iii Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'
In reading this book and others on W2tQ, I have to remember the purely USA context; with the additional caveat that I have never worked there. My experience is NHS-based. Another point is I will be quoting quite a bit, as there is much to bring to your attention.
As noted (i) there is much to whet the appetite, a paradigm shift, 'comprehensive, collaborative, and integrated care' (p.11) certainly have become popular topics in the medical literature. Not only that but 'interpersonal and intersubjective treatment models' too (p.12).
The role of 'Case Managers' is highlighted, plus the Case Management Society of America, which is committed to:
- Improved Consumer Health Outcomes
- Professional Diversity, Equity, and Inclusion
- Cultural Competency and Humility
- Advocacy for the Health Consumer
- Integrity and Ethical Principles
- Promoting Health Equity
- Educating Case Managers Across the Care Continuum
- Evidence-based Quality Care
- Holistic, Compassionate Care
- Fostering Communication and Collaboration
- Advancing Research, Innovation, and Use of Technology
- Fiscal Accountability [ https://cmsa.org/about/ ]
Whether the USA influences global trends in the structure and form of healthcare is another post, but there is a UK Case Management Society too: https://www.cmsuk.org. I can see a fit here [UK] with the development in recent decades on social prescribing. A different role, of course but part of a complex jig-saw.
As expected definitions are provided:
'Roger Kathol has eloquently defined "health complexity" as "the interference
with the achievement of expected or desired health and cost outcomes, due to the
interaction of biological, psychological, social and health systems factors when
patients are exposed to standard care delivered by their doctors" [1].' p.10.
Roger G. Kathol, Rachel L. Andrew, Michelle Squire, Peter J. Dehnel (2018) The Integrated Case Management Manual: Value-Based Assistance to Complex Medical and Behavioral Health Patients. 2nd ed. Basel: Springer.
I can see where this definition comes from, but for me, it does not sit right. The problem when there is interference is that assignment of responsibility and consequently blame can follow. Some of the terms here may be completely innocuous politically speaking (which is the author's intent of course), but they can also be 'weighted'. Hence they can become concrete terms of judgement. Think about it: achievement, expected, desired, cost (and) outcomes, standard care, delivered (by doctors)? Or, am I over-thinking again.
In the margin I pencilled/drew:
Standard -
| care |
Other - | factors |
As ever, the individual patient is our focus. The individual is supported (literally) by the social and political (infra-)structures that act as a scaffold, safety-net for most.
I had this notion of life-size cardboard cutouts representing the average people who use a given health service provider (local, or not so local these days?). The data will be there in statistical annual reports. I'd noticed the displays - analogue and digital that greeted visitors at a local NHS Trust HQ. This would be the book's 'routine patients' who receive standard care.
Chapter 3 introduces 'variables' which again is brief, but imporant as variables recur throughout the book. The 'Clinical Field' is first outlined, as in:
- Sources of clinically relevant factors;
- Dynamic factors;
- and: Variables representing contributions from practitioner(s).
Abstract variables are differentiated from those that are concrete. It's reassuring to read there is no true simplicity within the clinical field, and the author's goal is to 'unpack complexity so it remains as true to life as possible, not just manageable conceptually.' p.18.
Frankel et al. are primed to go beyond this. Maths, as in statistical procedures are one tool. Chapter 4 adds to this with a theoretical model to guide clinical understanding of patients with biopsychosocial complexities, the foundations of our paradigm shift. p.23.
If you have an understanding of Hodges' model you can picture my response to this. But, staying grounded, the whole book and paradigm shift represents a form of scientific "emergence". It is frustrating that literature searches fail to pick out Hodges' model.
Frustrating too as reading of "awe", also on page 23, I have experienced this many times (over say 1977 - 2019 ...). So, I held on to my dummy (pacifier!?) and read on ...
'We would also like to suggest that following the steps involved in "structural equation modeling" (path analysis) is a good way of conceptualizing and reasoning about complex clinical variables altogether. For example, constructing a clinical model informally (intuitively, loosely from data) and thinking about (diagramming) how the variables involved may moderate and mediate each other can be a useful activity for clarifying the nature and requirements of a complicated clinica1 situation.
In simplest terms, an independent variable is the causal or influential variable that impacts and effects the dependent variable. A moderating variable is a dichotomy, and refers to two comparison groups (e.g., male/female; passed/fail; religious/nonreligious; tall/short; high versus low socioeconomic status) that display significantly different degrees of magnitude on a correlated relationship. For example, the relationship between a specific treatment for a medical disorder and treatment outcomes may be moderated by socioeconomic differences. The treatment outcome relationship may be stronger and more positive for individuals with elevated socioeconomic standing who therefore have better support systems and access to medical professionals, and fewer economic stressors.' p.36.
Fritjof Capra and Pier Luigi Luisi (2014) The Systems View of Life - A Unifying Vision. Cambridge: Cambridge University Press.
nature?
| NATURE? |
NURTURE? | nurture? |
More to follow ...
Steven A. Frankel, Steven D. Thurber, James A. Bourgeois (2023) Complexity in Health Care: A Paradigm Shift for Clinical Practice. Cham. Switzerland: Springer. ISBN: 978303114948.
orcid.org/0000-0002-0192-8965
