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.

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

In reading this book and others on W2tQ, I must make the following points:

  * my need to remember the purely USA context (I have never worked there);
  * my healthcare, nursing, informatics experience is NHS-based;
  * this review (and others) is motivated by the project here - Hodges' model;
  * as a result, I will be quoting heavily, there is much to bring to your attention.

As noted in post (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 the assignment of responsibility and consequence that blame can follow. We've seen this, and in mental health too), with the recover model^. 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:

individual

|

INTERPERSONAL : SCIENCES

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

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.

Time flies, I can't believe it was 2007 I posted 

Plush HQ foyer, shame about the mannequins!

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 ...  

Chapter 4 Technical Considerations is one the longest and contributes all of Part III. Here you can read about science, measurement, statistics, empirical, operational definitions, intelligence, reliability. I often see a chapter, book section as a useful primer for students and the same applies here; with inter-judge realiability, validity, control, null hypothesis, statistical methods and much more. Reference to mathematics (axiomatic too) had me hoping for more. I picked out Structural Equation Modelling:

 '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.

I think from this the authors might be sympathetic to giving 'life' to the POLITICAL domain and Hodges' model; after all it lives in people's daily experience - acknowledged or not. The book's structure works thus far: Chapter 5 Nature-Nurture (n.b. no escape!)  and the Epigenome. The structure - flow - works, as at just over four pages, it begs further reading (beyond the listed references). I still have my copy of:

Fritjof Capra and Pier Luigi Luisi (2014) The Systems View of Life - A Unifying Vision. Cambridge: Cambridge University Press.

 

With the epigenome being added to the 'patient complexity equation' in chapter 5, I wondered whether this was predictable, a promise, or a tease?

individual

|

INTERPERSONAL : SCIENCES

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

nature?	NATURE?
NURTURE?	nurture?

 

Previously: 'complex' : 'nature' : 'mental health' : 'person(-centred)'

More to follow ...

^Jones P. (2014) Using a conceptual framework to explore the dimensions of recovery and their relationship to service user choice and self-determination. International Journal of Person Centered Medicine. Vol 3, No 4, (2013) pp.305-311. 

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.