Study: An examination of naturopathic clinical case management using complexity science principles

3.1.1 Force-based attribute mapping

Figure  1 is a complete combined attribute network mapping of all elements and associations identified by participants in 70 different patients with varying presentation problems. The combined network mapping of the 70 real patient data mind maps contains a total of 739 elements and 2724 links. The grade (number of incoming or outgoing compounds) ranged from one for 112 elements to 157 (systemic inflammation). The average degree of the top 10 most linked items was 84, while the average degree of items with 20 degrees or less (651 items in total) was 4.85. The elements identified by participants that were most connected and therefore integral to the 70 cases, as identified by size and central location, were: stress, fatigue, generalized anxiety, systemic inflammation, intestinal dysbiosis, nutrition, impaired immune function, gastrointestinal tract, nervous system, intestinal hyperpermeability, digestive disorders, and Nutrient malabsorption as well as impaired status of various nutrients (including iron, vitamin D, zinc, vitamin B complex). These were colored according to six different attributes: (i)Condition, sign or symptom , (ii) hypothetical risk , (iii) genetic, constitutional or familial predisposition , (iv) Organ or subsystem , (v) external or environmental influence , (vi) biomedical diagnosis or pathological result (Table  1).

3.1.2 Physiological and external system images (force-based and circular)

Elements were grouped and colored by physiological and external systems using force-based (Figure 2) and circular (Figure 3) mapping. There was a mean of 46.19 elements (min: 4, max: 105) for each physiological and external system (Table  2). The physiological systems with the largest number of elements included: the reproductive system ( n  = 105), that Gastrointestinal system ( n  = 88), that Nervous system ( n  = 75) and that immune system ( n  = 64). External factors ( n  = 88) and nutrition and nutrients ( n = 94) also had a significant number of elements, accounting for 25% of all identified elements. Figure  2 highlights the system groupings (see Table 2 for color key). Each physiological system had multiple relationships identified with all other physiological systems and the external elements, as evidenced by the connection patterns between elements (highlighted by  3).

3.1.3 Mapping modularity

In Fig. 4 is a Modularity layout in which the colors of the elements represent community rather than attribute. A total of 11 communities were Gephi- Algorithm identifying the communities of symptoms, subsystems, organs, symptoms, and environmental influences considered by practitioners to be most closely related. Using an EDA process, the largest communities identified included: nervous system and mood (red), Gastrointestinal tract, liver, nutrition, digestive enzymes (dark green), Immune function and immune system (orange), Nutrition and nutrients (pink), female reproductive system and hormones(Dark blue). A more dispersed community has also been identified systemic inflammation, the integumentary system, joint problems, the lymphatic system and physical activity (light green).

3.2.1 Network analysis: Node-level measures

Within the network, each element was connected to an average of 3,815 other elements, with a degree variation between 1 and 157 and a left-skewed degree distribution pattern (Supporting Information File  S1). The highest grade items (Table  5) included systemic inflammation (grade = 157), stress (grade = 140), gut dysbiosis (grade = 96), anxiety (grade = 92), impaired immune function (grade = 79), fatigue (grade = 76), poor sleep quality (grade = 58), nutrition (grade = 50). Items with high betweenness centrality values ​​are listed in Table  5. A total of 238 items had a betweenness centrality of zero, 190 items had a betweenness centrality between 0.50 and 500, and 147 items had a betweenness centrality between 501 and 1500. 139 items had more than 1501 betweenness centrality. See Supporting Information File S2 for the distribution of eigenvector centrality and Table 5 for the elements with high eigenvector centrality. The items with the highest eigenvector centrality values ​​were systemic inflammation, fatigue, and general anxiety.

3.2.2 Network analysis: measures at the network level

Network analysis showed that the diameter of the network was 13 and the average path length was 4.148. The average clustering coefficient was 0.126, indicating that each element in this network is connected to 12.6% of other elements on average. Applying the Gephi modularity algorithm, a total of 11 communities were detected with a size distribution of each community ranging from eight to 115 elements. The modularity value of the network was high at 0.425, indicating a well-connected internal structure with a high density of internal connections within the identified communities, as measured by the connections between communities.

4. DISCUSSION

In this study, network maps of the naturopathic clinical reasoning process were created and analyzed to examine primary health care through a complexity science lens. This research provides a preliminary insight into using a complexity science perspective to explore the manifestation of the holistic philosophy expressed by naturopaths through their processes of clinical reasoning.

