Defining Medical Complexity (Full Version)

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Sean_Collins -> Defining Medical Complexity (October 24, 2005 12:24:00 AM)

Therapists in several treatment venues refer to patient's that are 'medically complex.' Having completed a dissertation that required study of the emerging science of complexity, I decided I would try to address defining what it is about these patients that makes them complex. The goal would be to develop a better understanding of a patient's situation in light of the huge variability of patients in this group. Here is my first attempt at a definition for medical complexity - please let me knwo what you think:

Medical Complexity is when interrelated pathological processes interfere with the ability to maintain stability due to a new emergent “whole” with its own equilibrium, a set of “elements” that has REDUCED ability to adapt which may manifest as less range or variation.



avalon -> Re: Defining Medical Complexity (October 24, 2005 3:14:00 AM)

Sean,

I think that your definition is an "hard" scientific one that see the patient as responsible of his condition.

I might oppose the one where medicine/society is greatly responsible of the patient illness.

Modern Medecine is seeking for a "definite" definition of the human condition, now at a cell level, and all abnormality is seen as a defect that needs a correction. Trying to correct a perfect machine at this level will pull the cover of the Pandora's box... You may disturb more than cure? And you may lose the human dimension of our goal.



Sean_Collins -> Re: Defining Medical Complexity (October 24, 2005 3:54:00 AM)

Henry,
Thank you for the acute observation in the definition. What you have pointed out is by no means my intention with the proposal at hand. Interestingly, my doctoral degree is from a department of work environment, and my dissertation focused on the role of environmental control as a risk for disease.
I think in the proposed definition the multilevel - multicausal aspects of disease and the complexity that emerges from multiple diseases is supposed to be inclusive. Your comments point out that it is not obvious and I need to modify the definition to fully put forth my intentions. If you look at the figure linked through the thread on energy cycles in this forum you will have a better idea of the multi level / ecological structure from which I work.
Thank you again for your time and comments,
Sean



Yogi -> Re: Defining Medical Complexity (October 24, 2005 4:45:00 AM)

A Pt. I saw had what I think was a real simple definition, one I can understand anyway. He said "I did ok until I was 62 (years), then I fell apart."



jma -> Re: Defining Medical Complexity (October 24, 2005 6:13:00 AM)

A basic layman's definition for the consumer to understand.



SJBird55 -> Re: Defining Medical Complexity (October 24, 2005 1:29:00 PM)

I'd probably prefer the term co-morbidities versus pathology in the definition. I also don't believe that all the pathologies have to be interrelated but I view that kind of thing more in the lines of being a variable that requires consideration. Yogi brings up an excellent point - the elderly. Even healthy aging has a normal alteration in a variety of systems that we need to consider when dealing with those patients. I'd also think that a mention of medications is important with patients that are medically complex because pharmacology can have an impact on the services we provide and pharmacology should be something kept in our minds with patients in this category. Also in those patients, is there really stability, or more of a fluctuation of presentations that are observed that when they are receiving our services, we are constantly assessing, reassessing and altering our particular treatments?

Mentally when I think of a medically complex patient - a patient with more factors that impact his/her performance/ability to function than just what is seen at face value. Obviously an overly simplistic view.



Randy Dixon -> Re: Defining Medical Complexity (October 24, 2005 8:47:00 PM)

Frankly I'm not sure I understand the whole model you are describing, but it looks like the vicious cycle of chronicity. Looking at it from that perspective I wonder what part psychological conditions play in it, are they addressed in this model?



Sean_Collins -> Re: Defining Medical Complexity (October 24, 2005 11:53:00 PM)

Hi Randy,

The attempt to define medical complexity is an initial attempt at understanding the process by which multiple pathologies/impairments inter relate and emerge to a "whole that is more than the sum of its parts." Defining and understanding something of this sort is the first step towards being capable of building a knowledge base about it. Being limiting at the start, if not careful, can limit the entire process of building a knowledge base. While being too broad can lead to an inability to getting started.

In terms of a vicious cycle - it sounds like you are referring to the energy flow diagram. Yes, this is related to vicous cycle of chronicity - but is based in the known life cycle of energy flow from environment to organism. That cycle is nothing new - is a well understood biological process.

Psychological conditions - if interupting the flow of energy by interupting work in the environment that obtains that which is necessary for sustainability of the cycle - would be very troublesome. The figure depicted in the web site illustration is just based on cardiopulmonary conditions - one could, i am sure easily be produced related to psychological conditions. Another approach, one which you may be referring to, would be to add psychological conditions to the existing cycle with an expansion of the "coordinated and focused" black box.
Certainly, as any model of reality, this one is limited in several ways as it aims at a specific purpose.
Thank you for taking the time to look things over and think about this -
Sean



Jon Newman -> Re: Defining Medical Complexity (October 28, 2005 8:31:00 AM)

[QUOTE] Medical Complexity is when interrelated pathological processes interfere with the ability to maintain stability due to a new emergent “whole” with its own equilibrium, a set of “elements” that has REDUCED ability to adapt which may manifest as less range or variation. [/QUOTE]What do you mean when you state "maintain stability" and isn't an equilibrium stable even if it is a new equilibrium?

I would be interested in more elaboration on the words you have in quotations, "whole" and "elements". I'm hoping my ignorance will be of some value to you in developing your definition.

jon



Synergy -> Re: Defining Medical Complexity (October 28, 2005 8:45:00 AM)

Sean,

Are you perhaps referring to homeostasis when you state "maintain stability"? Jon and I are in the same boat with regard to "whole" and "elements". Please enlighten me. :)



Sean_Collins -> Re: Defining Medical Complexity (October 28, 2005 11:05:00 AM)

Hi all - stability involves more than just homeostasis - it also requires allostasis (variance in some systems to allow for homeostasis of others). A new equilibrium does not mean stability as the new equilibrium might lead to disruptions - for example: a new equilibrium might be elevated PCO2 and reduced PO2 in the COPD patient. This is not stable because there are changes in chemoreceptors over time due to this new state of equilibrium that will lead to reduced allostatic capability in ventilation related to changes in PCO2.

