这最近发表的审判由荷兰的德·科克（De Kock），诺本（Noben）和同事撰写，是我们在家庭医学中经常看到的事物的一个很好的例子：一项合理，合理的，复杂的干预措施的合理试验，会产生负面结果。在这种情况下，该论文报告了对家庭医生教授其他技能的试验。这些额外技能的目的是支持目前由于健康状况不佳而无法工作的人。我们知道，总的来说，工作对幸福（和财富）有益，因此帮助人们重返工作岗位是一个值得的目标。我们还知道，家庭医生可以直接通过认证或间接地通过他们提供的自我管理建议来维持患者的疾病缺席。因此，对家庭医生的教育干预应该产生影响是合理的。但是，试验没有发现。

So what went wrong?

这study was certainly well-designed: it was a cluster randomized trial (280 patients from 26 practices) and it was conducted thoroughly. The investigators recognized that the trial might not be big enough to see a difference in hard outcomes like time off work, so they also used an intermediate outcome measure that was closer to the intervention. Specifically, they used a work-related measure of self-efficacy that correlates well with actual return to work. This meant their findings should have been less susceptible to individuals’ circumstances, such as their personal and occupational situation. But there was no effect on either outcome. And perhaps that’s not surprising, because previous studies suggested that患者因素影响疾病认证不仅仅是从业人员的因素全科医生与职业医生之间的合作没有效果。

这项研究告诉我们什么？

这样的论文使我们有机会在医疗保健系统之间分享知识的知识，这与分享对什么的知识一样重要。

I suggest that this study teaches us two things. First, it reminds us we need to focus less on “complex interventions” and more on the “complex systems” within which these interventions happen. In their discussion, the authors fall into the trap of thinking “if only we had a better intervention” and suggest that better-tailored interventions might work. This is an appropriate way of thinking about relatively simple interventions – “if only we knew which drug to use for which patient…”, but with complex interventions it may be missing the point.

That is because complex interventions are mostly复杂系统的干预措施不仅在孤立的个人中。复杂的系统（例如患者的健康，疾病，家庭和工作网络）具有吸收（或缓冲）可能改变它们的大多数事物的特性。这并非总是如此，实际上有时复杂的系统会因单个输入而发生巨大变化，但通常它们只是吸收它们。结果是精心设计的复杂干预措施经常无法显示我们期望的整洁，统计学上的显着影响。那不是因为它们是不良的干预措施，而是因为他们试图在更复杂的事物或人网络中改变某物（或某人）的一个方面。该复杂网络或系统的效果通常是吸收单个变化。

这项研究的第二件事提醒我们，我们需要在国际上分享，什么有效和在家庭医学中无效的东西。全世界的政客，评论员和智囊团将不断提出通过家庭医学改善事情的想法。并非所有这些想法都会像最初看起来一样聪明，许多人会重复其他地方的较早计划的错误假设。这样的论文使我们有机会在医疗保健系统之间分享知识的知识，这与分享对什么的知识一样重要。