Primary care physicians spend a good many practice hours caring for patients with multiple medical conditions. Family physicians, in particular, are experts at coordinating the care of so-called complex patients.
But the term "complex" can be elusive and not easily defined.
That's why a group of Colorado-based researchers sought to more fully understand how primary care physicians conceptualize patient complexity, with an end goal of developing a corresponding typology.
Their work is highlighted in a study(annfammed.org) titled "Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care" that appears in the September/October issue of Annals of Family Medicine.
Corresponding author Danielle Loeb, M.D., an assistant professor in the division of general internal medicine at the University of Colorado (UC) School of Medicine, in Aurora, told AAFP News the release of research findings was perfectly timed, given the country's current and future health care needs.
"With the aging of the American population, chronic illness is increasingly common, leading to increasingly complex patient populations in primary care," said Loeb. "The medical system can be particularly difficult to navigate for patients with multiple chronic illnesses or psychosocial barriers to medical care, and providers often do not have adequate support in caring for their complex patients.
- New research published in the Annals of Family Medicine describes how primary care physicians conceptualize patient complexity.
- Researchers conducted one-on-one interviews with physicians who brought de-identified notes about patients they identified as "complex."
- Physicians described a typology of patient complexity that encompassed four categories: medical complexity; socioeconomic factors; mental illness; and behaviors and traits described as demanding, argumentative and anxious.
"Therefore, to improve patient care and to reduce primary care provider (PCP) burnout, we need to evaluate the best models of care for complex patients," she added.
The research was unique in that it offered PCPs "a view of complexity" from their professional vantage point, said Loeb, and thus may resonate with physicians' personal experiences. "It may also help them to identify patients in their practices who need additional resources, such as mental health resources and social resources," or perhaps a care manager intervention, she added.
Although caring for complex patients can be challenging, the job also brings rewards. "I personally care for a high number of complex patients because I enjoy helping patients overcome barriers to their care," said Loeb.
UC's Department of Family Medicine and the Kaiser Permanente Institute for Health Research in Denver also were involved in the study. Researchers conducted one-on-one interviews with 15 internal medicine physicians -- all female -- who worked in either a university clinic or a community health clinic setting.
"We limited our study to internal medicine physicians to increase consistency in their training background," the research team explained.
Each physician brought to her interview de-identified notes from three patients the physician identified as complex.
Interviewers explored with physicians how they identified patients as complex. "Interview questions also included broad impressions of complex patients and specific factors that contributed to patient complexity," wrote the authors.
According to the study authors, physician participants "described a typology" of patient complexity that encompassed four categories:
- medical complexity, including discordant conditions, chronic pain, medication intolerance, unexplained symptoms and cognitive issues;
- socioeconomic factors, such as the unaffordability of medication, family stressors and low levels of health literacy;
- mental illness, such as depression resulting in poor medication adherence, addiction, and anxiety that confused the clinical picture; and
- behaviors and traits described as demanding, argumentative and anxious.
Highlights and Next Steps
Importantly, "PCPs differentiated complex patients from 'difficult' patients," noted the authors. "They defined the latter as those who have difficult personalities but not necessarily complex medical conditions."
One physician told interviewers, "In my mind, when most people talk about a difficult patient, they talk about the ones that frustrate them. And sometimes that is somebody who is complex. Often that is just somebody who is hard to get along with."
However, noted the authors, PCPs "did identify patients who had chronic illness and also had challenging behaviors … as complex."
Now, pause for a moment and picture that patient who, in your clinic, argues with the front office staff about something at every visit.
PCPs told interviewers that such patients "strained the clinic's systems for the management of chronic illness."
In fact, one physician described such a patient like this:
"So literally, every time (she has contact with) with the hospital, somebody from somewhere sends me a note saying, 'We just talked to this patient and they were totally inappropriate.' On top of that, she has a condition that needs to be monitored periodically, and if it is not monitored appropriately could be fatal, and I don't feel like she really fully understands that.
"So she has … this impressive ability to alienate all these people who can potentially help her and also to reject the system that is in place to make sure … that the bad outcomes don't happen."
Another PCP described a medically complex patient and ended by saying there are "four different things that really complicate each other in his case."
Physicians also described how mental illness can get in the way of treating chronic medical illnesses. A physician described how severe depression, "the not-terribly-responsive-to-treatment depression," or the depression that hits some patients with the onset of comorbidities -- "really affects the management of their medical problems because of the hopelessness, and that affects adherence and other things."
Homelessness made the physicians' list of social conditions that impeded a patient's care. A PCP told of a patient who, with no place to call his own, drifted between his grown daughters' homes. Trying to reach the patient by phone was a nightmare, and his medications often were "misplaced between visits" to family members' homes, said the physician.
Physicians also were bothered by their inability to control situations such a patient's choice to live with an abusive spouse or alcoholic child, and this caused PCPs to view those patients as complex.
Loeb said she was surprised to find that PCPs interviewed by the researchers "struggled most when algorithms for a particular condition were not appropriate for patients due to conflicting medical or mental illnesses."
Researchers said that overall, PCPs said that patients they considered complex had "exacerbating factors beyond the presence of multiple medical conditions."
One physician put it this way: "I think for me, a complex patient is a patient who makes me think (about the patient when I am) outside the exam room …"
As for what's next, Loeb said she would like to see her team's findings used to refine existing complexity models. Updated models certainly would help "identify patients in need of a higher level of in-clinic resources" or spot patients who would benefit from specific interventions for their "overarching type of complexity," she told AAFP News.