What role does the science of complexity play in medicine? [PODCAST]

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“The science of complexity lays a conceptual foundation for understanding “complex adaptive systems.” What all complex adaptive systems have in common is that they are all bound by the same set of physical laws. Their “behavior,” i.e., growth, maintenance, and death, can all be described using the same set of mathematical relationships. These systems (animals, plants, ecosystems, etc.) are the most productive and functionally effective systems known to man.

Unfortunately, our health care system has not been bound by the same physical laws and mathematical relationships as other complex adaptive systems. Thus, it has not been able to implement the same mechanisms that our ecosystems and cells have in order to obtain optimization in their ability to perform a function. This is most blatantly highlighted by the fact that 100,000 to 400,000 (depending on the source) Americans die each year due to medical errors.”

Robert Trent is a graduate student.

He shares his story and discusses his KevinMD article, “What role does the science of complexity play in medicine?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system that are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Robert Trent. He’s a graduate student, and he wrote the KevinMD article “What role does the science of complexity play in medicine?” Robert, welcome to the show.

Robert Trent: Happy to be here.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Robert Trent: When I first started out in graduate school, you have this thing called core classes, which is basically a repeat of everything that you learned in undergrad. I was kind of hoping I was done with that at that point and ready to get into the actual research, but I ended up having to basically retake a lot of those biochem, molecular biology, and microscopy courses that most of you guys probably take as undergrads. And I’m not going to lie, I think it did a number on my mental health.

Show me anyone on the street who can recite squalene biosynthesis from memory, and I will probably show you someone who’s wasted their life. No one really, I think, has that material memorized well enough to where, outside of the class, they know what they’re talking about. And so for me, like most people who have to go through that kind of stuff, you start asking really weird questions, either out of boredom or, I’m not really sure where it comes from.

But I began to ask myself questions like, what exactly am I learning? If I were to go to another planet and find aliens there who used similar carbon-chain oxidation-reduction to maintain a steady state, what exactly would I be able to recognize? What exactly am I learning? And from there, that’s kind of what led me into the material for the article, right? I was like, OK, there are universally applicable concepts that you learn in biochemistry that are not just limited to biochemistry, and that is kind of the core foundation of complexity science.

I was very lucky to have learned about it from Geoffrey West, who wrote an amazing book called Scale. I really would recommend that if anyone finds the article interesting. Geoffrey West works at a place called the Santa Fe Institute out in New Mexico, and all they do is research on complexity science. It’s an emerging field, but it’s a very, very significant field, I think, for anyone who thinks that biochemistry is mindless and anybody who thinks that that stuff is just boring. There is something to be learned there. And so that’s kind of what the background was for that article.

Kevin Pho: So let’s go straight into it, and it’s titled “What role does the science of complexity play in medicine?” Now, for those who didn’t read it, or don’t even have a science or biochemical background, can you just summarize that article from the beginning and share the story of why you decided to share it?

Robert Trent: I guess I’ll preface this, because, I don’t know, we’re all geeks, right, to some extent. I think we all have things that we geek out about, and one of the things that I’ve always been big on is understanding the history of science. There’s a quote by Steven Weinberg that I think is really relevant to understanding the article. He says that more often than not, the mistake we make in science isn’t that we take our ideas too far, but that we don’t take them far enough.

And there’s some historical evidence to support that. I’m not a physicist, right, but when Einstein came up with general relativity, the mathematics from that made it possible for black holes to exist. To my understanding, it was a guy named Karl Schwarzschild who wrote that first proposition, and Einstein said, “Your mathematics is right, but your physics is wrong.” He didn’t take his own work, his own ideas, seriously enough.

And so basically, the core of the article is, OK, what are the things that we are studying? What are the things that we are learning about, and how far can we take those ideas? What they found is that a lot of the concepts for biology and for ecosystems and things like that are actually applicable to cities. They’re applicable to companies. And I believe that they’re applicable to hospitals. I believe that they’re applicable to health care systems.

We have a huge problem, in my opinion, with medical error in this country. There’s a debate about how you assess for and how you define medical error, but I still think that it’s a problem, regardless of how significant it may be. And so in order to solve those problems with medical error, we have to look at the way that the system, the health care system, is connected. Its interconnectivity is what really lends itself to its observable macroscopic behavior, and in this case, I’m talking about the phenomenon of medical error.

Kevin Pho: So go into more detail. Tell me about how that interconnectedness and that complexity that pervades our medical system, how does that specifically lead to medical error?

Robert Trent: OK, so one of the things that your body has, my body has, a cell has, and even an economy has is a feedback mechanism, right? These feedback mechanisms are what we call substrate-independent, right? It doesn’t matter the form that it takes. If I showed you a feedback mechanism, you could identify it, right, just because you’re a physician and you’ve been through that process.

And so in our health care system, there are very few feedback mechanisms in place. There are very few pathways that overlap that ensure processes are being done that need to be done. I think it is amazing to me that physicians, who are incredibly intelligent people who spend a very large portion of their life in school, have trouble adhering to the almost 300-year-old medical practice of washing their hands. That’s just one example; that’s kind of the most concrete.

And so the solution to that is we need to have feedback mechanisms in place to make sure that physicians wash their hands, and that’s really not present. There are some hospitals out there that are starting to do things like having the patients ask them. I don’t know how I feel about that. I don’t think that’s really the patient’s job, to ask a physician if they washed their hands. But other things, like Biovigil and monitoring systems and places like that, if they do that right, that creates a feedback mechanism that can help make sure that people and providers are washing their hands. So that would be just one example of it, and there are numerous other ones as well.

