vi Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'

The rest of the book is practice-based which is a strength. Chapter 18 has three clinical illustrations, were reflection and self-reflection is brought to fore. Especially so, as it pointed out that the 'clinical situation/encounter' introduces its own 'vagaries', or noise which can impact the 'quality of the bond between clinician and patient'. Rapport is the key. 

I was still missing 'complexity' and its dynamics, but I'm sure of the following:

If this was discussed - could be represented then the book would be theory-laden and I and other would-be readers would not be able to understand.

I still think Hodges' model can help, and in chapter 19 picked out 'manifold' (p.113), as if doing so, manifests something more esoteric. There is something here, the author noting the need to shift from individual to group perspectives. So, yes I think we can do more than embrace 'complexity' (p.114).

On page 116 there is discussion of the sometimes sudden path to recovery, 'probably common but often not comprehended'. Please pardon the naivety, but I scribbled 'hidden in complexity, what would (say) the three(?) equations be?'. For a book published in 2023 'artificial intelligence' is not indexed. This might be one area that AI could assist, given the progress in formal mathematics (but see below p.183!)? Algorithm is mentioned throughout the book. Further reading here, informed me that engaging with a reading group on 'Philosophical Counselling' is worthwhile. It is!

Part IX had me wondering if the debate about typical and complex cases, there is a slight of perspective going on? You can end up with paradoxes in terms of an individual's needs, criteria, risk, 'need for admission'. Which I must think about! Chapter 20 has three further reading texts on abductive reasoning. There's an appeal(?) on page 129 for an appropriate treatment model, well that is my take. Collaborative care and stepped care models are suggested. But with acknowledgement that:

'In truth, all models currently available may involve a defect in continuity within or between systems'. p.129.

I beg to differ. A role of Hodges' model is to help frame aspects of care through time, to facilitate and assure continuity.

Part X tackles the required precision in assessment, hence recourse to mathematics and statistics. The next two chapters may be useful for early career researchers and yet looking over our shoulders what is ai offering here? In Case 1 I was impressed by the suggestion of a health record that is over 70 years old. Not impossible of course, but I thought of the Lloyd George envelopes, their hospital equivalents, other paper sources and inevitable scanning this would entail here in the UK? Of interest to research is the creation and validation of complexity profiling inventories (tools) not just that, but their self-assessment form of delivery. And, yes in summary chapter 24:

'We are still left with the challenge of rating the patients' severely compromised health situations where "health" includes social, emotional, and financial well-being.' p.143.

'How do you factor this interpersonal situation into your complexity equation?' p.144.

Yes, how indeed? 

The realities of research of dealt with - funding for the development of tools a problem universally. The references here concern biopsychosocial complexity. Chapter 25 describes abstraction, and hiding detail, which is of great interest here. DSM-5 criteria for major depressive disorder are listed (DSM-6 may be released in 2029?). 

In chapter 25 the authors are once stymied by 'how to include (integrate? PJ) four dimensions, three time periods,and assorted assessment items in a single assessment.' 

As noted the four domains are here again (p.151): medical, psychological, social and care delivery and on page 153, introducing chapter 26, limitations of complexity assessment tools. Parity as in 'parity of esteem' is not indexed and I don't recall having read this, but this is well represented in later deliberations on variables #2. You will find psychosis, but not in depth or severity.

 In 'Creation of a New Model for Clinical Practice' (Chapter 31) identity is stressed, as a prompt to encompass those variables that contribute to preserving the person - what is humanistic. Allied with manifold, identity is a 'coi' for me, concept of interest - for this same reason. On page 172: the authors observe they 'are left with the question of whether there are acceptably accurate clinical models that are simpler and more straightforward than ours? We believe the answer is no!'. I believe there is a way, and a model to help 'keep the life in clinical work' - not take it out. There is a sense that Chapter 32 seeks what I was looking for above: as they explore random variable and 'sample spaces' descriptively - over a page.

Ah! 'Artificial intelligence' is found in text p.183. I'm surprised an editor, proofreader aloud the following sentence to go unchallenged?

'But, as will be discussed, these computer techniques have their limitations based on their lack of flexibility.' 

I was genuinely surprised to read this. Plus, again on ai on page 185: 'Making inferences is not reliably their domain.' I think I would look more at the human-ai interface. And the status of ai within psychiatry as opposed to medicine, but that is also another (parity - divide) debate. Things really are complex now on so many fronts: ethics especially.

Perhaps I am looking for the cookbook formula as introduced for chapter 35 clinical judgement. The further reading is combined with critical thinking. More detail on the empirical-collaborative method is welcome. When I read 'illustrated' I take this literally. Again I can disagree twice on page 220. I know Hodges' model is not validated, but it can - with practice(?) - do this light (simple) or heavy (complex) lifting. 

The warning about dogma needs to be repeated regularly. It is rather like the need for nurses to revisit their profession, role and work as relates to the law. Is Hodges' model an over-valued idea? Am I guilty of thinking I'm an expert? A problem with that view is that any assumed expertise is stretched across the whole model. So if anything there is a shallowness, but this means that I see my particular scope of practice, as other colleagues / professions see theirs. Here in the UK of late, this seems to have become rather blurred. 

