Posted by: Tony Shannon | April 30, 2013

Video: Simple, Complex, Complicated, Chaotic – in Emergency Medicine

For a change this month, I thought I would try a video. Based on some of my writing and a presentation I did at last years ICEM.. I’ve decided to try a brief related screencast.

These 7 slides start to explore the Simple, Complicated, Complex and Chaotic elements of work in Emergency Medicine.

If the video isnt displaying above, try this link to the original on vimeo

It also starts to explain the related Cynefin framework that brings these elements of Emergency Medicine work together.

The examples I use include;

  • Simple- Measuring a persons Vitals signs – some say simple tasks take about 10 hours to learn
  • Complicated- Managing a patient with Cardiac Arrythmia e.g. Atrial Fibrillation- some say complicated skills take 1000 hours to acquire
  • Complex- Managing 1/many patients in your resus room in a state of shock (?hypovolemic ?septic ?cardiogenic) takes 10,000 hours of experience.. to spot and harness the patterns
  • Chaos- Managing chaotic situations – requires instinct, leadership and action , e.g. patient in Ventricular Fibrillation needing defibrillation.

The Cynefin framework can be applied to Emergency Medicine, by pulling these elements of our work together to help make  sense of our daily challenges and suggests related solutions.

I hope you find these slides of some interest/value.




  1. Hi Tony,

    Nice work and very useful for us as we currently have a system running here in the Netherlands geared at assessing the patient/family experience w.r.t. childfriendly care in 9 Dutch hospitals (and counting).

    We are also planning to move the approach into Emergency so nice to find your input.

    I have however two comments:

    1) The 10.000 hours of training IMHO applies to the complicated domain while the training one needs for complex situations is zero. One cannot train for that. But it is a fact that earlier experiences may proove to be useful in complex situations. It is however just not from training in particular. It could just as well be experience you gained while your car was broken or when a family member’s business went broke ….

    2) The way you explain chaos seems based on what is known as the random walk and you speak about “bring order” while especially in chaos the task is not act random nor bring order oriented, but “getting to act” is most important. This can be trained to some extend.

    If you are interested feel free to contact us to see how we can work together to speed mutual efforts.



  2. Many thanks Harold,

    Its great to get such informed debate..

    As you’ll know the science of Complex Adaptive Systems etc is still at an early stage and I have seen several interpretations of how chaos/complex/complicated should be defined
    I find Dave Snowdens Cynefin framework the most coherent out there, though there are others of course.
    None the less my brief presentation (that I decided to put together briefly last night) is simply my own interpretation of this field and of course the length of time needed to master complicated versus complex could be easily debated..

    2 points back to you.
    1) Have you come across the Cynefin framework in your work already. I know I have met others from the Netherlands who are familiar with it.
    2) Have you seen this video from Noah Radford.. which exposes the Cynefin framework and suggests the 10/1000/10000 hours split which resonates with me. It is certainly worth a look
    You’ll also be familiar with the Malcolm Gladwell book “Outliers” and his theory on the key value of 10,000 hours to master a domain.

    So I think we have slightly different views on what we mean by chaos and complexity.
    re: Complexity…
    Certainly I believe one can be trained to manage complex systems, and would politely challenge that “one cannot be trained” for that..
    re: Chaos..
    I do concede as you say ““getting to act” is most important. This can be trained to some extend”. My explanation was a bit simplistic, though I do believe that some folk have a better instinct for leadership and decision making than others..

    Hope you enjoy the debate!
    + Yes would be interested to know more of your plans..


    • Hi Tony,

      Progress speeds up by disagreement, so I tend to disagree quite a lot usually. Hope you don’t take it personal. We Dutch tend to overstep the fine line between disagreement and bluntness too often too unconscious.

      So to continue: I finished my PhD on CAS in 1995 and at the time the science was already 35 years old. So we can confidently say it is not early days anymore. In the social realm it is a bit earlier, but we are also >40 years underway with the work of Beer c.s, Checkland c.s. and many others.

      Indeed Cynefin is very useful as is Kurtz’s Confluence model and Peirces Xbox, Sarbo/Breemens KiF, Richmonds Trikonic and Keidels Organizational Patterning. Each of them deserve a place under the sun when used in the right mix and for well-choosen challenges.

      Re Cynefin and my work: I run a 6 person company that is based on all of the above and – as you might guess – most of that work is 100% complexity/complicated/KM related. So yes :-). I’m a member of the CE network since 2006/7. Some of my colleagues joined even earlier, others a bit later.

      Re 10/1000/10000 I tend to disagree. To learn a complicated task like open heart operations it takes years of practice and counting of 6 year and 2000 hours/year leads to 12.000. My main point however is that a CAS (or better the complex aspects of any realworld system are non predictable so one cannot train for that. Being exposted to such a reality can however season a person, such as an Emergency worker gets seasoned by years of experience with the unpreditable landslides that happen when a large accident happens and turn the ward into frantic chaos up to the point where care patterns break down and people die.

      To give another example of a complex issue in heath: diabetes care. With the numbers of patients in the 100k’s of millions lineair models don’t work anymore (not enough people, time, money) so we should start using the co-evolution of training, internet exchange, formal care and innovative feedback from the lives of people (using a combi of above methods for which we just crafted a 1st prototype in the Dutch context) to “do more with “the same” of even less”.

      Next: sorry to say so, by complex systems can’t be managed. They can be perturbed and the impact can be assessed. It is a whole different ballgame.

      Finally, what I meant with “training for chaos” is that one can have staff experience a wide wide range of chaotic situations (f.e. in a flight simulator or via near-real situations like firemen do) to gain experience and train the appropriate responses. I guess “checking vital signs” is a good example in Health. Without any prior knowledge a Med can assess a patients any patients situation (dead? –> next, complex –> try something, known but complicated? –> start treatment here, known but simple? –> get him/her out of here!

      Does this help?


      PS: Will look at Raford, know Malcoms work.

      • Thanks Harold (& sorry for delay in reply)

        Debate is very welcome and I appreciate your effort to stimulate it.
        Its also reassuring to know you are a veteran of the Complex Adaptive Systems field! Glad to know your part of the Cognitive Edge network, an interesting group..

        My efforts to communicate this message to my Emergency Medicine colleagues are still at an early stage. I can tell you very few in the EM community have begun to discuss how to understand or leverage this science, so its early days in that sense.

        I can agree that the 10/1000/10000 split is a bit simplistic, though I think its helpful in several ways.
        Also which goes in which box .. complicated vs complex vs chaotic etc, is probably a matter of perspective.
        i.e. one man’s chaos may be another man’s complicated..,ie what is routine/complicated to an emergency physician could/would appear complex/chaotic to the layman.

        Whether complex systems can be managed is a good question. I feel like I can manage a complex Emergency Department most of the time, until it tips into chaos.. though as you suggest this may not be management in the traditional sense, but actively perturbing and constant reassessment.

        Yes, training for chaos I recognise..

        Anyway, many thanks for the discussion. Would be interested to know more of your project offline.



  3. […] 20 years practising in Emergency Departments I can explain them as perfect examples of “complex adaptive systems” where you are constantly juggling patients from major resuscitation to minor injuries and […]

  4. […] 20 years practising in Emergency Departments I can explain them as perfect examples of “complex adaptive systems” where you are constantly juggling patients from major resuscitation to minor injuries and […]

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