Some prior references to understand the conversational data below :
Conversational learning :
https://www.ncbi.nlm.nih.gov/
CBBLE : https://www.ncbi.nlm.nih.
UDHC : https://pubmed.ncbi.nlm.nih.
Case based reasoning :
https://www.ncbi.nlm.nih.gov/
Medical Cognition :
https://www.sciencedirect.com/
Clinical complexity :
https://bmcmedicine.
Research sampling techniques used:
Non probability sampling :
https://www150.statcan.gc.ca/
Snowball sampling :
4/13/22, 7:41 PM - Vivek Poddar 3: Hi I am here 🙏
4/13/22, 7:42 PM - Kims Aditya Samitinjay: Hi Vivek. So happy to have you.
4/13/22, 7:42 PM - Kims Aditya Samitinjay: First off, happy to work with this excellent team here. Dr. Manikanta will join shortly
4/13/22, 7:46 PM - Rakesh Biswas: Add Saptarshi as he made a very good case report of a patient with CKD and Spondyloarthropathy.
CKD and spondyloarthropathy and CKD and spondylodiscitis are two separate issues and will need to be handled differently
4/13/22, 7:47 PM - Kims Aditya Samitinjay: I don't have his contact sir.
4/13/22, 7:56 PM - Kims Aditya Samitinjay: Dr. Saptarshi. Pleasure 👍🏽
4/13/22, 7:57 PM - Saptarshi Saha BMJ Elective: Sir, I am not a Doctor yet. Just an ordinary student.
4/13/22, 8:00 PM - Kims Aditya Samitinjay: Let's hope you bring us to your level of enthusiasm. Please share your case report here.
4/13/22, 8:23 PM - Rakesh Biswas: Let's begin by reviewing the literature and developing our understanding of the term clinical complexity.
4/13/22, 9:21 PM - Kims Aditya Samitinjay added Manikanta Achuta Elective
4/13/22, 9:23 PM - Rakesh Biswas: "The MRC’s approach to complexity has thus shifted considerably – both in terms of where the complexity is assumed to lie (from the intervention to the system to the interaction between the two) and in relation to how best to study it (from the randomised controlled trial atop an assumed hierarchy of evidence to a genuinely pluralistic approach that gives appropriate weight to real-world case studies)."
https://bmcmedicine.
4/17/22, 7:13 PM - Rakesh Biswas: Theme :
Resolving organizational clinical complexity through quality improvement tools in a case based blended learning ecosystem
4/17/22, 7:32 PM - Kims Aditya Samitinjay: Okay sir. The key term is Organizational Complexity. What all qualify under this?
4/17/22, 7:37 PM - Rakesh Biswas: The key phrase is organizational clinical complexity.
Review the literature around it and share what you learn
4/17/22, 7:39 PM - Rakesh Biswas: For example "academics" or academic learning in medicine teaching learning programs is nothing but a tool to handle organizational clinical complexity.
It reduces the complexity by reducing it to it's simpler parts and enables focused solutions
Organizational Clinical complexity :
4/17/22, 8:02 PM - What all qualify :
Can look at this as an input output system with a number of layers like a neural network and let's say the input begins at
a) Casualty : relate the recent events that portray organizational clinical complexity where a fine example would be the recent lady with dka and abdominal pain who came at midnight and the medicine PG finally diagnosed ectopic pregnancy inspite of so many other red herrings and the "powers that be" rewarded him with a three month suspension order along with the other PGs involved in the case management due to their delay in diagnosing a clinically complex case which I am sure many wouldn't have been able to especially keeping awake all night
Wards :
Acute and Chronic and acute on chronic representational case studies that will highlight how we over the years have encountered organizational clinical complexity and tried to deal with it and how our recent QI lens or other tools can augment our abilities to deal with it better
4/17/22, 8:06 PM - Kims Aditya Samitinjay: Sir, why are we publishing this ? What are the exact goals and likely outcomes of publishing this paper
4/17/22, 8:09 PM - Rakesh Biswas: Good question.
Is publishing a tool toward resolving a broader canvas of "organizational clinical complexity" that is nothing but our lives?
4/17/22, 8:11 PM - Kims Aditya Samitinjay: Great argument. Does it require publishing though ? What have we achieved by publishing the TBI case and NTM case and now the CVID case in our own ecosystem?
