Introduction

Over 20 years ago, two separate groups of astrophysicists discovered something unexpected at about the same time. They found that the expansion of our universe is increasing at an accelerating pace, rather than decelerating as was previously thought. The groups would later share a Nobel Prize based on this discovery.1
Although this was unexpected, an increased pace of change in our world has been evident for many centuries. We can see this ever-increasing pace of change in our world through the innovation revolutions that had a major impact on lifespan and quality of our lives, from the Agricultural Revolution that took thousands of years, the Industrial Revolution over a period of hundreds of years and the Information Age that lasted a few decades. With the global and immediate communication capabilities of the internet, this pace of change will only continue to increase. We are now considered to be in the age of networks.2

Fragmentalism – the loss of focus on “what really matters”

With this ever-increasing pace of change, we can see the impact on the reductionist models for our industries and organizations. Fragmantalism has been described as an alternative term for reductionism. As the pace of change and the complexity of our world continues to increase, a reductionist model for an organization will lead to more fragmentation and disconnection. This occurs through the development of more and more department silos leading to poorer communication and more inefficiency and waste as well as almost completely stifling innovation.
To see the negative impact of this increasing pace of change on reductionist designed organizations, we can examine the lifespan of Fortune 500 companies in the United States: the average lifespan was more than 50 years in the 1950s but has decreased to less than 20 years in the 21st century and in 2017 only 60 companies remained in existence from the Fortune 500 list in 1955.3
Hospitals and Academic Medical Centers are no different and they may be in the most complex and constantly changing of all organizations in our world. But they have been relatively insulated, with massive subsidies from government, foundations and research dollars as well as philanthropic and investment proceeds. It was only a matter of time before this fragmentation and disconnection would catch up with an unsustainable business model, even in healthcare.
As I learned more about this, I came across graph published by Woolhandler and Himmelstein shown in Figure 1. The graph reveals a many thousand percentage growth of hospital administrators while the growth of physicians has been minimal compare to the growth of administrators.
This fragmentation also leads to systems designed inappropriately into the fragments of care rather than for a patient’s entire cycle of care. For example, Electronic Medical Record (EMR) systems are designed for the fragments of care, often with a primary purpose of documentation for the purpose of coding and billing. By only documenting a fragment of care, it is not possible to measure the outcomes of care for any definable, whole patient process. This also prohibits the appropriate data analysis that could be applied to learn how to better measure and improve outcomes.
Ultimately, this increasing pace of change resulting in increased fragmentation and an increase in administrative burden will predictably lead to an unsustainable financial situation. The Commonwealth Fund is one of many organizations that highlight the unsustainable financial situation in healthcare. A graph demonstrating the increase in per capita spending on healthcare for the US and many other countries is shown in Figure 2.
Although it is well-known that the US has the highest per capita spending on healthcare, it is not well-known that the slope of increase of per capita spending on healthcare is nearly the same in every country. We are all on the same unsustainable path- the US is just out in front of every other country.

Applying Systems and Complexity Science to Real Patient Care

For the past decade, our small abdominal wall hernia team has applied the principles of this newer scientific paradigm, systems science, to real patient care. Instead of testing a hypothesis using rigorous prospective randomized clinical trials (PRCTs), we collect data from real patient care, periodically analyze the data which provides feedback loops to allow the clinical team to gain insight into the factors and combinations of factors that are most correlated with good and bad outcomes.
This can then lead to ideas to improve how we measure factors and outcomes and generate new ideas to improve outcomes. The tools from a systems science paradigm include principles of continuous quality improvement (CQI) and non-linear analytics.
The reductionist paradigm relies on linear statistics to try to prove a cause and effect relationship between a factor (drug, device, etc.) and an outcome measure by attempting to isolate them from all other factors and outcome measures. In systems science, the analysis and feedback tools are meant for learning and improving whatever is measured in the real world of patient care.