Clinical case: Mr. Tremblay just turned 60 years old. He is known for hypertension, dyslipidemia, type 2 diabetes mellitus, coronary artery disease, chronic obstructive pulmonary disease, bilateral knee arthritis and depression. He is sedentary, obese and smokes 1 pack of cigarettes per day. His medication list includes aspirin, atorvastatin, enalapril, metoprolol, hydrochlorothiazide, metformin, ipratropium puffers, citalopram and ibuprofen as needed. He has an appointment with his family physician for his annual exam today and wants to discuss his constipation, painful hemorrhoids and his new low back pain.
When today’s family doctors were in medical school, patients like Mr. Tremblay were uncommon. A group of doctors once said to me ‘’when we were medical students, we were reluctant to see patients who were taking more than 3 medications, because they were considered to be complex’’. With the improvement in medical treatments and interventions, previously acute and/or life-threatening diseases are now better controlled such that they become chronic. Moreover, with the aging of the population, patients live longer with chronic diseases. Nowadays, patients like Mr. Tremblay are the norm, rather than the exception, whether you are working in the emergency room, on the wards or in the clinics. Indeed, more than half of the patients followed by family doctors have multiple chronic diseases. Those patients constitute a big weight on the health care system, which was designed to take care mostly of acute conditions. Therefore, primary care has a very important role in the management of chronic diseases.
When caring for patients with multiple comorbidities, a useful approach is the concept of empowerment.
Consequences for the patients
The patient with multiple chronic diseases encounters challenges on a daily basis. The more medications they take, the higher the chance they will have side effects from a drug. Medications can also interact together and cause dangerous side effects or unbalance the metabolism of a certain drug.
Patient’s quality of life and work life is also affected, as they spend an impressive amount of time going to medical follow-ups (which can easily take 2-3 hours per appointment in a busy clinic) and undergoing tests and investigations (waiting lines for blood tests and imaging techniques as an outpatient can easily take a few hours). A lot of their time is consumed by the follow-up and management of their numerous medical conditions.
The side effects, the time restraints, their struggle to make healthier choices, adopt healthier lifestyles and the frequent progression of their diseases despite their efforts accounts for a significant portion of psychological distress in this patient population, ranging from discouragement to anxiety and depression.
Challenges for the physician
For a family physician who sees a patient with multiple comorbidities on annual follow-up, there is a lot to do in a limited time frame. The patient often has his own agenda. In the above example, Mr. Tremblay is concerned about his constipation, his painful hemorrhoids and his new low back pain. The physician also has his own agenda, which in our example, includes verifying that Mr. Tremblay’s chronic diseases are well controlled (by verifying that his blood pressure, lipid profile and glucose are all within the normal range), screening for certain diseases (like colorectal cancer in his case), treating acute complications of chronic illnesses (like his worsening shortness of breath, which could be an exacerbation of his COPD) and promoting health (by encouraging the patient to stop smoking, adopt a good diet, exercise and loose weight). The only way to succeed is to discuss these issues with your patient and establish priorities.
Another challenge is the use of evidence-based guidelines in the clinical setting. Guidelines are extremely useful in synthesizing the best approaches based on scientific evidence. However, a few problems arise when trying to apply those guidelines to complex patients. Most of the guidelines come from clinical trials that study one disease at a time, and patients with multiple chronic diseases are often excluded from these trials. This creates an issue when trying to generalize the results from a clinical trial to a patient with multiple comorbidities. Family physicians must use their privileged relationship with their patients, their knowledge and their expertise in treating a patient in all its complexity with an integrative, patient-centered approach, which takes into account the patient’s perspective, expectations and context.
When caring for patients with multiple comorbidities, a useful approach is the concept of empowerment. There are many ways by which a physician can empower his patients. First, educating patients about their diseases and involving them actively in the management of their medical problems is very important. Second, focusing on patients strengths instead of weaknesses is primordial. Third, helping patients mobilize their own resources and find solutions that are tailored to their needs is the best way to ensure compliance. The physician must always work with the patient in order to find common ground regarding the identification of problems and their management.
Primary care is extremely important in the appropriate management of chronic diseases. The challenges are numerous but the rewarding feeling is immense!
For those interested, the movie ‘‘Remaking American Medicine: The Stealth Epidemic’’ is a documentary that discusses the issues of chronic diseases in the American context. The following youtube video is a short excerpt of the documentary.