How to deal with the growing complexity of clinical care “when you don’t know what you don’t know”

Today’s physicians are bound to encounter diseases, infections, new conditions and drug reactions they’re not familiar with

Elsevier editorial illustration complexity of care

Imagine an 8-year-old girl enters a clinic with flu-like symptoms, like as a sore throat and muscle weakness. Familiar terrain, right? The clinician has this under control.

Then imagine this: What if it’s not the flu?

What if the patient actually has a rare, aggressive disease whose cause is not well understood in the medical community? Even worse, what if this disease — if not diagnosed and treated properly — could progress rapidly to respiratory failure, paralysis or even death?

This hypothetical situation became reality for many clinical teams in the United States during the summer of 2018 when patients began exhibiting these frightening symptoms. Physicians saw many cases of young children experiencing a viral infection. And just as some seemed to be getting over it, they were becoming paralyzed.

What these clinical teams were actually facing was a spike of acute flaccid myelitis, or AFM. While AFM begins as a mild respiratory illness, it can lead within hours to physical disability, including long-term paralysis that requires ongoing care.

That summer, primary care doctors — the first line of defense in a scenario like this — had no experience with AFM and needed trustworthy answers quickly, not crowd-sourced information. To that end, some probably turned to synoptic content, which can be valuable when clinicians need a fast, simple answer. But what about when they’re dealing with an entity like AFM, where symptoms are complicated, unclear or require a deeper investigation?

In other words, what about when “you don’t know what you don’t know?”

At a time when medical knowledge is exploding at an unprecedented rate – and when diseases, medicine and practice are all growing in complexity – that question is gaining in urgency. No doubt, in a situation like the AFM spike in 2018, getting access quickly is key. But speed isn’t the only prerogative. It has to be better than fast — it has to be accurate and timely.

So what factors are complicating clinical teams’ ability to strike a balance between the two?

A medical knowledge boom in the age of misinformation and complex care

The year was 1980. MTV was about to launch, US President Jimmy Carter declared a grain embargo against the Soviet Union, and medical knowledge was doubling every 7 years.

That seemed fast at the time. But healthcare has a way of making doubling rates seem as dated as watching music videos on TV. By 2020, medical knowledge is expected to double every 73 days.

That knowledge boom, which is intensifying as care gets more complex, puts an even greater onus on clinical teams to gather more information and become better coordinated. This dynamic challenges clinicians to keep current and get trusted, evidence-based answers to their questions, particularly with respect to cutting-edge information and new developments that can impact medical decisions on a daily basis.

Three trends on the patient side further complicate this challenge:

  1. Patients are more informed or, depending on the source, more misinformed about their condition. This is a result of using easily available but not always vetted or reviewed information sources, like Wikipedia, YouTube, Google, and other sites where the information isn’t always reputable.
  2. Patients are taking a more active role in their health. Patients are better informed and want to make shared decisions with their care teams. This generates more questions in clinicians’ minds per patient encounter — about diagnoses, treatment plans, drug therapies and so on. However, 60 percent of these questions go unanswered because clinicians don’t have the time to pursue them.
  3. The population is older and sicker. More often now, patients present with comorbidities, chronic conditions and other complications. As the delivery of healthcare and the diagnostic process become increasingly complex, the frequency and severity of diagnostic errors can rise. Today, it is estimated that 5 percent of US adults who seek outpatient care each year experience a diagnostic error.

However, patient-side trends aren’t the only factors putting quality care at risk. Time-strapped physicians are also turning to unvetted, crowd-sourced information like Wikipedia, YouTube or Google. In fact, in a 2016 study, 42 percent of physicians reported using Wikipedia as a source of clinical content. In other words, some of the threats to driving quality care and desirable health outcomes may be self-induced.

The risks of fast, free and easy

Summary content may check off the boxes for timeliness and ease of access. But over-reliance on it creates very real risks, especially when patients present with comorbid conditions or complicated cases that require more in-depth evidence from books and journals. In fact, when used exclusively or incorrectly, summary content can lead to serious negative outcomes, including:

  • Diagnoses made in error
  • Misguided treatment plans
  • Longer hospital stays
  • Higher readmission rates
  • Patient dissatisfaction

An important — and justified — concern within the academic community is that physicians’ increased reliance on synoptic content has coincided with a decreased emphasis on critical-thinking skills in their training. Synoptic content has its place in the future of care. But it will always lag behind cutting-edge, evidence-based knowledge and will further struggle to keep up as medical knowledge continues growing exponentially.

At a time of growing care complexity, that could mean physicians struggle to recognize when they have an experience or knowledge gap they need to address.

Imagine — returning to the AFM example — that a physician is treating child who has become paralyzed after having a sore throat. That physician has to be able to take a step back and admit, “I have a knowledge gap and don’t understand this. Where do I go to get additional knowledge when the case in front of me doesn’t match up to the knowledge base and experiences I’ve had?”

That degree of self-awareness is part of what defines critical thinking in an age of increasing care complexity and rapid information expansion. That’s because tomorrow’s physicians will practice less from their personal experience and more from the assimilation of new knowledge. As a result, physicians need to know their limitations — and know when past experiences may not provide a roadmap for effective care.

So, what does that look like in practice?

Thinking differently about combating care complexity

For a better way forward that reduces diagnostic uncertainties and promotes better decision-making, care teams need clinical knowledge that balances efficiency and authority and that meets the need for deeper, more thoughtful investigation. That means providing care teams with access to the latest evidence-based information where and when they need it so they can answer even the most complex questions about patient treatment and care. It means providing broad but concise medical coverage of a wide range of topics and specialties. And it means physicians having an authoritative resource to turn to for the issues they face every day — so they can improve the accuracy of medical diagnoses and achieve better patient outcomes even when their practice enters unfamiliar terrain.

Today, physicians are bound to encounter disease entities, infections, new conditions and drug reactions they’re not familiar with. As such, they need help monitoring what’s happening with literature in areas they haven’t been exposed to or haven’t sought out because they haven’t had a case in that focus area. At a time when it’s becoming more likely that physicians “don’t know what they don’t know,” they not only need to be conscious of their knowledge gaps but equipped with the support to close them accurately and fast.

For more information on how physicians can improve their clinical practice to combat healthcare complexity, visit


Written by

J. Drew Furst, MD, DABFM, DABPM-CI

Written by

J. Drew Furst, MD, DABFM, DABPM-CI

As Vice President of Clinical Consultants in Elsevier’s Clinical Solutions Division, Dr. J. Drew Furst leads a team of clinician experts driving transformation of care processes while aiding in improved patient and client satisfaction.  

Prior to Elsevier, Drew lead a team of physician consultants for Siemens Medical for 10 years, focused on innovative HIT solutions.

A graduate of UNC Chapel Hill, he completed his Family Medicine Residency at Cone Health and became the founding partner and CFO of Carolina Emergency Physicians for 6 years.

Drew moved to Bristol, Virginia, where he managed Horizon Family Medicine, building it over 10 years from a solo practice to a group of 4 healthcare practitioners. He ranked in the top 5% of Virginia physicians in patient satisfaction surveys for BCBS.

A North Carolina native, Drew earned his bachelor’s degree in Mechanical Engineering from North Carolina State and his MD from UNC Chapel Hill. He is board certified in Family Medicine and Clinical Informatics and holds active medical licenses in Virginia and North Carolina.


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