4/17/22, 8:19 PM - Rakesh Biswas: Good question.
I think the question should be what have "I" and "We" gained by publishing the cases that you mentioned.
What you all have gained are a few publications to show in your CV.
What I have currently gained from your recent publications is a great collective perspective of how the same problem that I was seeing alone also looks through other's lenses. That is what "I" have gained currently.
But again this is our current gain and depending on the near future turn of events you cannot be sure that your current publications won't become a landmark because no one may have seen the problems that you describe in the manner that you did?
4/17/22, 8:20 PM - Kims Aditya Samitinjay: I just reviewed the alt metrics of both of our articles sir and they have been downloaded and read over 10,000 times sure. But where do you think those audiences exist? Most likely first world countries (who can get access to expensive journals like BMJ), where it is unlikely to matter much sir ?
4/17/22, 8:25 PM - Rakesh Biswas: In a complex organizational neural network, the individual actors comprising the powers that be) are just a few nodes in the synapses that make up the bounty of clinical organizational complexity in all it's finery.
Once you get to see the finery you get to solve the problems arising from it without having to untangle the layers. We publish to also show the world this finery.
I agree that we are currently targeting low impact platforms which is what most journals have become and these days social media (eg quora etc) may have better impact. Well I personally prefer publishing in quora but then I wouldn't get this team there and so have to settle for lower impact journal platforms
4/17/22, 8:36 PM - Kims Aditya Samitinjay: Hard ask but is there any evidence to support your statement that keeping yjem untangled will bring about change?
I'm more of a disruptive kind of guy and nearly 4 years of low seniority experience is telling me this has to be disrupted by naming them in the paper.
4/17/22, 8:42 PM - Rakesh Biswas: The point that I'm trying to make is that in complex systems it's not the individual nodes that matter much and their impact may be hyped to an extent but the network continues to function just as well even when these individual nodes die or are removed or moved.
So in systems thinking and problem solving one needs to look at the synapses
4/17/22, 9:28 PM - Rakesh Biswas: Let's follow the money and trace it at its input source (rca) or else we shall simply continue to keep wandering in the deep hidden layers.
4/17/22, 9:32 PM - Kims Aditya Samitinjay: Okay sir.
4/17/22, 9:33 PM - Rakesh Biswas: @91965xxxx if you recall our past renal transplant patient who was nearly dying due to pulmonary edema and hypertensive LVF it was our elective student @9779817xxxxxx who enabled us to break through this system flaw of low resources by outsourcing nearly 88,000 through online fund raising.
One of the other reasons we want to keep publishing our daily workflow is to make such local system impacts other than the global system impacts that I alluded to earlier
4/17/22, 9:34 PM - Kims Aditya Samitinjay: Yes sir
Organ systems clinical complexity :
4/13/22, 9:52 PM - Karnati Vaishnavi KIMs Med PG:
https://karnativaishnavi.
Previous case reports of infective spondylodiscitis
4/13/22, 9:54 PM - Rakesh Biswas: When did you upload the latest as third case into your blog? Today?
4/13/22, 9:56 PM - Karnati Vaishnavi KIMs Med PG: Yes sir just now
4/13/22, 10:00 PM - Rakesh Biswas: There are many more cases we have seen of bone infections related to dialysis
One was the young man with hip pain and upper femoral involvement with infection and consequent disability
Another man with elephantiasis of upper limbs also initially complained for a long time with upper dorsal pain before his focus shifted to his refractory heart failure. @9194933xxxxx Did we finally discharge him recently?
4/13/22, 10:01 PM - Rakesh Biswas: We saw it here around 8 PM
4/13/22, 10:24 PM - Karnati Vaishnavi KIMs Med PG: I know the patient with hip septic arthritis sir .
https://poreddyjahnavi128.
4/13/22, 11:32 PM - Sai Charan Kulakarni Kims Med: Unfortunately he expired recently sir.
4/13/22, 8:00 PM - Saptarshi Saha BMJ Elective: https://ssahamedicalcases.
4/13/22, 8:01 PM - Saptarshi Saha BMJ Elective: Sir, here is the link.
4/13/22, 8:06 PM - Kims Aditya Samitinjay: @919493xxxxxx please share all the fluorosis and spondylodiscitis case links here.
