Understanding complexity across clinical disciplines


Prof. dr. A.D.C. Jaarsma
mw E. Helmich

Nature of the research:
Qualitative research, using Rich Pictures and interviews

Fields of study:
medical education

Background / introduction
One of the major challenges in contemporary healthcare is taking care for the growing demographic of (often elderly) patients with complex health problems, which calls for a reform of medical education. Whereas in acute disease, cure often is the single goal, in chronic or geriatric care, goals are multiple, complex, and may be conflicting, ambiguous or uncertain. In the context of healthcare, different levels of complexity of a clinical situation can be distinguished: simple, complicated and complex. Simple situations encompass goals and actions that are relatively well defined and carry with it a high assurance of success, for example starting antibiotic treatment to cure a urinary tract infection. Complicated problems may be difficult, but still have a high degree of certainty in outcome, such as reaching optimal blood sugar control in older diabetics. Complex problems, however, are strongly associated with ambiguity and uncertainty. This may be illustrated by the decision whether or not to continue palliative chemotherapy to prevent progression of metastasised breast cancer, which may prolong life but can also lead to severe functional decline.

The understanding of what makes a situation complex might differ across contexts. Complexity can refer to medical or technical complexity, and might be primarily associated with the provision of top clinical care in highly specialized hospitals, e.g., complex diagnostics and treatment. But complexity might also pertain to social or systemic complexity, e.g., the need to navigate different perspectives, deal with multiple stakeholders, provide care in low-resource environments or within different systems. This type of complexity might be more prevalent in primary and community care, or palliative and elderly care, but will be present in other contexts as well.
Research question / problem definition
In this project, we aim at a better understanding of what represent the most complex situations in different clinical contexts and explore what makes a situation complex, in order to develop a specific training program for postgraduate trainees to better deal with complex situations.
The main research questions are:
1. What are the most complex situations in different clinical contexts inside and outside the hospital?
2. What makes those situations complex?
3. What do postgraduate trainees need to better deal with those situations?
To study complex situations we will make use of a specific tool from systems engineering, which is Rich Pictures. A rich picture is a pictorial representation of a particular situation including what happened, who was involved, how people felt, how people acted, how people behaved, and what external pressures they acted upon. We will ask clinical supervisors, preferably the heads of training (opleiders), in different postgraduate training programs for participation in an one-hour rich picture (30 min) and interview (30 min) meeting. First, the supervisor will be asked to create a rich picture that illustrates the most complex situation they can think of in their own clinical context. This will be followed by a semi-structured interview, in which the researcher will basically ask to explore the rich picture in as much detail as possible. Additional questions may include why the participant chose this specific situation, and if and how this situation is representative of other experiences with complexity in the participant’s specific clinical domain. We will ask participants to reflect on what made this situation particularly complex, and what they think might help postgraduate trainees to develop competence in dealing with this type of situations. Rich Pictures and interviews will be analyzed following a previously developed method, in collaboration with dr. Sayra Cristancho, a Rich Picture expert from Canada.
Helmich E, Diachun L, Joseph R, LaDonna K, Noeverman-Poel N, Lingard L, Cristancho S. ‘Oh my God, I can’t handle this!’: trainees’ emotional responses to complex situations. Medical Education 2018;52(2):206-215
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Laatst gewijzigd: 23 februari 2012