If You Change the Way You Look at Things, Things You Look at Change. Max Planck’s Challenge for Health, Health Care, and the Healthcare System

Abstract

Max Planck observed that ‘If you change the way you look at things, things you look at change’. It is high time for healthcare professionals to embrace the challenge—the linear reductionist view of health and disease is failing our patients, our profession and our societies. These insights are not really new, Osler has coined many aphorisms to emphasise the need to understand the person with an illness over and above the diseases that might be responsible for his predicament.

This chapter looks at health, health care and the healthcare system from a complex adaptive systems perspective—health is a subjective adaptive state, health care ought to aim at improving or at least maintaining the experience of health, and the health system ought to provide an integrated framework so that health for all can emerge. Looking at health, health care and the health system from the multiple dimensions spanning basic physiology and its networks to the organisational levels with the power to create an environment in which individuals can achieve their health potentials indeed makes ‘things we look at change’.

Appendices

Appendix 1: Disease Definitions and Re-definitions

Hypertension
1948	The blood pressure is [considered to be] raised when the systolic pressure is 180 or over, and/or the diastolic pressure is 110 or over, on three consecutive examinations, and in the presence of clinical, radiological and cardiographic evidence of cardiovascular hypertrophy.— Evans W. Hypertension. In: Cardiology. London, England: Paul B. Hoeber, Inc; 1948:204
1949	In a patient with mild benign hypertension—[defined as a] blood pressure ¡200/¡100mmHg, there is no indication for use of hypotensive drugs. Continued observation is desirable and conservative treatment consisting of reassurance, mild sedatives, and weight reduction is indicated.— Friedberg CK. Diseases of the Heart. Philadelphia, PA: WB Saunders Co; 1949
1960s	Hypertension = BP > 100+age
1977	JNC 1— Moser M. From JNC I to JNC 7-what have we learned? Prog Cardiovasc Dis. 2006;48:303–315 • Diastolic BP >105 mm Hg requires treatment
2003	JNC 7— Moser M. From JNC I to JNC 7-what have we learned? Prog Cardiovasc Dis. 2006;48:303–315 • Normal BP 120–129/80–89
2017	American College of Cardiology/American Heart Association (ACC/AHA) guidelines—Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA, Williamson JD and Wright JT. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017;71(6):1269–324 • Hypertension >130/80 mm Hg
Diabetes mellitus—definition is based on occurrence of diabetic retinopathy
1979	National Diabetes Data Group—Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. National Diabetes Data Group. Diabetes. 1979 Dec;28(12):1039–57
	Based on 77 out of 1213 people developing retinopathy • Fasting plasma glucose (FPG) concentration of ≥ 7.8 mmol/L (140 mg/dL), or • 2-h value after 75 g oral glucose of ≥ 11.1 mmol/L (200 mg/dL)
1997	Expert Committee on the Diagnosis and Classification of Diabetes Mellitus—Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20(7):1183–97
	Diagnosis of diabetes by linking levels of glycaemia with diabetic retinopathy in populations of Pima Indians (n = 960), Egyptians (n = 1081), and a randomly selected cohort in the Third National Health and Nutrition Examination Survey (NHANES III) (n = 2821) • Fasting plasma glucose (FPG) criterion of ≥ 7.0 mmol/L (126 mg/dL)
Diabetes mellitus—definition is based on occurrence of diabetic retinopathy
2010	American Diabetes Association— Diagnosis and classification of diabetes mellitus. American Diabetes Association. Diabetes Care. 2010;33(Suppl 1):S62–9 • HbA1c levels ≥ 6.5%
Depression—disease or syndrome
1920s–1970s	Textbook definitions of endogenous and reactive depression: • Endogenous depression (severe disorder with delusions and hallucinations) • Reactive depression (milder disorder without delusions and hallucinations; often with the connotation of a vulnerable personality, in the context of life stresses, features of diurnal variation with morning worsening, delayed insomnia with early morning wakening and greater somatic disturbances, such as loss of appetite and weight, and psychomotor retardation or agitation
2013	DSM-V major depression
	(A) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure
	Note: Do not include symptoms that are clearly attributable to another medical condition 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty and hopeless) or observation made by others (e.g. appears tearful). (Note: In children and adolescents, can be irritable mood)
Depression—disease or syndrome
	2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain) 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day observable by others, not merely subjective feelings of restlessness or being slowed down) 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
	(B) The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
	(C) The episode is not attributable to the physiological effects of a substance or to another medical condition
	Note: Criteria A–C represent a major depressive episode
	Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite and weight loss noted in Criterion A, which may resemble a depressive episode
	Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the contest of loss
	(D) The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified and unspecified schizophrenia spectrum and other psychotic disorders
	(E) There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic like episodes are substance-induced or are attributable to the physiological effects of another medical condition
DSM-V adjustment disorder
	• Emotional or behavioural symptoms develop in response to an identifiable stressor or stressors within 3 months of the onset of the stressor(s) plus either or both of (1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or (2) significant impairment in social, occupational or other areas of functioning • The stress-related disturbance does not meet criteria for another mental disorder and is not merely an exacerbation of a pre-existing mental disorder • The symptoms do not represent normal bereavement • After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months