4/13/22, 8:07 PM - Kims Aditya Samitinjay: https://saichennuru.blogspot.
4/13/22, 8:07 PM - Kims Aditya Samitinjay: https://
4/13/22, 8:07 PM - Kims Aditya Samitinjay: https://karnativaishnavi.
4/13/22, 8:08 PM - Kims Aditya Samitinjay: 4
4/13/22, 8:08 PM - Rakesh Biswas: Aren't all the links in KVs blog draft ?
4/13/22, 8:08 PM - Kims Aditya Samitinjay: No sir. Not all.
4/13/22, 8:08 PM - Rakesh Biswas: This is spondyloarthropathy not infective discitis.
We should not mix up the two
4/13/22, 8:11 PM - Rakesh Biswas: Yes only 3
When did she upload the latest as third case into her blog? Today?
4/13/22, 8:11 PM - Kims Aditya Samitinjay: Of course yes sir.
4/13/22, 8:12 PM - Kims Aditya Samitinjay: This is our theme?
4/13/22, 8:12 PM - Kims Aditya Samitinjay added Karnati Vaishnavi KIMs Med PG
4/13/22, 8:15 PM - Rakesh Biswas: I didn't have it that way in mind
4/13/22, 8:18 PM - Rakesh Biswas: Let's dissect each case to see if a common theme emerges
4/13/22, 8:20 PM - Sai Charan Kulakarni Kims Med: http://saikishan20.blogspot.
4/13/22, 8:21 PM - Sai Charan Kulakarni Kims Med: http://1601006180.blogspot.
4/14/22, 12:32 AM - Kims Aditya Samitinjay: From Uptodate - "Drinking water is not safe for use in hemodialysis applications and must, therefore, be treated further at the point of use. Healthy individuals seldom have a weekly water intake of more than 14 liters (ie, 2 L/day). However, a typical hemodialysis prescription (thrice weekly for four hours per session with a dialysate flow rate of 800 mL/min) exposes the patient to more than 500 liters of water per week across the semi-permeable membrane of the hemodialyzer. Because of this substantially higher exposure to contaminants in water, additional treatment of water used for preparation of dialysis fluid is required."
4/14/22, 12:32 AM - Kims Aditya Samitinjay: @9194933xxxxccc Can you please find out where the water for hemodialysis is sourced from
4/14/22, 12:33 AM - Kims Aditya Samitinjay: ?
4/14/22, 12:34 AM - Kims Aditya Samitinjay: This may present as a clinical complexity (improper application of an intervention to a system ?)
4/14/22, 7:07 AM - Rakesh Biswas: He was fine when we met him in the rounds last week! When did this happen? 😳
4/14/22, 8:25 AM - Sai Charan Kulakarni Kims Med: He came on 11th sir. 12th morning he expired sir.
4/14/22, 8:56 AM - Rakesh Biswas: Cause of death?
4/14/22, 1:35 PM - Avinash Gupta Nepal: This message was deleted
4/14/22, 1:35 PM - Avinash Gupta Nepal: This message was deleted
4/14/22, 1:37 PM - Avinash Gupta Nepal: This message was deleted
4/14/22, 1:41 PM - Avinash Gupta Nepal: This message was deleted
4/14/22, 1:43 PM - Avinash Gupta Nepal: IMG-20220414-WA0029.jpg (file attached)
May be lack of medication compliance causing failed eradication of bone infections leading to septic shock.
The data in case log is latest upto first week feb.
4/14/22, 1:46 PM - Avinash Gupta Nepal: So lack of data doesn't allow to make better guess.
4/14/22, 1:51 PM - Avinash Gupta Nepal: Tried but could not trace find data for this patient in local cbble group
4/14/22, 4:19 PM - Rakesh Biswas: Yes @9194xxxxx8 may be able to help with subsequent data
4/17/22, 5:47 PM - Kims Aditya Samitinjay: Any progress made here?
4/17/22, 5:59 PM - Rakesh Biswas: A lot of complex data to be assimilated, interpreted and shared meaningfully assuming all that data is already well captured.
4/17/22, 6:06 PM - Kims Aditya Samitinjay: I'm hoping for a theme to emerge, so that all assimilation and interpretion can be based on the background of that theme sir.
4/17/22, 6:06 PM - Kims Aditya Samitinjay: @9194933xxxcc and @9183746xcccxx the architects for this.
