The entropy of suffering : an inquiry into the consequences of the 4-Hour Rule for the patient-doctor relationship in Australian public hospitals

Abstract

As a medical practitioner, predominantly working in Australian public hospitals, I have always been interested in the factors that shape and influence my and my colleagues' performance in the practice of medicine. In 2011, the Australian Government instituted a range of reforms to the public health-care system, including some directed at improving access for patients to Emergency Departments, which had, over many years, become increasingly overwhelmed by the number and complexity of presentations. This included a target of four hours within which patients in Emergency Departments were to be discharged, admitted or transferred to alternative institutions. These reforms generated widespread strong emotional responses from medical and other health staff with whom I worked, and I was prompted to consider the origins of these powerful human reactions to the administrative intervention. Emergency Departments are often described, derisively, as chaotic working environments. However, this epithet may instead be describing something quite profound about the ontological nature of hospitals and Emergency Departments "" that they are, indeed, non-linear dynamical physical systems in which phenomena of complexity exist. Other human-centred interactional and transactional systems have been successfully examined from a complexity perspective, including economics and human physiology. Framing inquiry into Emergency Departments, and the humans who encounter each other within them, from a complexity perspective might also then prove useful in defining and characterising the complex and manifold relationships and interactions between people, technology and systemic organising principles. This health services research evaluates the lived experience of four medical practitioners through the paradigm of phenomenological inquiry, as actors on a performance landscape of clinical encounters and as key sources of information about the structure and functions of that performance manifold. Inquiry into and analysis of these rich descriptive data yield strong inferences that non-linear dynamics are operating across scales "" from the cellular to the organisational. The complexity perspective provides a unifying explanatory power for making sense of how energetic transactions and transformations between patients, health-care practitioners, technology and the hospital system unfold to result in the recovery from injury and trauma. Specifically, literature on interoception suggests that human biological systems are exquisitely sensitive to changes in dynamic steady-states that might indicate increased entropy. This inquiry suggests that suffering is a phenomenological experience of sudden increases in entropy. An explanatory model in complexity, using the Second Law of Thermodynamics in open systems, suggests that entropy "" that is, suffering "" can be understood as being transferred and expelled from patient to doctor. Framing in this explanatory model would suggest that the patient-doctor relationship is a powerful systemic attractor in a dynamic system. Elaborating this construct of energetic dynamics further suggests that insertion of system controllers, such as time-based targets, can have profound non-linear effects on the function of these dynamics and, hence, the outcomes of these patient-doctor encounters. The implications of this inquiry include a new and powerful reframing of the ontological characterisation of the practice of medicine in Emergency Departments in terms of nonlinear open thermodynamic functions operating at distance from equilibrium. It recommends a more thoughtful consideration of human experiences such as suffering and its relief. Giving priority and visibility to suffering within health-care, a recrudescence of times past when technology in medicine was limited, may elucidate ways of practising that improve patient experiences and health outcomes. Furthermore, the findings suggest that medical practitioners, health workers and administrators are called on to deeply consider embracing complex dynamics as problem framing references, and to engage with methodologies that build better theories about the nature of phenomena under investigation. Rather than seeking to diminish or extinguish the complexities of Emergency Departments, researchers and practitioners might acknowledge and engage with the next wave of complexity-informed health-care research to better understand how and why health-care relieves suffering and restores human function.

Date of Award	2018
Original language	English