Complexity and simplicity in healthcare: a vision of the future Kamran Abbasi, acting editor BMJ

What I will talk about Where will medical research be published in the future and how? Where will medical research be published in the future and how? What can paper journals and traditional publishing houses offer? What can paper journals and traditional publishing houses offer? Do we know what clinicians want to read? Do we know what clinicians want to read? Do journals affect practice? Do journals affect practice?

Doctors—be they clinicians or journal editors—are in the communication business and the challenge we face is how to create simplicity out of the complexity of information available to us?

Does this mean we should stand defeated by complexity? Far from it

Suppliers of information to doctors— and doctors themselves when informing patients—must grapple with complexity to deliver a message of such simplicity that it aids decision making and prevents adverse outcomes

Both google and ipod are interfaces (metaphorical gateways through which humans enter and navigate around a technology)

Both are picture book examples of simplicity concealing complexity underneath

Everything should be made as simple as possible, but not simpler (Albert Einstein)

Keep it simple. The healthiest buildings, according to the ancient Chinese principles of feng shui, are those that have no clutter, because clutter, which is complexity by another name, deadens the energy in a house (Economist)

But is this some Einsteinian fantasy? How might simplicity defeat complexity?

Research will be published in international registers and archives, probably not in journals

Predictions of Lord Kelvin, president of the Royal Society, Radio has no future Radio has no future X rays will prove to be a hoax X rays will prove to be a hoax Heavier than air flying machines are impossible Heavier than air flying machines are impossible

What are the drivers of a new form of publishing? Failures of the present system Failures of the present system A vision of something better A vision of something better Money Money Balkanisation of the literature Balkanisation of the literature Slowness Slowness Governments and consumers Governments and consumers

A vision of something better “It's easy to say what would be the ideal online resource for scholars and scientists: all papers in all fields, systematically interconnected, effortlessly accessible and rationally navigable, from any researcher's desk, worldwide for free.” “It's easy to say what would be the ideal online resource for scholars and scientists: all papers in all fields, systematically interconnected, effortlessly accessible and rationally navigable, from any researcher's desk, worldwide for free.” Stevan Harnad Stevan Harnad

A vision of something better “ If you have an apple and I have an apple and if we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.” “ If you have an apple and I have an apple and if we exchange these apples then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.” George Bernard Shaw George Bernard Shaw

“You can resist the invasion of an army, but you cannot resist the invasion of an idea” Victor Hugo

People are no longer divided by geography but by language

Research will be made available for free on publicly accessible databases OPEN ACCESS

What I will talk about Where will medical research be published in the future and how? Where will medical research be published in the future and how? What can paper journals and traditional publishing houses offer? What can paper journals and traditional publishing houses offer? Do we know what clinicians want to read? Do we know what clinicians want to read? Do journals affect practice? Do journals affect practice?

Benefits of publishing in the BMJ Full text articles available free Full text articles available free Wide international exposure in print and on web Wide international exposure in print and on web Media exposure Media exposure High impact factor >7 High impact factor >7 Fast track peer review and publication Fast track peer review and publication High quality reviewing and technical editing High quality reviewing and technical editing Indexed by Medline and Current Content Indexed by Medline and Current Content Authors retain copyright, share reprint revenue Authors retain copyright, share reprint revenue

Should a journal/newspaper be more like a computer screen (something the Times compact tries to do), and use visual prompts to guide people around the “screen”? (Robert Thomson)

The internet has changed newspapers’ role in society. Newspapers compete with the internet but also find ways to complement it (Robert Thomson)

Newspapers can’t compete with the web and tv for breaking news, but they can for views (Simon Kelner)

Technology has made life more complex (Chris Caposella, head of Microsoft’s desktop applications)

People read journals in different ways in print and different ways on the web

What I will talk about Where will medical research be published in the future and how? Where will medical research be published in the future and how? What can paper journals and traditional publishing houses offer? What can paper journals and traditional publishing houses offer? Do we know what clinicians want to read? Do we know what clinicians want to read? Do journals affect practice? Do journals affect practice?

Words used by 41 doctors to describe their information supply Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible Impossible Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Difficult Difficult Difficult Difficult Difficult Difficult Difficult Difficult Daunting Daunting Daunting Daunting Daunting Daunting Pissed off Pissed off Choked Choked Depressed Depressed Despairing Despairing Worrisome Worrisome Saturation Vast Help Exhausted Frustrated Time consuming Dreadful Awesome Struggle Mindboggling Unrealistic Stress Challenging Challenging Challenging Excited Vital importance

Conclusions of studies of doctors’ information needs during consultations Information needs do arise regularly when doctors see patients (about two questions per consultation) Information needs do arise regularly when doctors see patients (about two questions per consultation) Questions are most likely to be about treatment, particularly drugs Questions are most likely to be about treatment, particularly drugs Questions are often complex and multidimensional Questions are often complex and multidimensional The need for information is often much more than a question about medical knowledge The need for information is often much more than a question about medical knowledge Doctors are looking for guidance, psychological support, affirmation, commiseration, sympathy, judgement, and feedback Doctors are looking for guidance, psychological support, affirmation, commiseration, sympathy, judgement, and feedback

Conclusions of studies of doctors’ information needs during consultations Most of the questions generated in consultations go unanswered Most of the questions generated in consultations go unanswered Doctors are most likely to seek answers to their questions from other doctors Doctors are most likely to seek answers to their questions from other doctors Most of the questions can be answered—but it is time consuming and expensive to do so Most of the questions can be answered—but it is time consuming and expensive to do so Doctors seem to be overwhelmed by the information provided for them Doctors seem to be overwhelmed by the information provided for them

The information paradox: Muir Gray Doctors are overwhelmed with information yet cannot find the information they need Doctors are overwhelmed with information yet cannot find the information they need

Information paradox “Water, water, everywhere Nor any drop to drink” The Rime of the Ancient Mariner

What I will talk about Where will medical research be published in the future and how? Where will medical research be published in the future and how? What can paper journals and traditional publishing houses offer? What can paper journals and traditional publishing houses offer? Do we know what clinicians want to read? Do we know what clinicians want to read? Do journals affect practice? Do journals affect practice?

Evidence based policy making sets the context in which evidence based clinical practice can take place (Muir Gray)

Would it be better to stop talking about EBM and instead talk about evidence informed practice?

NICE guidance is implemented variably, suggests a national study BMJ 2004;329:

Factors that favour implementation are: strong professional support, convincing evidence base, no more costs, implementation tracking, and professionals not isolated

Evidence based guidelines or collectively constructed “mindlines”? BMJ 2004;329:

Clinicians: informed by brief reading but mainly by own and their colleagues’ experience, their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives

An insoluble paradox exists between the desire for consistent evidence based guidelines and the unique requirements of an individual patient

Decision makers are often forced to provide a definitive answer in conditions of high uncertainty, and unthinking adherence to guidelines and protocols can be harmful

Decision support systems are one attempt to impose simplicity upon complexity, providing clinicians with concise, evidence based, up to date, and—crucially—individualised information

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All of this, of course, raises serious questions about the existence of journals, once rated by the inscrutability of their language and the complexity of their subject matter

Those that survive the downturns in advertising revenue, subscriptions, and the threat of open access publishing will be the ones that, in the words of Einstein, make everything as simple as possible, but not simpler

They will be more readable to compete with other entertainment media

And the print and electronic versions, in their different ways, will be metaphoric gateways through which humans enter and navigate around

Simplicity concealing layer upon layer of complexity

In our information rich and highly complex world, those suppliers of information, and doctors, who succeed will be the ones who make simple sense of our messy world while capturing its fuzziness