Overall, a variety of elements and their diverse relationships were considered in the 70 clinical cases included in this study. The high modularity value of this dataset highlights its highly interconnected nature as perceived by naturopaths; Physiological systems and individual organs were not viewed by practitioners as discrete entities, but rather in complicated and entangled relationships. The naturopathic process for diagnosing and treating complex and chronic diseases is based on an integrative physiological approach ¹⁹ , an approach that is an integral part of naturopathic training worldwide. ⁴⁴ Steel et al. ¹⁹found that naturopaths incorporate at least two physiological patient systems into case management regardless of the problem at hand, and this holistic perspective is evidenced here. This integrated approach to clinical reasoning may be a result of the complex nature of chronic illnesses, which account for 75% of naturopaths' total caseload. ⁴⁵ Chronic diseases tend to be complex and multifactorial, favoring complexity-aware approaches rather than those involving simple causal inferences and linear treatments. ^{46 – 48} Myers and Vigar ⁴⁹found positive evidence for naturopathic treatment for a range of complex and chronic illnesses, and chronic illness was found to be significantly associated with patients seeking naturopathic clinical services. ⁵⁰It is unknown to what extent this integrated and complexity-aware approach is used by naturopathic practitioners when treating patients with acute illnesses, and how this holistic approach might compare to the case management and clinical reasoning processes of practitioners from other professions. Future research into the clinical reasoning processes of practitioners from different professions in managing diverse patient presentations may expand knowledge of primary health care practices while enabling improvements in efficiency, effectiveness, and safety.

In this study, several elements were identified as having key roles in the clinical process based on how many connections they had with other elements, how often they were positioned in mediating roles between other elements, and how often they were integral parts of structural communities. These key elements included systemic inflammation, fatigue, anxiety and stress, depression, immune function, sleep quality, gut dysbiosis and bowel function, and nutrition. McIntyre et al., ⁵⁰ found that mental health disorders were most commonly reported by those using naturopathic clinical services, while Steel et al., ¹⁹found that endocrine and digestive factors are critical to the clinical thinking of naturopaths. This study does not examine why these aspects of human health are most strongly represented in these naturopathic case studies. It is possible that these are truly vital aspects of health that may point to beneficial starting points and targets for disease prevention in a salutogenic treatment model, or it may be that these elements have some affinity with naturopathic clinical reasoning and are therefore prioritized for case management in particular situations. Either or both possibilities indicate potentially valuable areas of future research.

While the connections in the maps in this study are denser within specific physiological systems, external systems, and community cliques, they were abundant across all subsystems of the human organism and with the external context. This finding suggests that naturopaths not only apply a holistic perspective by considering each of the subsystems and their components within a network, but also think about how elements in this holistic network relate and interact with one another. There is a growing body of research identifying connections between different organs and systems within the body. For example, patients with hepatic encephalopathy (in itself a nervous system disorder caused by severe liver dysfunction) have been shown to have higher levels of cognitive impairment, systemic inflammation,⁵¹ ; Inflammation, commonly associated with gut dysbiosis, has been found to play a role in the etiology of a number of psychiatric disorders, particularly depression ⁵² ; psychological stress is associated with cardiovascular morbidity, ^{53 – 55} and the immune system and nervous system are connected via a bidirectional pathway. ^{31, 56} Researchers are recognizing elements of the complex structure of the human organism through the development of fields such as psychoneuroimmunology, ³¹ the microbiota-gut-brain axis, ^{52, 56, 57} the hypothalamic-pituitary-adrenal axis, ⁵³Psychodermatology ⁵⁸ and the stress response system (which includes the endocrine, nervous and immune systems) ⁵⁹ , indicating a move away from a reductionist mindset towards one of connection and complexity. Further research from clinical practice – both in naturopathy and other medical systems – could help identify further important complex clinical relationships. Embedding a complexity science perspective into clinical practice by integrating biological, biographical and contextual elements ⁴⁸ could revolutionize primary healthcare.

Within the mappings in this study, a quarter of all elements identified in the 70 patients were external and environmental, with the remaining 75% comprising internal states, organs, symptoms and physiological systems. As part of their case management process, naturopaths routinely consider an interconnected web of internal physiological systems and external influences - both as elements and as a collection of relationships. The treatment response to this pattern is a complete and complete response plan designed to function dynamically and completely ²⁵by addressing the environmental context and disruption of the whole person. Naturopathy addresses both the individual's unique external context (e.g. diet, lifestyle, social interactions, natural and built environment) and the disorder of the individual as a whole, as determined by the patterns of signs and symptoms present. ²⁵ Although the specifics of such an approach may be unique to naturopathic medicine, there is an evidence-based imperative for considering external factors in primary health care - for example, the connection between diet, lifestyle and well-being has long been recognized, ^{60, 61} Placebo research has established a connection between expectations, conditioning, context and treatment outcomes, ^{62 – 64}and a link between positive social connection and health and longevity has been demonstrated. ^{65 – 67} Addressing a patient's health needs without taking contextual considerations into account risks overlooking precipitating and ongoing elements on which treatment success depends.

This study is not without limitations. The small number of participants (seven in total) increases the risk of distorted data. The small sample also means that this study cannot be viewed as an example of the use of a complexity science research framework for the naturopathic case management process, but rather represents a preliminary investigation of this approach in this context. In addition, the research team assigned the element attributes in force-based mapping and the assignment of elements to subsystems in physiological and external systems mapping at their own discretion. This is not ideal, and in future studies of this type it would be desirable to reach consensus on these associations within the profession under study. Nonetheless, this exploratory study highlights the potential of complexity science in analyzing clinical practice and clinical relationships, as well as the feasibility of implementing such an approach within a profession. Larger, more rigorous studies using this methodology could help provide further insights and overcome the limitations of this study.