Whole is borrowed from the systems or cybernetics concept to mean just what it says whole - but is in parentheses to emphasize that the whole is more than the sum of its parts. Elements are the pieces of the whole - in essence the parts.

Whether or not all pathologies or co-morbidities are interrelated depends on how broad of a scale you look. For example pathologies - such as CHF and Arthritis - may not be interrelated at the physiological level of observation; but if you consider the mobility consequences of them and how those mobility consequences then feedback to physiological or celluar effects then one might suggest several mechanisms through which they are interrelated.

Thank you all for asking questions - this is something I have been working on for a bit of time and it needs lots more thinking and formulation. Having discussions such as this is very helpful.

Some books and an article I can recommend that have shapped my thinking include: Holland, Hidden Order 1995 and Emergence 1998; Ashby Intro to Cybernetics 1948; Weiner, Cybernetics 1946; von Bertalanffy General Systems Theory 1968; Prigogine I, 1978 Time, Structure and Fluctuations, Science vol 201 pp 777-785.



Jon Newman -> Re: Defining Medical Complexity (October 28, 2005 11:56:00 AM)

Hi Sean,

That helps but I'm still stuck on stability. Is stability referring to an element or a whole? Perhaps some examples would help. I'm stuck on classifying the following as elements or wholes; physiologic process, a person, a person and their environment, the universe. What aspects of these things are capable of stability over time such that we are concerned about maintaining that stability?

Thanks. And I'll check those references as my desire builds (I'm refraining from the cop-out of "when I have time").

jon



Sean_Collins -> Re: Defining Medical Complexity (October 29, 2005 6:28:00 AM)

Hi Jon,
Great questions. Stability from elements that are interacting as they should be interacting should emerge to stability of the whole. The concept, as a systems concept, it is generalized to any system. The richness is the possibility of using analogy to learn about different systems from investigating those unifying and differentiating aspects.
So to answer your question above - yes.
One limitation I apply to a context is limiting the definition of stability to a particular time period - because with a long enough time scale nothing is stable! Even the universe is running down hill from a second law of thermodynamics perspective.
So - your patient is "stable" right now - how about in a day? Or two days? How about in a year? Are things at this point in time - is the state of the patient's system including the patient's environment such that over a long period of time there are effective flows of energy for sustained stability over a year?

Again - work in progress - these questions are helpful. Let me know if anything I am saying is 1. answering your question; 2. making any sense??

Thanks!



Jon Newman -> Re: Defining Medical Complexity (October 29, 2005 6:52:00 AM)

Hi Sean,

I appreciate that this is a work in progress and your answers have been fine by me.
I admittedly don't have a deep understanding of the concepts being discussed but it seems to be that perhaps you are speaking about a rate of something rather than the stability of something. Perhaps I'm off track.

jon



Jon Newman -> Re: Defining Medical Complexity (October 29, 2005 11:37:00 AM)

Hi Sean,

I've started looking more into complexity theory and it's, well, complex. I'll keep reading.



Sean_Collins -> Re: Defining Medical Complexity (October 29, 2005 3:34:00 PM)

Wow - a complexity theorist in the making. Would you believe my first interest in complexity theory came from reading Jurassic Park and the Lost World? Crichton actually mentions John Hollands books in the text of Lost World and at the end of the books - which was where I started after I read those fictions.
I was, at the time, thinking that if complexity provides a description of adaptation, and if adaptation is an essential concept to rehabilitation that i should benefit from an understanding.
I have to consider your question about stability vs. rate - but will respond once I think about it a bit.
Best -



Jon Newman -> Re: Defining Medical Complexity (October 29, 2005 3:39:00 PM)

For others that may be interested here's a link to some webcasts/podcasts. The last one in the list "Introducing Complexity" was helpful if you can tolerate the bad audio and the information missed during the segments of bad audio. I'm glad I'm not being tested on it. Anyway, here's to [URL=http://complexity.vub.ac.be/~comdig/]Complexity digest webcasts[/URL].

jon



Jon Newman -> Re: Defining Medical Complexity (October 30, 2005 2:39:00 AM)

Here's another [URL=http://complexity.martinsewell.com/]link[/URL] for those interested.

Hi Sean,
In reading a bit, I came across the concept of "control ability" in the sense of limiting run away effects. Is the lack of runaway effects the stability to which you refer in your definition?

jon



Sean_Collins -> Re: Defining Medical Complexity (December 23, 2005 12:51:00 AM)

Finals are over - grades are submitted - getting ready for next semesters courses and some grant applications over the break. But now I also have some time to reconnect with the board - thanks to all that have been posting here - it has certainly become a very productive area for dialogue - especially thank you to Dr. Wagner for joining me as moderator and leading so many great discussions!

Jon - yes, the lack of run away effects is certainly a part of stability used in the medical complexity definition. What is very important to the definition is the concept of maintenance of stability - this can also be called robustness - likely best understood from the Sante Fe Institute Research program on robustness:
http://www.santafe.edu/research/robustness.php

On a mildly related note - I wrote a letter to the editor of PT last month on the impact of complex systems on our desire to accumulate evidence for practice and for research dialogue between clinicians and scientist/philosophers. It is in the december issue is anyone is interested in comment/dialogue.

One interesting find from this letter was a therapist in Arizona - Matt Taylor - that is also interested in complex systems and has created an online learning community on the topic:
http://www.dynamicsystemsrehab.com/main.php



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