Clinically Complex, Or Just Poor Clinical Reasoning?

During my 25 years of clinical practice, I have seen my share of patients tagged with the "complex" label. Many of the patients that I see in the clinic come to me after having failed other treatments. Colleagues will refer patients for case review or for second opinion. I truly enjoy the process of problem solving and being the clinician charged with the task of finding the essence of the patient's problem.

Sometimes, complex patients are truly complex. They may have co-morbidities or confounding variables. It may be a challenge to sift through their history. They may present with confusing signs and symptoms.

But more often than not, complex patients aren't so complex. They are complex in our minds as we become victims of our own poor clinical reasoning processes.

How does this happen? Surely we don't make mistakes in the clinical reasoning process - or do we? It happens far more frequently than our clinical egos would allow us to believe. The mistakes pass under our own radar in a number of ways.

1. Cause-and-effect relationships are poorly understood or left unresolved. Regardless of your treatment approach, if you fail to establish a cause-effect relationship - based on relevant testing - it will be exceedingly difficult to pursue an appropriate treatment intervention. We must remember that every testing procedure or treatment intervention is a test-retest scenario: benchmark, loading strategy, and re-assessment of the benchmark. With this in mind, causation and correlation are simply not the same.

2. Falling prey to confirmation bias. Many clinicians will collect data simply to attempt to prove their hypothesis correct. However, from a clinical reasoning process, it is far more valuable to use your efforts to prove your hypothesis incorrect. Shortcuts are often taken based on this confirmation bias in the desire to "get on with treatment". As they say, the road to hell is paved with good intentions.

3. Arbitrary treatments without sound relevance and context. It is important to not put the treatment cart before the assessment horse. Having more tools in the toolbox is only helpful if your clinical reasoning establishes the relevant tool of choice. Oftentimes, clinicians will "try" another treatment intervention simply because other things don't work - and not because it is the right intervention given the right context.

4. Failing to use the KISS principle. "Keeping It Simple" is a critical part of the clinical reasoning process. Clinicians will oftentimes get pulled down rabbit holes of thinking by looking for more obscure, atypical answers that confirm their guru status. But as the saying goes, if you don't blind them with brilliance, baffle them with BS. Creating more novel hypothetical explanations is rarely the best solution. We make our lives as clinicians more difficult by willingly seeking out the more obscure clinical entity first instead of simply tidying up our clinical reasoning process.

Oftentimes, decisions that we make in the assessment process - often unrelated to data - sabotage our ability to pursue good clinical reasoning strategies.

How can we safeguard against this? Before seeking complexity, reflect on your clinical reasoning process first. Refine it. Question it. Not only will it make those complex situations less complex clinically, but it will make life better for the patient as well. And that should be our number one goal.

Photo credits: J Skilling