Almost 40 years ago as a first-year medical student, I was toiling away in the gross anatomy laboratory attempting to learn the intricacies of the “complicated” human body. The instructor, a gruff general surgeon perhaps 80 years old with a cigar stuffed into his mouth (yes, those were different times) asked me where I was from. “Wisconsin,” I said with some degree of pride on the state of my birth. “I thought so,” he replied. “You cut like a farmer!” Obviously, his remark was not meant as a compliment nor was it taken as such. Little did I know how honored I should have been!

Virtually everyone agrees that the health care system in the United States has severe problems. Many equate, rightly or wrongly, the terms “health care system” and “medical care system”. As we will see in subsequent discussions, the terms are not equivalent but for today, let’s assume they are. In a series of landmark publications such as “To Err is Human” and “Crossing the Quality Chasm”, the Institute of Medicine explored the deficiencies in the current system and made recommendations for improvement. The executive summary of “Crossing the Quality Chasm” can be found here: I would recommend anyone interested in health care reform to read it. It heavily emphasizes changing the processes of care. Here is an example:

Carefully designed, evidence-based care processes, supported by automated clinical information and decision support systems, offer the greatest promise of achieving the best outcomes from care for chronic conditions.

Before I met David Snowden and learned of Complexity Theory, this made absolutely perfect sense to me. I was literally immersed in process. I was a firm believer in “evidence based medicine” as the ONLY answer. I was a Six Sigma Blackbelt, with years of earnest effort at decreasing the variation in care processes. I believed that the human body was complicated, diseases were complicated and of course, the solutions to the problems we faced, be they in clinical treatment or health care delivery were complicated. I should have read Paul Plsek’s “Appendix B” to that same document, available here:

Even if you don’t read the Executive Summary, you must read this! It is the clearest and most concise declaration of the problem in health care, as well as the road map for the surest of solutions. It cuts through the ideology that has so clouded the health care debate in the United States these past months. As Paul Plsek so eloquently states:

It is more helpful to think like a farmer than an engineer or architect in designing a health care system. Engineers and architects need to design every detail of a system. This approach is possible because the responses of the component parts are mechanical and, therefore, predictable. In contrast, the farmer knows that he or she can do only so much. The farmer uses knowledge andevidence from past experience, and desires an optimum crop. However, in the end, the farmer simply creates the conditions under which a good crop is possible. The outcome is an emergent property of the natural system and cannot be predicted in detail.

CAS science suggests that we cannot hope to understand a priori what a CAS will do or how to optimize it. A design cannot be completed on paper. Past attempts to do this in health care have not succeeded in part because they may not have been satisfactory designs, but mainly because a new understanding of “design” is needed….


Complexity science provides a new paradigm to guide system design. Some key questions raised by a CAS-inspired approach to redesigning health care for the 21st century include:

How can conditions in the health care system be established to allow many new ideas to emerge and mix into the existing system, while maintaining discipline to do just a little bit of nurturing, see what happens, then decide what to do next?

How can diverse people be brought together, information shared, and forums convened among those to stimulate creative connections who do not normally come together to do so (similar to genetic cross-over and mutation)?

How can desirable variation (innovation) be separated from the variation that ought to be reduced (error and waste)?

What are the few simple rules that might guide the local development of the 21st-century health care system?

What is the implicit, existing set of simple rules from which current innovations in health care emerge?

How can these existing, implicit rules and underlying assumptions be modified?

How can communication infrastructures be set up to disseminate the new simple rules?

How can infrastructures be established in public policy to encourage experimentation and innovation under the new simple rules?

How can experimentation be made highly visible so that the “fitness” of each evolution can be judged to quickly spread the best ideas?

What is a “good enough plan” to begin the change?

Who should take on the role of continuing to evolve the plan as the CAS plays itself out?

David and his collaborators have pointed out the differences between what is simple, complicated, complex and chaotic. They have also pointed out the catastrophic result of treating the complex as though it was complicated. We need to move to the edge of chaos in our quest for the solution to health care delivery,not jump over the precipice. We need creativity and innovation, not rigid process compliance. We need a resilient system, not one that attempts to be robust enough but cracks under the disaster we know from Power Law Distribution is much more likely than we have planned for.

I now realize that when my anatomy professor told me, “You cut like a farmer!”, I should have saluted him and let out a booming, “Yes, sir!”

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