Clinical Complexity: medicine is information-intensive and time-critical

The practice of medicine and delivery of healthcare is complex because of many factors, principle among which are:

  • patient individual heredity and personal history uniqueness
  • extreme volume, velocity, variety and veracity of information
  • multiplicity of caregivers and variety of care delivery venues
  • time-critical, concurrent, complicated processes/procedures
  • professional training and experience limitations and biases
  • conducting a scientific experiment (medical diagnosis) under uncontrolled conditions with no opportunity to replicate

“Medical thinking has become vastly more complex, mirroring changes in our patients, our health care system, and medical science. The complexity of medicine now exceeds the capacity of the human mind …

It’s ironic that just when clinicians feel that there’s no time in their daily routines for thinking, the need for deep thinking is more urgent than ever. Medical knowledge is expanding rapidly, with a widening array of therapies and diagnostics fueled by advances in immunology, genetics, and systems biology. Patients are older, with more coexisting illnesses and more medications. They see more specialists and undergo more diagnostic testing, which leads to exponential accumulation of electronic health record (EHR) data. Every patient is now a ‘big data’ challenge, with vast amounts of information on past trajectories and current states.

All this information strains our collective ability to think. Medical decision making has become maddeningly complex. Patients and clinicians want simple answers, but we know little about whom to refer for BRCA testing or whom to treat with PCSK9 inhibitors. Common processes that were once straightforward — ruling out pulmonary embolism or managing new atrial fibrillation — now require numerous decisions.

So, it’s not surprising that we get many of these decisions wrong. Most tests come back negative, yet misdiagnosis remains common. Patients seeking emergency care are often admitted to the hospital unnecessarily, yet many also die suddenly soon after being sent home. Overall, we provide far less benefit to our patients than we hope. These failures contribute to deep dissatisfaction and burnout among doctors and threaten the health care system’s financial sustainability.”

Source: The Limits of the Human Mind and the Future of Medicine, Ziad Obermeyer, M.D., and Thomas H. Lee, M.D., N Engl J Med 2017; 377:1209-1211September 28, 2017; DOI: 10.1056/NEJMp1705348

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