Complex care is the most important problem faced in general/internal medicine as it is a real challenge to treat patients with multiple co-morbidities. It is very common for patients to have several conditions that exist at the same time as the primary condition, in the same patient.
Results from studies done in patients with a single disease are often used to treat patients with multiple diseases, and even if the evaluation of medical decisions typically focuses on one disease, one source of risk, in the real world multiple sources of risk co-exist when considering most medical decisions.
For doctors it is difficult to achieve equilibrium, based on how the multiple co-morbidities and all the drugs interact. It requires daily updated knowledge of the trade, but not only that, it is fundamental to know everything about the patient and having the real “feeling” of the whole situation.
Despite telemedicine, there is no substitute for a family physician taking adequate time and assessing the patient with a big picture outlook.
Specialisation and Generalists
In modern medicine, technical knowledge and science are becoming more complex every day.
Specialist disease management has been the fashion, considering that patients benefit from having a team of disease-specific specialists matched to each of the patient’s chronic illness, rather than having a generalist-orientated primary care physician caring for these conditions to start with and getting the expertise of the specialists as and if necessary.
When patients’ individual conditions are considered one by one, it is not unlikely that they end up going to the diabetes programme on Monday, the cardiac programme on Tuesday, the arthritis programme on Wednesday, and the depression programme on Thursday. A big confusion and an even bigger bag of medicines…
What is needed is a model of care that addresses the whole person and integrates care for the person’s entire constellation of co-morbidities.
Specialty care can offer expertise and unique services to the care of patients with chronic illness, and its value must be appreciated and never denied, but the generalist approach affirms a central role for the primary care clinician as the coordinator and integrator of speciality care and other referral services, working in partnership with the patient, the patient’s family and other health care personnel to optimise overall physical functioning, mental health, and well-being.
The whole, not the parts!
The generalist is interested in the big picture with all of its nuances, connections, and complexities.
It is no surprise that primary care physicians manage, on average, two chronic medical conditions per patient along with delivering preventive care, addressing psychosocial issues, and treating acute complaints. In patients with multiple co-morbidities, primary care physicians must always juggle their own care plan with that of their consultants. With the changing epidemiology of illness in industrial societies, chronic conditions, not acute ailments, are now the most common problems in health care.
Acute infections caused by a single microbe that can be definitively identified and eradicated have given way to chronic illnesses such as diabetes, arthritis, and dementia, and even among children chronic conditions such as asthma have assumed greater prominence.
Patients with chronic illnesses do not have a single, predominant condition, but the simultaneous presence of multiple chronic conditions seek care for all of their co-morbidities, not just for a solitary major condition. To any practicing primary care clinician the straightforward patient with diabetes and no other medical problem is the exception rather than the rule. What matters is to care for the whole person.
Co-morbidities interact, producing a complex and challenging clinical dynamic. Respiratory conditions and arthritis interfere with patients’ ability to adhere to exercise programmes for diabetes and obesity, and medications for one condition have adverse effects that aggravate another condition.
Generalists and specialists must co-manage patients in a collaborative manner thus enhancing patient outcomes, and the work of family medicine is essential to meet the needs of people and society in a changing environment. Fortunately, the “specialists for everything fashion” is going out of fashion… for everybody’s benefit.
Special consideration is necessary in primary care in order to fully capture the complex, multifactorial nature of health at the holistic level of a patient in the context of family and community, as well as to sense and match the patient’s own hierarchy of preferences for symptom control, well-being, and dignity of life, thus sharing with him the understanding of priorities.
No doctor should ever forget that it is diseases that can be found in medical books, definitely not patients. This is why medicine is not only a science, but also an art.
Best health wishes,
Dr Maria Alice
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Dr Maria Alice is a consultant in General and Family Medicine. General Manager/Medical Director – Luzdoc International Medical Service. Medical Director – Grupo Hospital Particular do Algarve