4/17/22, 6:53 PM - Karnati Vaishnavi KIMs Med PG: Theme could be Challenges and difficulties faced in management of chronic kidney disease on Hemodialysis in tertiary care center sir ?
Main issues i observed were sir
1) Wide range of Infections ranging from post dialysis fever to severe infections like infective endocarditis, spondylodiscitis, Central line sepsis
2) Chronic malnutrition and loss of appetite
3) Frequency of hemodialysis is also low , and problem with arranging PRBC everytime .
Chronic anemia further worsening heart failure.
4) Non compliance to anti hypertensives
5) Repeated admissions for htn emergency and pulmonary edema
6) Erythropoietin and iron sucrose given once in every 15 days or one month maximum.
7) Ckd and Bicarbonate therapy in itself a huge issue
4/17/22, 6:53 PM - Karnati Vaishnavi KIMs Med PG: <Media omitted>
08 HIC CME AIG - Dr Rekha 23-3-2022.pdf
4/17/22, 6:54 PM - Karnati Vaishnavi KIMs Med PG: This is an article shared by Dr Faraz for infection control measures in hemodialysis unit
4/17/22, 7:06 PM - Kims Aditya Samitinjay: I think your points 3, 4 and 5 make realise that one of the biggest challenges is the incredibly low rates of Renal transplants we do, all over the country. I think that is the number 1 clinical complexity that needs to be solved.
4/17/22, 7:09 PM - Kims Aditya Samitinjay: Except point 1, I have witnessed 2 to 6 from close quarters. A renal transplant was considered but was impossible
4/17/22, 10:00 PM - Karnati Vaishnavi KIMs Med PG: I truly agree with this sir . Nothing can change the way most hospitals function in the country and all they do is blame a doctor for it or reward them . All they care about is do IP and discharge patient.
4/17/22, 10:00 PM - Karnati Vaishnavi KIMs Med PG: There are many loops to this sir. Not just the money issue ,which is always a big factor . But starting from aarogyasri package , which has to be improved definitely . In outside countries everyone gets dialysed 3 times per week . But we have limitations here.
2) And to cover for complications associated with dialysis.
Most of the packages are just day care and wouldn't cover medications
3) I guess anemia is a huge problem sir. I dont know we often neglect it . But so many times , patients are vexed of getting donors , and simply won't show up /delay next hemodialysis
Moreover management here won't allow ,blood from other blood banks . So it's again a huge issue to get healthy donors .
4) Av fistulas have to be done more faster , as central lines are culprit for all those infections .
Apparently it takes 1-2 months to get a fistula at our place . Have to take prior appointment for Doppler 2 weeks before.
Some one month later he gets fistula and that takes again 6 weeks to mature .
Failure rate again very high.
Why can't we publish in quora sir ?
I think publishing it in wider platforms and in simple understandable language where many people (non-medicos ) can understand, would hit larger audience sir .
4/17/22, 10:01 PM - Rakesh Biswas: This is a link to some basic ideas about neural networks that may help in everyone's analogous understanding of organizational clinical complexity 👇
https://www.r-bloggers.com/
4/17/22, 10:02 PM - Kims Aditya Samitinjay: Great points. Ultimately the people in power should read it and the audience in Quora are usually not?
4/17/22, 10:02 PM - Kims Aditya Samitinjay: We should publish it on Page 1 in The Hindu and The Times of India.
4/17/22, 10:04 PM - Karnati Vaishnavi KIMs Med PG: Haha they might not allow it sir😅
4/17/22, 10:04 PM - Karnati Vaishnavi KIMs Med PG: May be social media
4/17/22, 10:04 PM - Kims Aditya Samitinjay: Thank you sir.
4/17/22, 10:06 PM - Rakesh Biswas: Thanks @9183746xxxx
Will need you to do an rca of each point that you mentioned with your building the weights and synapses to join the dots toward the rca (root cause analysis).
@9188852xxxx how do you compare the resources and organizational clinical complexity with the place where you did your pg from. Would be great if you can also introduce yourself to the group.
