ICE Book Review – Thinking in Systems: A Primer

By Rob Cooney (@EMEducation)

Thinking in Systems: A Primer By: Donella Meadows

Medical practice, and medical education, have become increasingly complex. Interconnections are everywhere, and the lay press and literature offer no shortage of reports on how we fail to produce competent physicians and high-quality care. To change the long-standing structures and processes, we need to better understand the systems we work and learn within. Donella Meadows’ Thinking in Systems offers a thought-provoking perspective on addressing complex problems by understanding systems. This book provides a valuable framework about understanding systems, comprised of elements, interconnections, and purpose that can help medical educators who are looking to impart systems thinking skills to students.

Meadows opens with and overview of how systems are composed of elements, interconnections, and purpose. A key takeaway is that system behavior arises from these components interacting, not just the elements themselves (i.e., the result is more than the sum of its parts). Therefore, changing relationships and goals can profoundly alter system performance, even if the parts remain unchanged. She also notes that systems with similar structures exhibit analogous behaviors, even if the systems seem superficially dissimilar.

Several concepts resonated as relevant to medical education:

  • Leverage points – in complex systems, small well-chosen interventions can produce significant changes. As educators, identifying “high-leverage” concepts or skills to focus our limited teaching time on is crucial.
  • Delays – delays in feedback loops can drive oscillations and instability in systems. In medicine, feedback delays are everywhere, from diagnosis to treatment response. Teaching students to anticipate and manage delays is vital.
  • Paradoxes – counterintuitive behaviors frequently emerge from complexity. Preparing students to expect and reconcile paradoxes, rather than see them as failures, may lead to more agile problem-solving.
  • Resilience – resilience – the capacity to recover from perturbation – is a hallmark of healthy systems. Cultivating resilience is a hot topic in medicine as recognition of the intensity of burnout and the adverse effects grows, our bounce back from errors and maintain performance under stress has reached a critical level.

Thinking in Systems reminds us that medicine is not a series of isolated events, but a web of complex interdependent structures. The book offers perspective on imparting the systems thinking expertise students need to improve healthcare delivery and offers medical educators a perspective on how to approach teaching these key systems concepts that will serve students throughout their careers as they encounter medical systems challenges.

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