The attitudes of general practitioners (GP) play an influential role in their decision making about patient treatment and care. Considering the GP-patient encounter as a complex system, the interactions between the GP and their personal network of peers give rise to “aggregate complexity,” which in turn influences the GP’s decisions about patient treatment. This study models aggregate complexity and its influence in decision making in primary care through the use of social network metrics. Professional network and attitudinal data on decision making responsibility from 107 rural GPs were analysed. Social network measures of “density” and “inclusiveness” were used for computing the “interrelatedness” of components within such a “complex system.” The “number of components” and “degree of interrelatedness” were used to determine the complexity profiles, which was then used to associate with responsibility in decision making for each GP. GPs in simple profiles (i.e., with low components and interactions) in contrast to those in nonsimple profiles, indicate a higher responsibility for the decisions they make in medical care. This study suggests that social networks-based complexity profiles are useful for understanding decision making in primary care as it accounts for the role of influence through the professional networks of GPs. 1. Introduction The attitudes of health professionals such as general practitioners (GPs) play an influential role in their delivery of medical care, such as communication and decision making in patient care. A number of other studies have focused on examining the GP’s delivery of medical care from various perspectives: quality of the consultation [1]; psychological and medical functions [2]; measuring informed decision making through evaluating patient-GP encounters [3]; influence through professional networks [4, 5]. More recently, there is evidence showing how medical care delivery can be conceptually analysed using principles of complexity thinking, where the GP-patient consultation is deemed to be a complex adaptive system [6]. According to Plsek and Wilson [7], “complexity thinking suggests that relationships between parts (of a system) are more important than the parts themselves, and that minimum specifications yield more creativity than detailed plans.” It is useful to consider the meaning of systems within which complexity is situated and derived and the type of systems that is referred to in this paper. Broadly speaking, “systems” consist of multiple parts (or components) that are connected and interrelated in one or
References
[1]
N. C. H. Stott and R. H. Davis, “The exceptional potential in each primary care consultation,” The Journal of the Royal College of General Practitioners, vol. 29, no. 201, pp. 201–205, 1979.
[2]
L. Gask and T. Usherwood, “ABC of psychological medicine: the consultation,” British Medical Journal, vol. 324, no. 7353, pp. 1567–1569, 2002.
[3]
A. Leader, C. Daskalakis, C. H. Braddock III et al., “Measuring informed decision making about prostate cancer screening in primary care,” Medical Decision Making, vol. 32, no. 2, pp. 327–336, 2012.
[4]
K. S. K. Chung and L. Hossain, “Measuring performance of knowledge-intensive workgroups through social networks,” Project Management Journal, vol. 40, no. 2, pp. 34–58, 2009.
[5]
J. S. Coleman, E. Katz, and H. Menzel, “The diffusion of an innovation among physicians,” Sociometry, vol. 20, no. 4, pp. 253–270, 1957.
[6]
A. D. Innes, P. D. Campion, and F. E. Griffiths, “Complex consultations and the ‘edge of chaos’,” British Journal of General Practice, vol. 55, no. 510, pp. 47–52, 2005.
[7]
P. E. Plsek and T. Wilson, “Complexity, leadership, and management in healthcare organisations,” British Medical Journal, vol. 323, no. 7315, pp. 746–749, 2001.
[8]
R. L. Ackoff, “Towards a system of systems concepts,” Management Science, vol. 17, no. 11, pp. 661–671, 1971.
[9]
Y. Bar-Yam, “Improving the effectiveness of health care and public health: a multiscale complex systems analysis,” The American Journal of Public Health, vol. 96, no. 3, pp. 459–466, 2006.
[10]
T. G. Kannampallil, G. F. Schauer, T. Cohen, and V. L. Patel, “Considering complexity in healthcare systems,” Journal of Biomedical Informatics, vol. 44, no. 6, pp. 943–947, 2011.
[11]
M. Mitchell, Complexity: A Guided Tour, Oxford University Press, New York, NY, USA, 2009.
[12]
N. Johnson, Simply Complexity, Oneworld Publications, Oxford, UK, 2007.
[13]
P. E. Plsek and T. Greenhalgh, “Complexity science: the challenge of complexity in health care,” British Medical Journal, vol. 323, no. 7313, pp. 625–628, 2001.
