How complex are clinical situations, really?
We began to discuss this topic in Complex Cases, Part I. Here’s what we said: “When looked at closely, clinical work is astonishingly complex. We are referring to the multiple determinants that shape a diagnostic formulation and treatment plan as well as the way we come to our moment-to-moment decisions about how to treat.”
We continue to develop that topic here.
There are at least two primary sources of clinical complexity, the aggregation of factors that shape “a case.” The first, which we call “inherent complexity,” reflects the general, descriptive variables selected to define the case and the assortment of personal and interpersonal factors always at work in a clinical situation. The second, “technical complexity,” consists of the mixture of diagnostic considerations specific to the case, whether psychiatric, medical, or psychological.
Inherent Complexity, Components:
Remarkably, features of “inherent complexity” may include any or all of the following. There are at least 10 categories:
(1) The general characteristics of the patient and his or her medical issues, psychology, or psychopathology.
(2) A more inclusive perspective involving psychological and sociological factors that interact with the patient’s psychology, and incorporate, for example, the patient’s social milieu and cultural background.
(3) The care systems within which the patient is being treated, private or public.
(4) The patient’s prognosis including: (a) its near-term outlook, as in the situation, for example, of a hospitalized patient, or (b) the longer view, as one would have with an office or clinic based outpatient.
(5) The precision with which a clinical process is formulated and carried out.
Clinical work also often lacks technical, e.g. diagnostic clarity, and can easily be complicated by:
(6) Inexact communication between involved clinicians, as well as between these clinicians and the patient and his or her family.
(7) When several clinicians are involved in a case (in our new book, Comprehensive Care for Complex Patients, we call this category of complexity, “operational complexity”), there may be differences between the points of view each introduces, and how and when each chooses to act.
(8) For each case there may be multiple diagnostic and case formulations, each potentially reflecting the involved clinicians’ training and personal biases.
(9) A “case” therefore is likely to mean different things to different clinicians, each one’s position additionally influenced by person specific factors, including the clinician’s specialty, training, clinical experience, and personal psychology and preferences.
(10) The product of all these “inherent” sources of complexity is the dissimilarity in strategies separate clinicians working with the same patient might decide to use.
Technical Complexity, Case Example:
Using the following case example we now introduce the topic of “technical complexity” and its management, that is, complexity involving the mixture of individual or co-morbid diagnostic issues associated with the case.
Randy was an 18-year-old patient who had survived a serious automobile accident at age 6. In addition to orthopedic surgeries requiring at first total and then partial immobilization for about six months, her medical course was further complicated by disfiguring facial lacerations and fractures requiring extensive repairs. Several years later, presumably in part as a result of her early medical trauma, she presented with anorexia nervosa and a conduct disorder that included substance abuse and sexual promiscuity. I (Steve Frankel) was originally called in to provide treatment for Randy’s multiple psychiatric difficulties.
My initial focus was to work with Randy’s primary-care physician for dealing with the medical consequences of Randy’s by now life threatening eating disorder. The responsibility for organizing and monitoring her medical care, however, was soon mine since Randy generally refused to cooperate with any of the adults in her life, including physicians. The second focus involved targeting the psychopathology and management of Randy’s substance use disorder and rebelliousness.
However, Randy characteristically insisted on doing things her own way. Soon after I became involved in her care she moved in with her boy friend, cut off regular communication with her parents, and throughout this time neglected her doctors’ cautions about the life threatening nature of her disease. She simply “didn’t want to hear” the facts.
In addition to interpersonal negotiation with Randy, working effectively with her behavior and eating disorder required strict coordination between her internist, a dietician who specialized in eating disorders, and her divorced parents. Also involved was a psychologist who performed psychological testing in order to get a clearer picture of the nature and extent of Randy’s psychopathology. In spite of her parents’ and physicians’ insistence, Randy was unwilling to enroll in a rehabilitation program for substance abuse or even, at critical points, consider hospitalization for treatment of her active and progressing eating disorder.
At this point we return from technical complexity (Randy’s diagnoses) to inherent complexity (the considerations defining and shaping a case). In cases like Randy’s, coordination among professionals, and between them and the patient and family, while critical, may be fraught with difficulties. At one point, for example, Randy’s parents failed to alert the rest of the treatment team that Randy had disappeared for a week and had reemerged only when she required emergency medical care. A similar disruption in the team’s effort occurred when Randy’s always angry mother skipped two consecutive family therapy meetings and brought Randy instead to an alternative medicine practitioner who wanted to treat her anorexia nervosa with natural remedies. This episode, for a second time, led to a trip to the emergency room, this time by ambulance. On arrival she was cachectic (weighing 95 pounds, height 64″), had poor skin turgor, and some hair loss and the proliferation of lanugo. Her physical exam revealed sinus bradycardia and orthostatic hypotension. The EKG showed QTc prolongation. She was moderately anemic, while her electrolytes were within normal limits. She was admitted for medical hospitalization, but a week later refused transfer to an eating disorders unit.
Meanwhile, my own problems engaging Randy continued. She perceived me as the doctor who was primarily intent on restricting her. As Randy saw it, her assignment was to resist most anything her doctors recommended. Our treatment alliance was tenuous and needed constant repair.
“Inherent complexity” establishes the general requirements as well as limitations associated with a case. Patients with challenging clinical requirements are also usually “technically complex.” As with Randy, their treatment may require the collaborative involvement of multiple professionals. To minimize the sources of variance (inherent complexity plus technical complexity) in a clinical process, coordination between all the people involved and strong team leadership is required. Hence our Medical-Psychiatric Coordinating Physician (MPCP) treatment model, where unraveling all of the complexity in a case is allocated to a single person who is responsible for coordinating a treatment team.
An interesting paper on the subject of complexity as encountered in primary care medicine was authored by a local Kaiser physician, Richard Grant: Grant, R. et al. (2011). Defining Patient Complexity From the Primary Care Physician’s Perspective, A Cohort Study. Annals of Internal Medicine, 155: 797-804.