In closing with this and achieving a "real-life" understanding of a case, with synthesis - path analysis diagram, the author's underline the value of their book which I have enjoyed and informed my preparation for WCCS26 (more to follow there). The authors can perhaps be reassured that all practitioners have a means to achieve their paradigm shift as described here - with added value and values.

There is a missed word: "of the situation ['with'?] him" on page 114. And revision needed re. text beginning with 'his boyish Paul McCartney "mop-top" ... on page 214. Spelling error on 216 'retu(r)ning'. 

Thanks again to Daniela and colleagues at SpringerNature for the review copy.

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.

v Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'

Chapter 11 held promise in the title 'Formalising the Clinical Field'.

If anyone is interested, formalisation is what I would like to focus upon - using Hodges' model - over the next several years (taking nothing for granted). If truth be told, I'd be stressed as if (true) formalisation was discovered here, I may find this is beyond me, but this is the course I have chosen.

There was nothing new, the 'clinical illustrations' continued. The reading is worthwhile, in trying to define complexity, or what constitutes a 'complex case', hence 'Each new entry expands the complexity and gravity of the case, moving it beyond "plain vanilla" of a single medical or socially based condition'. I was reminded here of the user personas used in developing online communities. And in health the way personalised detail gets lost as personal details - emotional content gets lost (necessarily) as data is aggregated. The chapter revists the definition of clinical complexity.

'So, how does this information fit with our tentative understanding of clinical complexity as "the potential for progress toward health recovery in the context of a particular set of diagnoses and available treatments" (Kathol et al. 2018)? The phrase "particular set of diagnoses" could be replaced by "clinical challenges?" After all, where do you fit cultural considerations or family disjunctions here? Neither are diagnoses per se. Both have typically been relegated to the periphery of diagnostic considerations. Instead, they are elements in a loose matrix of clinical influencers.' p.76. [My emphasis].

Well, Hodges' model provides an ideal place for cultural considerations and family disjunctions. But replacing 'particular set of diagnoses' with 'clinical challenges' will be met with a challenge itself. This serves my purpose in advocating for Hodges' model, if challenges across the model's four care/knowledge domains can be seen as 'clinical'.

Identity morphism

Part VI on Subjectivity and Intersubjectivity is an important lesson to look; then look again - beyond the (basic!) subjective-objective dichotomy. You want patients - clients to recover quickly. The clinical illustrations are helpfully carried forward, as per the longevity their being 'complex' portends. The fact that in a clinical conference, social aspects are barely mentioned is one rationale for use of Hodges' model in practice. What has not been discussed? For 'Seth' a case formulation is raised, (I sketched a 'simple'  triangle) and the limited conceptual scope acknowledged above (p.80). Reading, I did wonder what a new edition might look like given developments in the USA? Would it make a difference? There a question about to categorise one client. And I scribbled 'identity' in the summary for the subjectivity between client and clinician.

I've always liked archaic terms^ and here cussedness springs to mind as the authors seem compelled to return to the issue of a definition for complexity. You could say - they can't put it to bed! 'Lifestyle' is not indexed. But it is clear that the adopted lifestyle of many clients also compounds, contributes to the clinically complex presentation. Case, condition, set of sign/symptoms, state of affairs, situation - all may be simple or complex. On page 87 regards Mark: 'The management challenge of this situation is evident. The situation itself is not medically complex. However, managing it is.'

When I read the aforementioned formalisation (chapter 11), I thought logic might follow, a specific illustration? Abduction is a teaser introducing chapter 14. It is chapter 15 that inference including abduction is usefully discussed:

'Abduction goes further than obtaining general and specific logical conclusions. Abduction seeks explanations beyond logic. The clinician listens to the utterances of a patient and integrates word meanings and word referents with other gathered data. The clinician abductively decodes information and concocts potential explanations for the words of the patient that fit with aggregated clinical findings. This rational processing results in what the clinician considers the best explanation for the information at hand. However, other explanations remain as viable until and unless eliminated by subsequent data. The clinician using abductive reasoning always maintains an openness to changing explanations and an intention to expunge unsatisfactory conclusions as accumulating data dictate [1].' p.96.

The author's empirical-collaborative (E-C) approach spans the book. They might find that Hodges' model as a conceptual framework can seamlessly fit with E-C. A reference on Bayesian Statistics. Lee PM (2013), plus further reading is listed.

There is a spelling mistake p.73; 'contacted a disease'?

One more post to follow ... may add here also.

Thanks again to Daniela and colleagues at SpringerNature for the review copy. 

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. 

Image:

https://krossovochkin.com/posts/2020_04_26_category_theory/ 

 

^Which is ok, I'm a grandad now. 

Come on Healthcare: catch up will you!