[14]
G. Bloom and S. Wolcott, “Building institutions for health and health systems in contexts of rapid change,” Social Science & Medicine, vol. 96, pp. 216–222, 2013.
[15]
N. Keshavarz, D. Nutbeam, L. Rowling, and F. Khavarpour, “Schools as social complex adaptive systems: a new way to understand the challenges of introducing the health promoting schools concept,” Social Science & Medicine, vol. 70, no. 10, pp. 1467–1474, 2010.
[16]
H. J. Lanham, L. K. Leykum, B. S. Taylor, C. J. McCannon, C. Lindberg, and R. T. Lester, “How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts,” Social Science and Medicine, vol. 93, pp. 194–202, 2013.
[17]
P. Nugus, K. Carroll, D. G. Hewett, A. Short, R. Forero, and J. Braithwaite, “Integrated care in the emergency department: a complex adaptive systems perspective,” Social Science and Medicine, vol. 71, no. 11, pp. 1997–2004, 2010.
[18]
Y. Bar-Yam, S. Bar-Yam, K. Z. Bertrand et al., “A complex systems science approach to healthcare costs and quality,” NECSI Report, 2012.
[19]
J. Horgan, “From complexity to perplexity,” Scientific American, vol. 272, no. 6, pp. 104–109, 1995.
[20]
S. M. Manson, “Simplifying complexity: a review of complexity theory,” Geoforum, vol. 32, no. 3, pp. 405–414, 2001.
[21]
S. P. Borgatti, A. Mehra, D. J. Brass, and G. Labianca, “Network analysis in the social sciences,” Science, vol. 323, no. 5916, pp. 892–895, 2009.
[22]
A.-L. Barabási, “Network science,” Philosophical Transactions of the Royal Society A: Mathematical, Physical and Engineering Sciences, vol. 1987, pp. 1–3, 2013.
[23]
S. Knoke and J. H. Kulinski, Network Analysis, Sage, Newbury Park, Calif, USA, 1992.
[24]
J. O'Connor and I. McDermott, The Art of Systems Thinking, Thorsons, London, UK, 1997.
[25]
M. Benham-Hutchins and T. R. Clancy, “Social networks as embedded complex adaptive systems,” Journal of Nursing Administration, vol. 40, no. 9, pp. 352–356, 2010.
[26]
D. Meltzer, J. Chung, P. Khalili, et al., “Exploring the use of social network methods in designing healthcare quality improvement teams,” Social Science & Medicine, vol. 71, no. 6, pp. 1119–1130, 2010.
[27]
E. West, D. N. Barron, J. Dowsett, and J. N. Newton, “Hierarchies and cliques in the social networks of health care professionals: implications for the design of dissemination strategies,” Social Science and Medicine, vol. 48, no. 5, pp. 633–646, 1999.
[28]
S. Wasserman and K. Faust, Social Network Analysis: Methods and Applications, Cambridge University Press, New York, NY, USA, 1994.
[29]
M. S. Granovetter, “The strength of weak ties,” The American Journal of Sociology, vol. 78, no. 6, pp. 1360–1380, 1973.
[30]
D. Mascia and A. Cicchetti, “Physician social capital and the reported adoption of evidence-based medicine: exploring the role of structural holes,” Social Science & Medicine, vol. 72, no. 5, pp. 798–805, 2011.
[31]
J. Scott, Social Network Analysis: A Handbook, Sage, London, UK, 2000.
[32]
R. E. Mitchell and E. J. Trickett, “Task force report: social networks as mediators of social support. An analysis of the effects and determinants of social networks,” Community Mental Health Journal, vol. 16, no. 1, pp. 27–44, 1980.
[33]
U. Pfeil and P. Zaphiris, “Investigating social network patterns within an empathic online community for older people,” Computers in Human Behavior, vol. 25, no. 5, pp. 1139–1155, 2009.
