Complex Cases, Part I

Our last two newsletters introduced the topic of clinical strategy. In this newsletter we continue that theme, building a model for treatment that most adequately supports the kinds of difficult cases we encounter in our practices, and at the Center for Collaborative Psychiatry, Psychology and Medicine.

When looked at closely, clinical work is astonishingly complex. We are referring to the multiple determinants that shape a case formulation and the way we come to our moment-to-moment decisions about how to treat. There are at least two primary sources of clinical complexity. The first, which we will call “inherent complexity,” reflects the treatment variables selected to define the case and the assortment of interpersonal factors always at work in clinical situations. The second we call “technical complexity,” complexity introduced by the mixture of psychological, psychiatric, and, at times, medical factors specific to the case.

Let’s consider exactly what we mean when we talk about “a case.” Here are some possible variables, each associated with inherent complexity: In framing a case we may primarily be referring to (1) the patient and his or her psychology (“this is a 34-year-old depressed man…”). Instead, we may want to invoke a more comprehensive perspective that includes (2) factors beyond the patient’s psychology, incorporating, for example, the patient’s family. We may also elect to add (3) the care systems with which the patient is involved (“this is a case of a recently hospitalized…”; “this is a case being managed collaboratively by…”). In addition, we may decide to focus on the patient’s (4) near-term status or, alternatively, the longer view.

From there we move to another source of “inherent complexity,” that associated with the imperfections of the clinical process. When looked at closely, clinical work can, and often does, lack (5) technical clarity (e.g., what exactly do we mean when we say someone is “depressed,” or “needs support?”) and can easily be confounded by (6) imprecise communication between involved clinicians, as well as between these clinicians and the patient.

Finally, when several clinicians are involved in the case, there may be (7) incompatibilities between the points of view and procedures each introduces, and their judgments about how and when to act.

Note, of course, that every case — even if its parameters are clearly spelled out — is (8) susceptible to multiple formulations, each one subject to influence from the involved clinician’s training and personal biases.

So, “a case” is likely to mean different things to different people, each clinician’s take influenced by a multitude of factors including his or her specialty, training, experience, and personal psychology.

The product of all these “inherent” sources of complexity is the dissimilarity in strategies separate clinicians would come up with if they attempted to work with the same patient.

Why make all this fuss about clinical complexity? At the Center, we are attempting to develop our own model for how to frame and conduct a case, one that is notable for accuracy and reliability. We have already classified several types of “inherent complexity.” As we go on to discuss the following case we bring in “technical complexity,” the challenges when the patient presents with a confounding mixture of clinical issues.

Consider Michael, a 16-year-old patient who survived a serious head injury followed by three months of coma at age 11. Complicating his course was a displaced hip fracture that was only identified late in his hospitalization. Several years later, and presumably also as a consequence of his accident, he developed diabetes mellitus. Over the ensuing years he has required three joint revisions and continues to walk with a severe limp. He presented most recently with complications of uncontrolled diabetes and a conduct disorder focused around risk-taking. I (Steve Frankel) was called in following a serious episode where the patient went on a drinking binge with friends and engaged in an orgy of junk food. His blood glucose rose to 320 mg/dL. Frighteningly high!

The first order of clinical business was medical, working with Michael’s primary-care physician to bring the diabetes under control. Its monitoring, however, soon had to be taken on by me since Michael, his adolescence in the lead, refused to cooperate with his medical doctor. The second, shifting squarely to Michael’s psychology, was to find out why he allowed this medical situation to develop in the first place. The third job was for the clinician now coordinating his care, myself, to create a relationship with Michael that would promote his cooperation.

As you can probably guess, this teenage patient was only half interested in understanding his diabetes. He was, “sick and tired of being weird” and didn’t exactly buy into his doctors’ cautions about his disease. He “didn’t want to hear” the facts. In addition to interpersonal negotiation, working effectively with him also required strict coordination between his internist who specialized in diabetes, his orthopedist who was planning another hip surgery that would disable Michael for several months, and his divorced parents. Also on the team was a neuropsychologist who performed serial testing, in part to assess the extent of Michael’s brain injury.

Shift back for a moment from “technical” (Michael’s medical problems and psychopathology) to “inherent” complexity. In cases like this coordination among professionals and between them and the patient and family frequently isn’t easy. Managing and repairing disruptions in treatment is always the responsibility of the team coordinator. Here are two examples from our work with Michael. On one occasion Michael’s internist failed to alert the rest of the treatment team that, as an alternative to his taking insulin by mouth, she had started him on an insulin pump. The management of that device required Michael to be more accountable than was possible for him at that point. A similar disruption in the team’s effort occurred when Michael’s always-angry mother skipped two consecutive team meetings and brought Michael to an alternative medicine practitioner who wanted to replace his conventional diabetes medications with natural remedies.

Meanwhile, my problems engaging Michael continued. He perceived me as the doctor who brought only news about what he shouldn’t do. Michael’s self-appointed job, therefore, was to resist rather than listen to me. Our treatment alliance was fragile and needed constant attention. Required, for example, was listening to Michael’s endless descriptions of sexual escapades with his friend’s girlfriend, how “cool that was,” or how he and his friends “escaped the cops” after stealing a bottle of wine from a convenience store. After moments like these, Michael haltingly permitted me to make statements about “the importance of his regulating his blood glucose since that could keep him out of the hospital.” We then, at times, were able to move to the technicalities of diabetes management.

When designing a treatment, “inherent complexity” is always there, framing the boundaries and requirements of the case. Like Michael, many patients, those with difficult-to-treat medical or psychiatric pathology, are also “technically complex.” Reflecting this aspect of complexity, their treatment may require the collaborative involvement of multiple professionals. In the medical literature these are one of a broader variety of patients that are referred to as “complex patients” (regarding this topic see the interesting book by Kathol and Gatteau, 2007).

The bottom line? We believe that to reduce the multiple sources of variance (“inherent” complexity plus “technical” complexity) in a clinical process (“a case”) and to obtain optimal results, coordination between involved professionals, as well as between these people and the patient, is mandatory. This kind of dedicated collaboration becomes especially important when the case is “technically complex” in addition to its being “inherently complex.” This perspective is the starting point for understanding our evolving integrative practice model at the Center, the Medical-Psychiatric Coordinating Physician Treatment Team-Coordinator Model. Phil Erdberg and I have completed the first draft of a new book about this model.

If an individual practitioner rather than a multi-professional team, for example a primary care physician or a psychiatrist alone, had assumed Michael’s care, things might have turned out quite differently. It is likely that each clinician’s treatment would have been narrowly formulated, evolved through the lens of his or her own discipline. Missing would have been the checks and balances inherent in our collaborative, team-focused model.

In future newsletters we plan to further explicate this model. In so doing we will especially focus on clinical strategies for working with technically complex cases.

References:

Kathol, R. G. and Gatteau, S. (2007). Healing Body and Mind. Westport, CT, Praeger.