William Cayley: Complexity and care

bill_cayley_2Words that sound wonderful can come back to haunt you.

As a case in point, I recently responded to Elizabeth Wortley’s eloquent blog “Please refrain from using that kind of language” with the question: What if we decided to try to become “experts” in treating the difficult (patients)?

That sounds great in a conversation, but those high sounding sentiments were followed (for me) by an overly full week of complicated inpatient and outpatient care that left me feeling overwhelmed and quite inadequate. It’s easy to treat the straightforward conditions, and perhaps relatively easy to become expert at caring for individual complex conditions, but what about our complex and difficult patients? What does it take to care for them?

Expert though I’m not, last week got me thinking again about some of the important elements of care for those with complex lives who land in our clinics, emergency departments, or hospitals:

Continuity: It seems that it should go without saying—the better you know someone’s story, the better you can care for that person. Nevertheless, as medical systems in the so called “developed” world grow more and more sophisticated, our emphasis on specialization and high tech care undermines the very continuity that could help us understand those who are more complex. Patients do not need separate physicians to care for them in a clinic, in hospital, at home, or at a nursing home. Our patients, especially our complex ones, need ongoing and continuous relationships with physicians who know the depth and breadth of their complexity.

• Boundaries: Conversely, those of us caring for complex patients need boundaries to keep us healthy and sane. I cannot be available to all my patients, all of the time, and such access might only encourage neediness on the part of some. Boundaries help establish structure, expectations, and routine—and even for the neediest of patients (barring true emergency situations), the setting of boundaries may provide a structure that helps them find freedom from chaos.

Teamwork: I cannot be all things to all patients, all of the time, but an effective team that communicates well can be smarter and provide better care than any one individual. Teamwork must not be a group of “bounded sets” (separate professionals, each only caring for his or her own piece of the puzzle), rather teamwork must consist of a group of overlapping “fuzzy sets.”

• Professional compassion: Medical care is hard, and good care for the difficult and complicated people among us is even harder. We all feel compassion towards our neighbors in need. Medical professionals are members of a “moral community whose defining purpose is to respond to and to advance the welfare of patients.” We are called to be compassionate even when we do not feel that way.

• A thoughtful, balanced approach: Complexity is, obviously, complex! We cannot solve a complex problem by addressing just one piece. Appropriately thorough, yet balanced, attention needs to be paid to medical, cognitive, social, physical activity, and spiritual concerns.

It’s never easy, and it’s not always rewarding, but caring for complex patients is what someone, somewhere needs to do. I don’t think anyone is ready to sign up for doing this every hour of every day, but some of us need to try to do it well—at least some of the time.

Maybe next time I have an overwhelming week, I can take enough of a deep breath to remember to give each of these areas proper attention from the get-go.

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.

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