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The Complexity of 21st Century Health Care

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The doctor will follow a very well laid out set of steps, beginning with a thorough history. A review will be engaged of all body systems that may be involved in creating the symptoms. The doctor may ask other clinicians who have more expertise regarding specific conditions to evaluate the patient. Together, these physicians will prepare what is called a differential diagnosis (a set of potential conditions, disorders or diseases being considered). A battery of tests and diagnostic imaging may be ordered and pursued.

At the conclusion of the process, a clear diagnosis is made. A treatment is undertaken that resolves the condition to satisfaction of the doctor and the patient. Although not required to address a complicated health problem, it is not unusual for a physician to bring in other members of the medical community to participate in finding clarity and pathways to success. It is a complicated arrangement–yet all members of the medical team will work within a sequential set of steps that move the complicated problem toward a relatively simple and attainable resolution.

For a healthcare organization, a comparable complicated problem would be discharging a patient from the hospital. There are a series of steps the doctor and healthcare team must follow that lead to the patient eventually being released from the hospital. This is often called “discharge planning.” One person is usually in charge of the process to make sure all necessary steps are taken in a sequential manner until the patient is ready, in his or her street clothes, sitting on the hospital bed with a bag full of medications, awaiting his or her family member to pick him up now. The room is not cleaned while the patient waits for his or her ride, the room is only cleaned immediately after the patient leaves, getting it ready for the equally regimented “admission process” to bring a new patient into the room.

In summary, complicated problems are generally sequential multi-step, simple problems all linked together in a series that has been pre-determined and been standardized. Deviations from standard sequential steps can lead to a great deal of confusion and would convert a complicated problem into a rugged or complex problem.

Rugged Problems

These problems indicate some level of uncertainty and difficulty in finding resolution. The terrain is not a flat plane with a series of simple steps required to move from point A to point B. There are pitfalls and hills to be climbed, brush in the pathway that must be cleared to allow movement forward. Deviations from standard protocol will be required, so that one must go from point A to point C, then perhaps briefly move to point D prior to reversing course to target point B.

In the complicated problem with a differential diagnosis that we described above, a family member arrives and indicates the patient drinks 4 bottles of vodka a day and smokes 2 packs of cigarettes a day. These are two things that the patient declined to admit when asked about smoking and alcohol history by the doctor. And heroin, injected daily. Did he mention he has had a fever for 3 weeks and had a strange rash on his lower limbs?

None of those vital pieces of information were shared with the original doctor. She is now quite perplexed and realizes several vital new diagnoses may be possible given this new information. She was about to say it was Lupus, but with this new information, she needs to evaluate the patient’s heart with a special test to see if his heart valve is infected. She orders blood cultures. Maybe she needs to put the patient into the hospital? Can she trust this patient to follow-up with his heroin habit? Will he be deceptive about what is going on?

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