The problem with quora, twitter is that they are dependent on single user handles to publish while journal platforms encourage a much more polished version with a multi author paper driven by the kind of team based learning that you are hopefully witnessing here
4/17/22, 10:10 PM - Karnati Vaishnavi KIMs Med PG: Okay sir . I ll link the underlying problems and their root causes
4/17/22, 10:11 PM - Rakesh Biswas: Build a diagram based on the neural network complexity framework shared above
4/17/22, 10:18 PM - Rakesh Biswas: @919652xxxxc Those apparently powerful individuals are a product of system hype and are essentially puppets to other complexly synapsed nodes driving them. You already know there is no such thing as free will
4/17/22, 10:20 PM - Kims Aditya Samitinjay: Yes sir I agree with you. Only concern is that instead of several small nodes, one large dominant node has taken over (greed and power)
4/17/22, 10:21 PM - Rakesh Biswas: That large dominant node is driven by a complex synapse of many hidden nodes who need to be traced and repaired
4/17/22, 10:38 PM - Rakesh Biswas: @918374610190 The review of literature around this https://www.researchgate.net/
4/17/22, 10:49 PM - Karnati Vaishnavi KIMs Med PG: Thank you sir. Will try to make one
4/18/22, 10:37 AM - Rakesh Biswas: This patient is currently Hale and hearty in the ward. @9194xxxxx Should have corrected @9779817xxxx
4/18/22, 10:51 AM - Avinash Gupta Nepal: Thanks sir! That's great update
5/23/22, 12:29 PM - Kims Aditya Samitinjay: Clinical Complexity - Preliminary Problem List.docx (file attached) and pasted below :
Case 1 - https://poreddyjahnavi128.
Individual level – What is the cause of CKD in this young man ? What are the factors which inhibited a full and thorough work-up of all his problems ?
Family level – Why did the patient stop medication due to a distressing event in his familial life ? What are the factors that led to this and what can be done ?
Community level – What role did the community have in his disease process ?
Ecosystem/Medical system level – What are the prevalent factors which led to ESRD in a young patient ? How did the medical fraternity fail in providing care to this patient ?
Case 2 - https://saisurya100.blogspot.
Individual level – What is the cause of CKD in this young man ? What are the factors which inhibited a full and thorough work-up of all his problems ?
Family level – What role did the family have on his disease process? What effect did the patient’s problems have on his family ?
Community level – What role did the community have in his disease process ?
Ecosystem/Medical system level – What are the prevalent factors which led to ESRD in a young patient ? How did the medical fraternity fail in providing care to this patient ?
Case 3 - https://saichennuru.blogspot.
Individual level – What is the cause of CKD in this young man ? Why did this patient develop diabetes at a young age ?
Family level – What role did the family have on his disease process? What effect did the patient’s problems have on his family ?
Community level – What factors in the community precipitated diabetes and CKD in this patient ?
Ecosystem/Medical system level – What can be done to improve access to primary, secondary, and tertiary health care at the ecosystem level ?
Case 4 - https://nikhithapulipeta130.
Individual level – What is the cause of CKD in this young man ? Why did this patient develop diabetes at a young age ?
Family level – What role did the family have on his disease process? What effect did the patient’s problems have on his family ?
Community level – What factors in the community precipitated diabetes and CKD in this patient ?
Ecosystem/Medical system level – What can be done to improve access to primary, secondary, and tertiary health care at the ecosystem level ?
Common questions to all patients
4 young to middle aged men – Common theme – Fairly active lifestyle and then biochemically found to have kidney injury, drastic change in life with sudden initiation of dialysis (or even MHD) in all of them.
All 4 went on to develop osteopathologies. What factors at the levels mentioned above may have contributed to these ?
At each level, how was institution of care impeded ? What factors can we modify and what are beyond our control ?
5/23/22, 12:30 PM - Kims Aditya Samitinjay: Preliminary set of questions for this project. Of the top of my head, considered issues at various levels affecting healthcare, such as individual, family. community levels etc. These are just preliminary questions and will be glad to discuss modifications and quickly set this project up and rolling.
5/23/22, 1:09 PM - Sai Charan Kulakarni Kims Med: Okay sir wil go through once
5/23/22, 2:21 PM - Rakesh Biswas: 👏
5/23/22, 2:24 PM - Rakesh Biswas: Thanks.
Sharing this in the larger group in case we can get a few more students into this project who may be able to contribute
5/23/22, 2:27 PM - Kims Aditya Samitinjay: Yes sir. Please do.