Appendix 2: Prevalence of Long-Term Conditions in the Australian National Health Survey

	2001a	2014b
Arthritis		15.3% (3.5 million people)
Asthma	12% (2.2 million people)	10.8% (2.5 million people)
Cancer	1.6% (311,300 people)	1.6% (370,100 people)
High cholesterol	6.0% (1.1 million people)	7.1% (1.6 million people)
Diabetes	2.9% (554,200 people)	5.1% (1.2 million people)
Heart disease		5.2% (1.2 million people)
Hypertension	10% (1.8 million people)	11.3% (2.6 million people)
Kidney disease		0.9% (203,400 people)
Mental and behavioural conditions	18% (3.3 million people)	17.5% (4.0 million people)
Osteoporosis		3.5% (801,800 people)

1. ^aAustralian Bureau of Statistics. National Health Survey. Australia 2001. http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/90A3222FAD5E3563CA256C5
2. D0001FD9D/\protect\T1\textdollarFile/43640_2001.pdf
3. ^bAustralian Bureau of Statistics. National Health Survey. First Results Australia 2014–15. http://www.ausstats.abs.gov.au/Ausstats/subscriber.nsf/0/CDA852A349B
4. 4CEE6CA257F150009FC53/\protect\T1\textdollarFile/national%20health%20sur
5. vey%20first%20results,%202014-15.pdf

Appendix 3: Annas’ Analysis of the Consequences of the Military and Market Metaphors on Health Care [144]

Military metaphor	Consequences
• Medicine is a battle against death • We are almost constantly engaged in wars on various diseases, such as cancer and AIDS • Diseases attack the body, patients fight the disease and doctors intervene or counterattack • Doctors are mostly specialists and backed by allied health professionals all of whom are trained to be aggressive, fight these invading diseases with weapons designed to knock them out • Doctors give orders in the trenches and on the front lines, using their armamentaria in search of breakthroughs • Treatments are conventional or heroic, and the brave patients soldier on • We engage in triage in the emergency department, invasive procedures in the operating theatre, and even defensive medicine when a legal enemy is suspected • Health plans and hospitals market products to consumers, who purchase them on the basis of price • Medical care is a business that necessarily involves marketing through advertising and competition amongst suppliers who are primarily motivated by profit • Health care becomes managed care • Mergers and acquisitions become core activities	• Ignore costs • Strengthens the belief that all problems can be solved with more sophisticated technology and scientific advances, prompting hospitals and doctors to engage in medical arms races • War analogies lead to acceptance as inevitable that organisations are hierarchical and largely dominated by men • The patient’s body becomes a battlefield, thus appropriate to have short-term, single-minded tactical goals • Concentrates on the physical, sees control as central and encourages the expenditure of massive resources to achieve dominance • We failed to assert that medicine, like war, should be financed and controlled only by the government • The metaphor has also become mythic. As a historian of war, John Keegan, correctly argues, modern warfare has become so horrible that ‘it is scarcely possible anywhere in the world today to raise a body of reasoned support for the opinion that war is a justifiable activity’ • Emphasis is placed on: – Efficiency – Profit maximisation – Customer satisfaction – The ability to pay – Planning – Entrepreneurship – Competitive models • The ideology of medicine is displaced by the ideology of the marketplace • Trust is replaced by caveat emptor
• Chains are developed, vertical integration is pursued and antitrust worries proliferate • Consumer choice becomes the central theme of the market metaphor • In the language of insurance, consumers become ‘covered lives’ or even ‘money-generating biological structures’ • Economists become health-financing gurus • The role of doctors is radically altered as they are instructed by managers that they can no longer be patient advocates (but instead must advocate for the entire group of covered lives in the health plan) • The goal of medicine becomes a healthy bottom line instead of a healthy population	• There is no place for the poor and uninsured in the market metaphor • Business ethics supplant medical ethics as the practice of medicine becomes corporate • Non-profit medical organisations may tend to be corrupted by adopting the values of their for-profit competitors • A management degree becomes at least as important as a medical degree • Public institutions, which by definition cannot compete in the for-profit arena, risk demise, second-class status or simply privatisation • Patients, as consumers, are to make decisions that are governed by corporate entities • The market metaphor conceals the inherent imperfections of the market and ignores the public nature of many aspects of medicine • It ignores the inability of the market to distribute goods and services whose supply and demand are unrelated to price • The metaphor pretends that there is such a thing as a free market in health insurance plans and that purchasers can and should be content with their choices when unexpected injuries or illnesses strike them or their family members • The reality is that American markets are: – Highly regulated, – Major industries enjoy large public subsidies, – Industrial organisations tend towards oligopoly and – Require strong laws that protect consumers and offer them recourse through product-liability suits to prevent profits from being too ruthlessly pursued

1. Compiled from Annas: reframing the debate on healthcare reform by replacing our metaphors; italics emphasise pertinent concepts from the paper. Taken from: Sturmberg et al. [135]