Saturday, January 15, 2011

Addressing the Challenges of Multiple Chronic Diseases

This is a reflection on the article, "The Growing Burden of Chronic Disease in America" by Gerard Anderson and Jane Horvath, Public Health Reports, May-June 2004, Volune 119. The essence of the article is that a growing percentage of Americans have multiple chronic diseases; that the costs of treating people with multiple chronic diseases is high; that people with multiple chronic diseases usually see multiple physicians; and that physicians are not very successful in coordinating their efforts with one another to address the needs of specific patients. The theme here is complexity.

The human mind/body is a complex system. Physicians always take into account the complexity of multiple body systems when addressing a single medical need. But when the same body has multiple needs the complexity of interactions among the conditions drives up the complexity of trying to help the patient. And then when multiple physicians become involved (and multiple medications are prescribed by various physicians) the entire situation is likely to get out of hand. The patient is the center of the system of care but is unlikely to have the knowledge necessary to try to orchestrate the entire effort.

W. Ross Ashby introduced his Law of Requisite Variety in about 1958. The law states that if a system is to be stable the number of states of its control mechanism must be greater than or equal to the number of states in the system being controlled.

In the case of a patient with multiple chronic conditions, it follows from Ashby's Law of Requisite Variety that the coordinated medical care delivery system (the "control mechanism") must be at least as complex as the human body as a macro system (system of systems). Well, we are going to lose that one!

I believe there is another approach. It is root cause analysis. What becomes manifest in a patient as multiple chronic conditions may be the product of a few root causes. Stephen Wolfram has demonstrated that recursion among a very few simple rules can produce very complex fractal patterns. A chronic condition (or a combination of them) may possibly be interpreted as complex fractal patterns derived from a relatively few root causes.

While reflecting on the article by Anderson and Horvath I am wondering if it may be possible to make clincal applications of root cause analysis in the treatment of patients with multiple chronic conditions. As it is, these authors are advocating addressing complexity with complexity, as per the insights of Ashby. Medical conditions are products of causal trees. If physicians aim too high on the causal trees they are likely to produce cascading complexities. It is the difference between the perspectives of physics and the other sciences. While others see complexity, physicists search for the simpicity from which complexity springs. If it is possible to aim closer to the roots of causal trees it may be more feasible to address the needs of patients with multiple chronic conditions more effectively.

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