific ways. Life is complex with many complicated systems, designed to improvise. Life forms have to be complex, because they need to adapt and be dynamic in order to sustain themselves in a chaotic environment.

Reductionism, as a scientific approach, is very good at solving complicated problems and making sense of things like the brain. Reductionists tend towards being dichotomous, or seeing things as having two sides. For instance, a favorite study design for randomized controlled trials is known as a 2x2 matrix: Yes vs No on one variable, compared to Yes vs No on a second variable. Such designs examine the interactions between two 2-sided elements.

During the last couple of decades, more emphasis is being placed on the continuum concept. This is more sophisticated, shades of gray instead of black and white, but still tends to be dichotomous extremes with the continuum lying in-between the two endpoints of healthy and unhealthy.

Neither dichotomous nor continuum reductionism can accurately portray the complexity of health ecology.

Health care workers - physicians, nurses, nutritionists, administrators, exercise specialists, physical therapists, etc. - train to be reductionists. Many health conditions have complicated but solvable underlying mechanisms. Mental health workers - psychiatrists, psychologists and social workers - may be more well-suited to complexity, because these professions train to apprehend the Big Picture of a patient’s life. Nonetheless, mental and social health workers mainly use reductionism, constrained as they are to working within our health care system.

Lifestyle and Complexity

Turn your mind to the couple in our example case in Part 1 (click to review their challenging situation) - what would you advise them to eat (as if there is a perfect diet), what exercise would you advise them to do and when/how/where to do it (as if there is a perfect exercise)?

Unfortunately, there is no simple and easy answer. The couple may have chosen their home because one of the children has special needs, or the grandfather may be in the early phases of senile dementia. Such social factors introduce complexity to which the couple must adapt.

Now imagine the couple moving away from New York City, first to center-city Vancouver, British Columbia, and then to the suburbs of Dallas, Texas. In each place, they would choose a different lifestyle solution, since environment has such a huge influence. Vancouver and Dallas have very different transportation infrastructures. Say they choose active transportation (walking/biking to work) in Vancouver, while in Dallas they choose to commute by car. Their exercise program needs would be different in each location, depending on how they approach other environmental constraints.

Add in the chaos of modernity and it’s even more difficult. Imagine the mother, living in Texas, finding herself driving in a wave of commuters, each sealed-off inside their air-conditioned cars listening to music or talk-radio and not paying full attention to traffic, her children quarrelling in the back seat as a vehicle suddenly pulls into her lane. Coping with such stress and competing time demands is commonly solved by reliance on convenience foods - dropping into the drive-through for breakfast, on a path towards a diet of highly-processed foods.

Best Practice for Lifestyle

Studies that look at lifestyle interventions for such families tend to have specific diets (e.g., American Heart Association step II diet, Mediterranean diet, DASH diet, etc.) and/or exercise programs (Health & Human Services Physical Activity Guidelines, American College of Sports Medicine Guidelines, etc.) - interventions largely based on reductionist research. Most studies mainly examine methods of delivering these particular interventions - who gives it, how often, for how long, through what media, etc. - rather than attempting a complexity solution. From the perspective of methodology, innovative; from the perspective of the intervention, highly reductionist and not far from one-size-fits-all.

The most complete review on interventions (see below, Artinian et al., 2010) that produce sustained adoption of better diet and an active lifestyle concluded that the essential component is:

Frequent and prolonged contact.

Surprising? Not really. Pathways to health are long and complex, sometimes arduous (cognitively, physically and spiritually), and everyone’s path is unique. It’s predictable that people need frequent and prolonged help to find their own way.

But our health care system is so deeply rooted in reductionism that we are creating a seemingly infinite number of evidence-based guidelines, constantly being updated, all in an attempt to define best practices. Complex lifestyle interventions will likely have common features, but no best practice - not if everyone needs their own unique solution. Our example case reveals that counseling must make contextual sense of the patient’s life through a process that is complex and integrative, not reductionist.

Lifestyle interventions for diet and exercise have very high failure rates of about 80% at 1 year post-intervention. In attempt to do better, we look for better ways to deliver the same old reductionist message. Maybe it’s not the delivery medium, but the message! What if applying any reductionist solution to any complex situation rarely works more than 20% of the time?

Reductionist guidelines on lifestyle have not and, very likely, may never be highly successful at improving health ecology. Reductionism has shown us what health looks like, but cannot help us produce health. If so, we will need to give up on reductionist lifestyle intervention guidelines and turn to embracing complexity. This will be quite scary for evidence-based reductionists, because the health care system is terrified of uncertainty. After all, perhaps the most difficult sentence for a physician to learn to say to a patient is:

“I don’t know”.

RESOURCES

Rickles D, Hawe P, Shiell A. A simple guide to chaos and complexity. J Epidemiol Community Health 2007; 61:933–937.
doi: 10.1136/jech.2006.054254

Litaker D, Tomolo A, Liberatore V, Stange KC, Aron D. Using complexity theory to build interventions that improve health care delivery in primary care. J Gen Intern Med 2006; 21:S30–34.
doi: 10.1111/j.1525-1497.2006.00360.x

Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, Meininger JC, Banks J, Stuart-Shor EM, Fletcher BJ, Miller TD, Hughes S, Braun LT, Kopin LA, Berra K, Hayman LL, Ewing LJ, Ades PA, Durstine JL, Houston-Miller N, Burke LE. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: a scientific statement from the American Heart Association. Circulation. 122(4):406-41, 2010.

Auspos P, Cabaj M. Complexity and Community Change: Managing Adaptively to Improve Effectiveness. The Aspen Institute, Washington, DC, 2014.
http://www.aspeninstitute.org/publications/complexity-community-change-m...