PLoS Medicine -- Decision Making in Health

Two articles suggest systems analysis as an alternative to reductionism for clinical decisions:

"The Limits of Reductionism in Medicine: Could Systems Biology Offer an Alternative?" (Ahn AC, Tewari M, Poon CS, Phillips RS (2006) The Limits of Reductionism in Medicine: Could Systems Biology Offer an Alternative? PLoS Med 3(6): e208)

Since Descartes and the Renaissance, science, including medicine, has taken a distinct path in its analytical evaluation of the natural world [1,2]. This approach can be described as one of “divide and conquer,” and it is rooted in the assumption that complex problems are solvable by dividing them into smaller, simpler, and thus more tractable units. Because the processes are “reduced” into more basic units, this approach has been termed “reductionism” and has been the predominant paradigm of science over the past two centuries. Reductionism pervades the medical sciences and affects the way we diagnose, treat, and prevent diseases. While it has been responsible for tremendous successes in modern medicine, there are limits to reductionism, and an alternative explanation must be sought to complement it.

The alternative explanation that has received much recent attention, due to systems biology, is the systems perspective (Table 1). Rather than dividing a complex problem into its component parts, the systems perspective appreciates the holistic and composite characteristics of a problem and evaluates the problem with the use of computational and mathematical tools. The systems perspective is rooted in the assumption that the forest cannot be explained by studying the trees individually.

"The Clinical Applications of a Systems Approach" (Ahn AC, Tewari M, Poon CS, Phillips RS (2006) The Clinical Applications of a Systems Approach. PLoS Med 3(7): e209)

In the first article in this series, we examined the reductionist approach that pervades medicine and explained how a systems approach (as advocated by systems biology) may complement it [1]. In order for a systems perspective to have any practical clinical significance, we must understand when a systems perspective is or is not helpful, and conversely when a reductionist approach is helpful. In addition, we must be able to envision how a systems perspective can be implemented to appreciate the potential benefits derived from its application. In this article, we address these issues and present a practical discussion of systems application to medicine.

The third article deals with a group decision process.

"Transparent Development of the WHO Rapid Advice Guidelines" (Schünemann HJ, Hill SR, Kakad M, Vist GE, Bellamy R, et al. (2007) Transparent Development of the WHO Rapid Advice Guidelines. PLoS Med 4(5): e119)

Emerging health problems require rapid advice. We describe the development and pilot testing of a systematic, transparent approach used by the World Health Organization (WHO) to develop rapid advice guidelines in response to requests from member states confronted with uncertainty about the pharmacological management of avian influenza A (H5N1) virus infection. We first searched for systematic reviews of randomized trials of treatment and prevention of seasonal influenza and for non-trial evidence on H5N1 infection, including case reports and animal and in vitro studies. A panel of clinical experts, clinicians with experience in treating patients with H5N1, influenza researchers, and methodologists was convened for a two-day meeting. Panel members reviewed the evidence prior to the meeting and agreed on the process. It took one month to put together a team to prepare the evidence profiles (i.e., summaries of the evidence on important clinical and policy questions), and it took the team only five weeks to prepare and revise the evidence profiles and to prepare draft guidelines prior to the panel meeting. A draft manuscript for publication was prepared within 10 days following the panel meeting. Strengths of the process include its transparency and the short amount of time used to prepare these WHO guidelines. The process could be improved by shortening the time required to commission evidence profiles. Further development is needed to facilitate stakeholder involvement, and evaluate and ensure the guideline's usefulness.