Table 2 Constituents of complexity with example quotations

Overall clinical picture does not match the pattern

Unexpected outcome

“So he was started on Cefotaxime. And about five days went by and he did not improve; he became more encephalopathic. He had trouble recalling not the city but the state and the country he was residing in”

Risky patient characteristics

“So he’s on antiretroviral for his HIV. He is on two psychotropic medicines. He was in a car accident 10 years ago and had brain trauma at the time and he’s on one of the medications for improving memory”

Unusual case

“I’ve never seen a case of Brucellae; that was my first one. I think I may have ordered a Brucellae culture once in the past and it was negative. But I thought that the case was just very strong for that. You know, TB of course is a common thing and that would be something that it could have been as well”

Lack of comprehension of the situation

Lack of and/or conflicting indicator data

“You start to get a trend, and when you get 20 min of data and you have a fever in a guy with pan resistant drugs it’s scary. When you have three days of the same guy going down for a smoke break, relaxing, chilling in his room, watching TV, you’re a lot more comfortable with the plan”

Lack of evidence about treatment effectiveness

“We knew he had stuff everywhere at one point. He was sort of stalled in his clinical improvement. We were having some slight to moderate suspicion that there’s another pocket of infection, and what was the best imaging study to get. The problem is if you asked 10 radiologists you might have gotten 10 different answers. And what really happened is he probably got a very expensive, non-specific test that then led us to do a CAT scan”

Lack of diagnosis

“Could he have candida endocarditis, or could he have some occult viscous rupture, like a ruptured diverticulum; something that would let all the candida in the GI tract suffuse into the peritoneal fluid where then it would grow like in a bath of mycology broth?”

Gaps in physicians’ knowledge

“We looked at some review papers on vertebra osteomyelitis and we looked for guidelines. There’s guidelines about to be published but they’ve not yet been published so we looked for clinical trials but didn’t find much except for some vague low-grade recommendations that you should treat until epidural collection was resolved – but that was not specified what that meant, absolutely disappear versus no longer abscess versus no longer bone involvement. So that wasn’t very helpful”

Social and emotional pressures

Frustration/regret

“I also see sometimes there’s a nervousness or an anxiety about stopping so they continue but they never make clear in their own minds or in the medical record why they’re anxious, why they believe their patient deserves a longer duration of therapy than standard. And I think it’s an important exercise to at least be able to clarify in your own mind why you’re doing things differently and be able to express that and argue that”

Liability and/or fear

“This is a guy who had in the past, recent past, been critically ill on various occasions, and when you look at his microbiology it’s terrifying frankly the number of bugs he has and the various resistance”

Multiple care providers/conflict

“But the cardiology and the transplant team is very aware of all of these because anytime anything happens to the kidney all of their other medicines get screwed up including all the anti-rejection drugs. So they’re watching it like a hawk, you know”