Scientific Paradigm Shift
In May 2013, I was in Gdańsk, Poland for the annual meeting of the European Hernia Society. In a session on guidelines, a European surgeon presented a paper that looked at expert consensus regarding published treatment guidelines.
The guidelines were presented based on levels of evidence, with Level 1 evidence being the highest quality and Level 5 being the lowest. Interestingly, in this review, Level 5 guidelines were evaluated as appropriate by experts about 85% of the time (a solid ‘B’ grade); but amazingly, Level 1 guidelines (supposedly the best evidence science has to offer) were judged as appropriate only about 60% of the time, a near-failing grade.
The science we have applied to healthcare (Reductionism), with its hierarchy of evidence, is based on the principles of isolated or mechanical systems rather than complex biologic systems. Because of this we’re often left with incomplete and inaccurate results and interpretations as well as unintended consequences.
Our world is going through the first major scientific paradigm shift since the time of the Renaissance when the concepts of Reductionism were developed. At that time (around A.D. 1300 – 1600), and for our world over the next few hundred years, this was a great advance that led to the Industrial Revolution. We learned how to use raw materials and make useful products. We learned to harness energy and apply it in ways that led to improved quality of life for many people. But I think more and more, people are realizing that we’re approaching the Law of Diminishing Returns for our Reductionist Science Paradigm.
We’re expending tremendous resources and working harder and harder while we achieve less and less improvement in our health and quality of life. I think we’re also beginning to realize the waste and harm that can occur when we rely on a paradigm that doesn’t apply well to our complex biologic world that is constantly changing.
Thomas Kuhn coined the term ‘paradigm shift’ in his book The Structure of Scientific Revolutions, published in 1962 – in it he describes the process of Scientific Evolution. It’s not a linear process as previously thought where we would just continue to gain knowledge and improve as a society. According to Kuhn, the impetus for a shift in a paradigm is that there needs to be enough anomalies (things that just don’t make sense according to the rules of the current paradigm) that enough people realize that the solution isn’t to figure out why the anomalies are occurring, it’s to figure out a new paradigm that better aligns with what is really happening in the world.
The anomalies are only anomalies because the current scientific rules say they are. There are many examples of the fact that Reductionism is not adequate in our complex biologic world, and you can read some examples from the US Air Force and the NFL in my past blog posts.
The Systems Science Paradigm accommodates constant change and uncontrollable biologic variability. Its tools are about measurement and improvement – instead of one static hypothesis, there are feedback loops that provide insight to inform clinical teams so that process and outcome measurements are improved and outcomes that are measured are also improved over time.
To explicitly define the differences between the Reductionist Science Paradigm and the Systems Science Paradigm, please see the table below:
Table: Reductionist Science Paradigm vs. Systems Science Paradigm
The Gdańsk Shipyard is where Lech Wałęsa and others founded the Solidarity movement, a labor union to address the inequities of communism. I think we need the same kind of movement to address the inequities and unintended consequences in healthcare, recognizing that continuing to function in the current scientific status quo is not sustainable. Systems Science isn’t just our future, it can be our present.