But it also kind of comes into the structure of the health care system as well. We are a very big, top-heavy hierarchical structure that can’t respond to changes fast enough. COVID has been a great example of that, right? I mean, imagine if you stuck your finger on a stove and it took too long to get that pathway activated to make you move your finger away, right? There are serious problems associated with that. So all of this stuff, I think, is laid out in the framework of complexity science, and I think that’s really going to be the way to go as far as the future.

Kevin Pho: You said there were a couple of other examples that you had that really demonstrated that intersection between complexity and medicine. What’s another example that you could name off the top of your head?

Robert Trent: The health care structure. I don’t really want to get into too much detail on that, but I think the problem with the way that our health care system is structured is that, aside from, to go back to feedback, right, there’s not a lot of feedback. If a hospital is good at its job or if a hospital is bad at its job, there is insatiable need, I think, for health care, and so we can’t really rely on free-market forces to establish that, right? I mean, that would be one example. But really, at the end of the day, if we could have something that is called scale invariant, which means something where the size of the system no longer becomes the problem, then you would avoid the problems associated with that top-heavy hierarchical structure.

To give another example that I think maybe is a bit more concrete and a bit more down to earth, I believe that one of the bigger problems that we have is that providers kind of tend to think all or nothing in terms of diagnosing patients, in terms of interacting, in terms of doing things. And I get where that comes from. I think that comes from, in my assessment, but I’m not a physician, right, I think that comes from the fact that you have to learn an astronomical amount of information your first one to two years. I mean, you’re basically a professional. Graduate-level medical physiology and graduate-level physiology courses are basically the same thing, as far as I can tell.

And I think that causes you guys to simplify things into all-or-nothing phenomena, which is the way that you learn. That’s the way our brains work: We simplify things into all or nothing, and then we kind of integrate them later. But complexity science can’t do that. You can’t break down something that’s complex, like, let’s say, the brain. You can’t break that down into the individual neurons and, just from studying individual neurons, understand thought patterns, understand emergent phenomena like that. So I think it would fix a lot of the issues as far as feedback mechanisms go, and I think it would fix a lot of issues as far as dealing with people who reduce things to an all-or-nothing phenomenon, because it can’t be reduced to that.

Kevin Pho: We’re talking to Robert Trent. He is a graduate student, and he wrote the KevinMD article “What role does the science of complexity play in medicine?” Robert, you mentioned feedback mechanisms as one solution to some of the potential problems complexity brings to medicine. What are some other solutions from the science of complexity that can be applied to fix some of the problems that you bring up?

Robert Trent: Biovigil would be one, like having some type of feedback mechanism that lets people know, “Did you wash your hands, yes or no?” and some type of monitoring device there. And it’s also easier from a social perspective, as a physician isn’t going to get mad at a device beeping, right? As opposed to, I think a lot of physicians feel like it’s not the patient’s place to ask them if they washed their hands.

So I think, in addition to that, though, second opinions, I think, are something else. I wrote that in another article as well, just kind of the essentialism of a second opinion. Let’s say that you receive some type of diagnosis that’s very bleak, I don’t know, myelodysplastic syndrome. There should be some type of feedback mechanism in place to ensure that that diagnosis was correct, and I think one of the things that we could do is immediately, kind of reflexively, have a second opinion, the second assessment, done. I think that would probably reduce it.

Things have probably changed since I worked in health care, but whenever I did work in health care and LVNs or someone like that were to administer insulin, they would withdraw the syringe, they would give the amount, “This is how much insulin I’m going to give,” and they would show it to a coworker, and a coworker could verify, “Yes, you’re giving them however many mLs of insulin.” And they know how much insulin is in there, right? There’s nothing really new there, but I’m just saying that is an example of a feedback process and a feedback pathway. That’s what our natural killer cells use to decide whether or not they want to kill a cell, and it’s really just that extra layer of feedback that allows for our system to be more effective, in order to optimize its ability to perform a function.

Kevin Pho: And if one wanted to read more about the science of complexity, what are some resources you can recommend?

Robert Trent: Santa Fe Institute does an amazing job. They have whole courses in complexity science that you can take kind of just at your own leisure. Geoffrey West has written an amazing book out of there. And then also, at MIT, there’s a guy named Max Tegmark who does a lot of research on artificial intelligence, but because artificial intelligence relies on information, he has done a lot of stuff on complexity science as well, so he’s pretty good at that.

Kevin Pho: OK, my final question: What’s your take-home message you want to leave with the KevinMD audience?

Robert Trent: I think most of your audience is probably clinicians, right? So I’m probably going to get a lot of flak for saying this, but, OK, excluding theoretical biologists, excluding systems biologists, and excluding the ecologists, I think most of the major innovative breakthroughs in molecular biology and in the biomedical sciences have been really just describing things, discovering details of systems, right? The Human Genome Project was just a set of descriptions: These are the genes of the human genome, right?

As we get better and better, as we develop more and more, and as we keep making progress, you’re going to have to start to move into explanations. How do we explain these things that we’re studying? And I think the explanation side is really going to come in as complexity science. It’s not enough just to know that DNA is the genetic material of the cell. You have to understand how DNA specifically interacts with all the other different types of inputs and outputs that go along in the cell.

So I think my words to your audience would be, before they make it a big deal with the textbooks and ruin the education process, I really would recommend your audience take some time to look into complexity science, because it will help you so much. It will make you a better clinician, and that will give you things that you can digest better, and it will also help you learn to think not just in terms of individuals, not just in terms of all or nothing, but in terms of whole systems. And that’s really, I think, where things are moving in terms of progress.

Kevin Pho: Robert, thank you so much for sharing your time and insight, and thanks again for being on the show.

Robert Trent: Thanks. Happy to be here.

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