Within philosophy it is recognised that Immanuel Kant provided a means by which the rationalists and empricists can be reconciled. Some background:

In philosophy, rationalism is the epistemological view that "regards reason as the chief source and test of knowledge"[1] or "the position that reason has precedence over other ways of acquiring knowledge",[2] often in contrast to other possible sources of knowledge such as faith, tradition, or sensory experience. More formally, rationalism is defined as a methodology or a theory "in which the criterion of truth is not sensory but intellectual and deductive".[3]  https://en.wikipedia.org/wiki/Rationalism

In philosophy, empiricism is an epistemological view which holds that true knowledge or justification comes only or primarily from sensory experience and empirical evidence.[1] It is one of several competing views within epistemology, along with rationalism and skepticism. Empiricists argue that empiricism is a more reliable method of finding the truth than purely using logical reasoning, because humans have cognitive biases and limitations which lead to errors of judgement.[2] Empiricism emphasizes the central role of empirical evidence in the formation of ideas, rather than innate ideas or traditions.[3] Empiricists may argue that traditions (or customs) arise due to relations of previous sensory experiences.[4]

Historically, empiricism was associated with the "blank slate" concept (tabula rasa), according to which the human mind is "blank" at birth and develops its thoughts only through later experience.[5] https://en.wikipedia.org/wiki/Empiricism

If health and social care, must be evidence-based, then as far as Hodges' model is concerned we are then duty-bound to use the most readily available 'evidence' to us, including (while taking liberties?):

• The structure of national health and social care organisations (NHS, DHSS ...)
• Physical infrastructure
• Human Resources Organisation
• Unions and Labour relations
• Texbooks, journal papers, conferences
• Organisational structures from the regional to the local
• Professional bodies and governance of licensing/registration
• Curricula that students follow^
  
• Models, frameworks, teaching and learning tools and methods
• Data, statistics, information and reporting (national, international)
• Research projects ongoing (whatever scale, methods, methodology)
• Accounts from lived experience of patients, carers and public (^and students)
• Policy
• Funding
• Law relating to Health and Social Care
• Public (Mental) Health? Discuss
• Media (Social) Control, Advertising
• . . .
  

Hodges' model: Structure and Content

Using this evidence, we still see the Cartesian divide, the mind-body distinction writ large in health and social care. The continuing impact is evident in theory, practice, (hence) lived experience, policy and managment. Since its creation in the 1980s, Hodges' model mirrors (literally) this philosophical, epistemological and ontological legacy, thereby acknowledging the ancient history of medicine, and 'modern' development of healthcare and nursing. Through this device, Hodges' model can facilitate debate, critique, reflection, and critical thinking; to encourage progress in our thought, motivations, action and subsequent evaluation.

This explains the structure of Hodges' model and predicts the range (contextual signature) of content when the model is applied.

Evidence permitting of course!

See also: BBC The Great Philosophers:

Series 1: 4. Descartes

Series 1: 5. Spinoza and Leibniz

Series 1: 8. Kant

n.b. I video taped this marvellous series when first screened. When studying for my BA(Hons), audio taped, they also provided a great learning resource in the car. The programmes are on BBC 4 (UK) once again, but are readily accessible.

c/o Marschalek (2017) Public Engagement in Responsible Research and Innovation

This blog often features EU research initiatives and conferences and a European project (2014-2016) to build a Responsible Research and Innovation (RRI) Toolkit also has a conference series and various publications. Marschalek's dissertation is a invaluable resource on RRI, drawing on the need for reflection, reflexivity, critical thinking and highlighting many models within sciences and participative methods. Reading the following you will hopefully glean the basis for my interest in the document and what might follow the project overall.

1.2 The Relevance of (Self-)Reflection and Reflexivity  

Scientists are not typically asked to anticipate future societal effects of their work. ...  

... But reflections, particularly on non-intended effects, are rarely undertaken. Reflection is not (yet) viewed as an integral part of scientific work. Many other more important issues need to be addressed within a scientific career. ...  

... Studies like this and others have revealed that researchers are rarely encouraged to self-reflect. ... 

... What is needed is to »step into the helicopter« (Schuurbiers, 2011, p. 784) to look at one’s own work from a distance. A look from the outside and feedback also help reflection. »Researchers are not accustomed to viewing their decisions from a normative perspective or discussing the normative aspects of decisions explicitly. ... 

... Unfortunately, not many reflection tools are available as yet. Quality standards and codes of conduct should »stimulate the reflection of the relation between one’s own values and that of external parties« (Asveld, Ganzevles & Osseweijer, 2015, p. 585) and there are self-reflection initiatives to motivate individuals to reflect on the impact of their work, e.g. a »Hippocratic Oath for individual scientists« (Sutcliffe, 2011), but even fewer ask organisations for self-reflection. Marschalek (2017) pp.15-16.

Marschalek, Ilse. (2017). Public Engagement in Responsible Research and Innovation.
A Critical Reflection from the Practitioner’s Point of View. University of Vienna, Vienna.
https://www.zsi.at/object/publication/4498/attach/Marschalek_Public_Engagement_in_RRI.pdf


My source and with thanks:
International Science Shop Contact Point
Norbert Steinhaus
Wissenschaftsladen Bonn - Bonn Science Shop
Reuterstr. 157 - 53113 Bonn – Germany

Responsible Research & Innovation: RRI Tools
www.rri-tools.eu
www.facebook.com/RRI.Tools.Project
Twitter: @RRITools