Misunderstanding complexity to the detriment of all

I anticipate the vague and overly-generalized conclusions of this article being used against primary care…perhaps in funding determinations, perhaps just in macho-posing.  The authors measured “complexity” of patients seen in one Canadian province using nine criteria and determined that the nephrologists, infectious disease physicians and neurologists see the most complex patients and that others, including family physicians, see the least complex.   

The nine criteria?  Risk of mortality, long-term care placement rates, ED visits, physician types, number of different physicians, hospital length-of-stay, comorbidities, risk of mental health conditions, and number of prescribed medications.  They also calculated an “overall ranking” based on those.  No surprise, family doctors came out at the bottom of most of the individual rankings and on the overall ranking.

In the discussion, the authors note, 

Our primary analysis used the characteristics of the average patient seen by each specialty to assess complexity, which arguably best reflects the workload associated with a typical day of practice.


The day a nephrologist chooses to DO something about a mental health condition that causes the patient to be more complex is the day that I’ll start listening to absurd conclusions like this.

There is nothing in this study about socio-economic determinants of health, which we constantly address in primary care.  There is often no “coordination of care” between different specialists offered from the nephrology office.  A nephrologist will treat the kidneys, maybe a little blood pressure, and street the patient.  Then where does the patient go?  Often, back to primary care so that the primary care physician can 1) find a generic medication the patient can afford for the patent-extending sample given them in the specialist’s office,  2) attempt to interpret and contextualize the organ-specific recommendations written in the specialist’s note and 3) anticipate the consequences of the newest recommendations on the patient’s other organ systems, savings account, other medications, intimate relationships, mental health, etc. 

This is not a helpful study.  There is no doubt that a random sample of patients from the waiting room of my clinic will have fewer doctors, fewer ED visits and fewer comorbidities than a sample from a nephrologists’ office.  Is this really news? It’s pretty much why I went into family medicine.  It’s how primary care works – we care for everyone in a community sample.  We have shorter visits and larger patient panels.  The measures of complexity chosen by the authors are then averaged in with the less complex.  It doesn’t mean we don’t see these patients and work with them also…often treating their mental health conditions, working on trying to avoid their hospitalizations and ED visits – trying to pull it all together for the patient.

My concern is not the actual findings from this study, but how those findings and conclusions will be used.  LOTS of context needs to be understood prior to drawing conclusions from this study.  Unfortunately, I see a few specialists on the Altmetrics for this article quoting the conclusions without much further discussion.

The authors themselves conclude that the specialists at the top of these rankings need more training in multimorbidity and complexity.  Well, yes, as long as they’re willing to DO something about the complexity they see.  Of course, they also need a more complete definition of what complexity means – one that measures more than what is available in a national administrative dataset.

I would back off on some of my admitted vitriol about this article, were it not for the authors’ first admitted limitation of this study:

First, most of the authors of our study are nephrologists, and given the findings, there may be a perceived conflict of interest.

Ya think?

This study does not deserve the attention it seems to be getting.  In my opinion, it is limited in its assumptions and conclusions, and is biased to a very narrow view of the healthcare landscape.

One thought on “Misunderstanding complexity to the detriment of all

  1. Dynamite. Picking metrics out of a hat and then calling conclusions from those metrics valid offers limitless opportunities to publish “science” that muddies the waters at best and causes misallocation of resources at worst (or at least, I hope that’s the worst).


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