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Problems with by-the-book care and patients

Problems with by-the-book care and patients with more than one disease

IT IS a real challenge to treat patients with multiple co-morbidities – conditions that exist at the same time as the primary condition, in the same patient. It is very common for patients to have several.

Complex care is the most important problem faced in general/internal medicine. Many, many times we have to use the results from studies done on patients with a single disease to treat patients with multiple diseases. The evaluation of medical decisions typically focus on one disease, that is on one source of risk, but, in the real world, when considering most medical decisions, multiple sources of risk co-exist.

Doctors have to achieve a difficult equilibrium based on how the multiple co-morbidities and all the drugs interact. It is not easy and it requires an every-day updated knowledge of the trade, but not only this, as it is also fundamental to know everything about the patient and to have the real “feeling” of the whole situation.

“Despite telemedicine, hospitalists, and the new fashion of grocery store minute clinics run by RN’s (Registered Nurses), and ‘eight minute per visit’ doctors, there’s no substitute for a qualified FP (Family Physician) taking adequate time and assessing a known patient with a big picture outlook. Too bad there are almost none of those around anymore,” said Dr. Barbara Turner, president of the Society of General Internal Medicine and Professor of Medicine at the University of Pennsylvania.

Specialisation and generalism

To some extent, there is always a competition between the human instinct to keep things whole, complete and general. We also have the tendency to distinguish, sort and reduce.

With the evolution of human society, specialisation in every field is spreading. As we know more and more about everything and anything, technical knowledge and science are becoming more complex everyday.

Modern medicine has been influenced by this specialisation tendency and specialist-directed disease management has been the fashion, believing 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-oriented primary care physician initially and then seeking advice from specialists later on.

It is not unlikely that when patients’ individual conditions are considered one by one, they could 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. This usually causes 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. However, the generalist approach affirms a central role for the primary care clinician as the co-ordinator and integrator of specialty 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 wellbeing.

The whole, not the holes!    

It is said that when students enter medical school, they care about the whole person, and by the time they graduate, all they care about is the hole in the person …

The generalist is interested in the big picture with all of its nuances, connections, and complexities – the whole, not just the holes.

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. Measures for complicated patients need to reflect such factors as co-ordination, prioritisation, and drug-drug interactions. With the changing epidemiology of illness in industrial societies, chronic conditions, not acute ailments, are now the most common problems in health care.

“The acute infection caused by a single microbe that can be definitively identified and eradicated, has given way to chronic illnesses such as diabetes, arthritis, and dementia. Even among children, chronic conditions such as asthma have assumed greater prominence. For chronic, incurable conditions such as these, the goals of care are to enhance functional status, minimise distressing symptoms, cope with the psychosocial stresses of pain and disability, and prolong life through secondary prevention. In chronic illness, care of the whole person is paramount,” says Kevin Grumbach, MD (San Francisco School of Medicine – University of California).

Most patients with chronic illnesses do not have a single, predominant condition but the simultaneous presence of multiple chronic conditions. They seek care for all of their co-morbidities, not just for a solitary major condition. This does not come as a surprise to any practicing primary care clinician, as for them the straightforward patient with diabetes and no other medical problem is the exception rather than the rule.

Well-managed teamwork

Co-morbidities interact to produce a complex and challenging clinical dynamic. Respiratory conditions and arthritis interfere with patients’ ability to adhere to exercise programmes for diabetes and obesity, while medications for one condition have adverse effects that aggravate another condition.

The virtue of generalism is not that it should compete with specialty care on a disease-by-disease basis, but rather that the overall quality of generalist care is more than simply the sum of atomised, disease-specific measures. Furthermore, generalists and specialists must co-manage patients in a collaborative manner thus enhancing patient outcomes.

Generalism and the work of family medicine are essential to meet the needs of people and society in a changing environment. Fortunately the ‘specialists for everything fashion’ is starting to go out of fashion … for everybody’s benefit.  

Special consideration is necessary in primary care in order to fully capture the complex, multifactor 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, wellbeing 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, not patients. This is why medicine is not only a science, but also an art.

Best health wishes,

Dr. Maria Alice

Consultant in General and Family Medicine

Director – Luzdoc International Medical Service Tel. 917 811 988