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The “true clinicians” do not need formal tools to define the complexity of their patients. Is this statement always true?

Published:November 07, 2017DOI:https://doi.org/10.1016/j.ejim.2017.10.013
      In the daily clinical practice, doctors often use their experienced “gut feeling” and/or “spot eye” in the assessment of their complex patients. According to this point of view someone could affirm that the “true clinicians” do not need any formal tool to define the complexity of their patients. But this statement is not always true. Indeed the concept of complexity in Internal Medicine lacks a precise definition. “The Complexity of Measuring Clinical Complexity” is the title of an editorial published on the Annals of Internal Medicine in 2011 [
      • Turne B.J.
      • Cuttle L.
      The complexity of measuring clinical complexity.
      ]. Moreover, despite the complexity is emerging as the hallmark of Internal Medicine of the third Millennium, many unresolved issues are still open: a) no one indicator is able to exhaustively define the complexity of our patients nor their prognosis; b) the study of complexity is not expected in a systematic medical training; c) complex patients are regularly excluded from the large trials; d) in the comparison of populations/sub-groups/patients in clinical trials there is a high risk of selection bias due to a flaw in the sample selection process without considering the attribute of the complexity of patients; e) the same guidelines, being centered on the individual diseases, are often difficult to apply, since mostly limited to the “ideal but not real” complex patient. There is the urgent need for more research on the optimal assessment and management of this growing population. The combination of actuarial (probabilistic-statistical) medical assessment may be a gold standard for multidimensional evaluation in an integrated prognostic model [
      • Muers M.F.
      • Shevlin P.
      • Brown J.
      Prognosis in lung ABET physicians' opinions compared with outcome and a predictive model.
      ,
      • Royal College of General Practitioners, National Gold Standards Framework Centre Prognostic Indicator Guidance Paper
      ]. A number of validated indices are available to evaluate the complexity of patients, such as the PROFUND and the multidimensional prognostic index, recognized as useful both in internal medicine [
      • Bernabeu-Wittel M.
      • Ollero-Baturone M.
      • Moreno-Gavino L.
      • Baron-Franco B.
      • Fuertes A.
      • Murcia-Zaragoza J.
      • et al.
      Development of a new predictive model for polypathological patients. The PROFUND index.
      ] and geriatric wards [
      • Pilotto A.
      • Ferrucci L.
      • Franceschi M.
      • D'Ambrosio L.P.
      • Scarcelli C.
      • Cascavilla L.
      • et al.
      Development and validation of a multidimensional prognostic index for one-year mortality from comprehensive geriatric assessment in hospitalized older patients.
      ]. Even recently a further prognostic rating index has been proposed as equations to assess frailty and predict the short term risk of death in aged 65 or more, taking account of demographic, social, and clinical variables [
      • Hippisley-Cox J.
      • Coupland C.
      Development and validation of QMortality risk prediction algorithm to estimate short term risk of death and assess frailty: cohort study.
      ]. Many doctors argue that predictive/prognostic scores are not helpful and that the subjective assessment is more accurate. This observation, however, can be strongly influenced by the competence and skills of the single professionals. Nevertheless, the most experienced physicians base their assessments—often implicitly—on the same clinical information considered in the forecast scores. The information provided by the indexes/scales/scores available should not mortify the role of clinical judgment and professional experience in decision-making. They just provide an objective basis on which to plan the diagnostic/therapeutic path in the patient's care. In conclusion, how to measure clinical complexity in Internal Medicine wards? In this matter anything and everything could be said. In Internal Medicine all guidelines and risk scores not originally designed on the elderly patient with multiple comorbidities cannot be applied and directly transferred to the real world. To carry out a prognosis in advanced disease and frail patients in Internal Medicine we do not have to “look in the crystal sphere” [
      • Ntaios G.
      • Papavasileiou V.
      • Michel P.
      • Tatlisumak T.
      • Strbian D.
      Predicting functional outcome and symptomatic intracranial hemorrhage in patients with acute ischemic stroke a glimpse into the crystal ball?.
      ]. It is also an ethical issue when a doctor decides on his/her feeling of complexity and poor prognosis to shift to palliative care. Measuring patient's complexity has important implications for clinical decision-making, organization of care, resources allocation and pragmatic clinical research. Medicine is a stochastic art that often requires, in taking decisions, to consider probabilistic, non-deterministic variables and wide unpredictable causality and uncertainty [
      • Sonnenberg F.A.
      • Beck J.R.
      Markov models in medical decision making: a practical guide.
      ]. Deciding in uncertainty means to consider—and share—the available scientific evidence, personal opinions, expectations, and patient values that are commensurate with those of the physician in relation to the challenges posed by patient complexity and emerging problems. A purely humanistic role, not aseptic or merely statistical, but empathetic, consistent with intrinsic skills. Despite the subjective self-referred—but not certified—competence of doctors in judging patients complexity and the availability of objective several tools, there is a stringent need for a simple—user-friendly but comprehensive—method for patient's prognostic stratification, better if using some assessment tools commonly applied in the hospital Internal Medicine wards, both by doctors and nurses.

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