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Complexity and PCBH

My mind definitely says this is a rumbling point with folks and is one of the most fundamental and profound aspects of PCBH and mental health care overall. We often are asked, "what do you do with complex patients?" To me, the question does not make much sense, as we assume every patient we see is complex. Meaning, even things that we think are "easy" to intervene on (my mind gives examples of smoking, weight loss, DM management, mild depression, etc.) comes from a context. If the ACEs research has taught us anything, it is that nothing happens in a vacuum, rather, behaviors and symptoms arise from a context that most likely will be complicated. Thus, all the patients we see are complex, regardless of what they are presenting with.

Further, the research on complexity is pretty interesting, indicating and supporting a "less is more" approach. I love this quote from UpToDate on working with patients with comorbidities: "To maximize quality of life, patients with multimorbidity must strike a daily balance between attending to their health problems… while avoiding the potential for their lives to be ruled by the demands of chronic disease management. Clinicians' well-meaning attempts to aggressively treat all conditions all the time, without sufficient attention to the whole person and his or her shifting priorities, may result in treatment recommendations that the patient finds overwhelming, unaffordable, or otherwise unrealistic.”

Meaning, while our minds as providers may say this person needs X treatment that is higher care, what the reality is that 1) we are not good at predicting who will respond to what and 2) it may not be realistic for the patient to access that care anyway. The best treatment for complexity, ironically, may be interventions that are pragmatic and realistic. We rumble regularly with individuals about the concepts that we can predict who needs what and that more is better. While not well researched, what we are seeing is that the concept of "more is better/higher intensity is needed" is purely an assumption our mind makes, rather based on actual evidence. Rather, what is actually recommended for complexity/multimorbidities is a focus on functioning and value congruent behavior that is derived by a collaboration between the patient and provider that incorporates the patient's wants and desires. That very well could be SMH and high intensity, and, honestly, more often than not, will be what we can give in primary care...

Lastly, we have to remember the relational frames we create with patients when we tell them they need higher care, as well as the relational frames we create with PCPs that someone may be too complex for us. To the first point, how often do we reinforce to patients, "oh, buddy, you are broken and are too much for us, go see that other guy." This is often why I think patients come in even asking for SMH because we have programmed them that they are too messed up for us... that isn't a very human approach IMO. To the latter point, and I remember talking to Kirk about his beginnings which occurred by Kirk asking his PCPs to give him the patients that had the most complexities, the patients that really gave the PCPs trouble. By doing so, that created a relational frame with the PCP that the BHC was up for anything and willing to jump in. And, as Kirk beautifully described, he was able to help a great number of those patients in our model of care...

One final point, my mind also wants to very much address the elephant in the room... We, as a MH field, have bought into this idea that people have disorders and we are able to fix them... we aren't going to fix someone that is dealing with a horrendous context that is causing expected behavioral concerns. The reason we can't is that there isn't anything to fix per se. Yes, difficult contexts produce difficult behaviors, that is what being human is all about. When we begin to give up the misconception that it is our job to fix people, we become more flexible in how to help people. When individuals say, "that is not good medical care," my mind says, "that sucks, because your mind really believes we can heal this person." Our goal with PCBH is not to heal or fix people, we believe people are doing the best they can, what they present with has a context and a function. Our goal is to contextualize and normalize what they are dealing with and help them recognize their life path and move a little further down that path...

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