[34]
J. Cockburn, D. Killer, E. Campbell, and R. W. Sanson-Fisher, “Measuring general practitioners' attitudes towards medical care,” Family Practice, vol. 4, no. 3, pp. 192–199, 1987.
[35]
C. Fullwood, A. Kennedy, A. Rogers, et al., “Patients' experiences of shared decision making in primary care practices in the United Kingdom,” Medical Decision Making, vol. 33, no. 1, pp. 26–36, 2013.
[36]
V. J. King, M. M. Davis, P. N. Gorman, J. B. Rugge, and L. J. Fagnan, “Perceptions of shared decision making and decision aids among rural primary care clinicians,” Medical Decision Making, vol. 32, no. 4, pp. 636–644, 2012.
[37]
C. B. Forrest, P. A. Nutting, S. von Schrader, C. Rohde, and B. Starfield, “Primary care physician specialty referral decision making: patient, physician, and health care system determinants,” Decision Making in Clinical Practice, vol. 26, no. 1, pp. 76–85, 2006.
[38]
R. M. Epstein, P. Franks, K. Fiscella, et al., “Measuring patient-centered communication in Patient-Physician consultations: theoretical and practical issues,” Social Science & Medicine, vol. 61, no. 7, pp. 1516–1528, 2005.
[39]
A. Mascarenhas and J. Norrie, Older Doctors Suffer the Shock of the New, The Sydney Morning Herald, Sydney, Australia, 2005.
[40]
J. A. Jones, J. S. Humphreys, and M. A. Adena, Doctors' Perspective on the Viability of Rural Practice, 2004, http://pandora.nla.gov.au/pan/20865/20041115/rrh.deakin.edu.au/articles/archiveview363d.html?ArticleID=305.
[41]
R. P. Strasser, R. B. Hays, M. Kamien, and D. Carson, “Is Australian rural practice changing? Findings from the National Rural General Practice Study,” The Australian Journal of Rural Health, vol. 8, no. 4, pp. 222–226, 2000.
[42]
R. S. Burt, “Structural holes versus network closure,” in Social Capital: Theory and Research, N. Lin, K. S. Cook, and R. S. Burt, Eds., Aldine de Gruyter, New York, NY, USA, 2000.
[43]
J. S. Humphreys and F. Rolley, “A modified framework for rural general practice: the importance of recruitment and retention,” Social Science and Medicine, vol. 46, no. 8, pp. 939–945, 1998.
[44]
M. Mellow, “The work of rural professionals: doing the gemeinschaft-gesellschaft gavotte,” Rural Sociology, vol. 70, no. 1, pp. 50–69, 2005.
[45]
N. K. Choudhry, R. H. Fletcher, and S. B. Soumerai, “Systematic review: the relationship between clinical experience and quality of health care,” Annals of Internal Medicine, vol. 142, no. 4, pp. 260–283, 2005.
[46]
K. S. K. Chung, Understanding Attitudes to Performance in Knowledge-Intensive Work: The Influence of Social Networks and Information and Communication Technologies Use, Lambert Academic Publishing, Berlin, Germany, 2011.
[47]
P. Marsden and K. E. Campbell, “Measuring tie strength,” Social Forces, vol. 63, no. 2, pp. 482–501, 1984.
[48]
H. R. Bernard, P. Killworth, D. Kronenfeld, and L. Sailer, “On the validity of retrospective data,” Annual review of anthropology. Vol. 13, vol. 13, pp. 495–517, 1985.
[49]
L. C. Freeman, A. K. Romney, and S. C. Freeman, “Cognitive structure and informant accuracy,” American Anthropologist, vol. 89, no. 2, pp. 311–325, 1987.
[50]
M. Hammer, “Explorations into the meaning of social network interview data,” Social Networks, vol. 6, no. 4, pp. 341–371, 1984.
[51]
C. M. McCarty and A. Wutich, “Conceptual and empirical arguments for including or excluding ego from structural analyses of personal networks,” Connections, vol. 26, no. 2, pp. 82–88, 2005.
[52]
R. S. Burt, Structural Holes: The Social Structure of Competition, Harvard University Press, Cambridge, Mass, USA, 1992.
