Understanding complexity: multimorbidity in general practice

To mark the launch of BMC Family Practice's new thematic series on comorbidity and multimorbidity, Section Editor Carolyn Chew-Graham provides some personal insights on the challenges patients with multiple conditions pose to general practitioners in this guest blog.

Multimorbidity, commonly defined as the occurrence of two or more long-term conditions in a single patient, is becoming more prevalent as the global population ages. It is often associated with poor quality of life, disability, psychological problems and increased mortality. It greatly increases the complexity of disease management in patients, and is linked to increased frequency of health service use including emergency hospital admission, adverse drug events, poly-pharmacy and fragmented care.

As a general practitioner (GP), I am made well aware of this as more and more of the patients I encounter display a multitude of long-term conditions. Here I describe two recent consultations to illustrate the confusions and frustrations patients with multimorbidity experience daily. They also help to demonstrate the challenges healthcare providers face when dealing with patients who have multimorbidity, and include an opportunity for reflection.

Consultation 1

M is in her 90s and still able to get to the surgery with the help of a neighbour and a walking stick. Her main problem, as she sees it, is the pains in her knees. She doesn’t like to take pain-killers and is cross with the orthopaedic surgeon who told her, a couple of years ago, that she didn’t need a knee replacement. The injection he gave her in one knee was helpful for a while, but that soon wore off. M takes the tablets her GP prescribes for high blood pressure, although often asks if she can stop them.

She also worries about the ‘statin’ she is prescribed (and doesn’t always take), although her husband died of a heart attack, so she is unsure about asking the GP if she can stop it. She doesn’t take the big calcium tablets, but the Pharmacist keeps delivering them, so she has a cupboard full. Her memory is ‘not that good’, but she was upset when, two years ago, a specialist came to see her at home and said she had a memory problem. She does forget people’s names, but she thinks that this is no worse than anyone else in the sheltered accommodation where she lives. She certainly doesn’t want anyone ‘coming in and fussing’, but does admit to being lonely.

Consultation 2

H, a middle-aged accountant, has had diabetes for 15 years. He is worried about the number of tablets he has to take, yet the GP added another one two months ago: he feels that he ‘rattles’. He was also alarmed when he spoke to the practice nurse who told him he had ‘kidney disease’; the GP, however, said it was ‘just CKD (Chronic Kidney Disease), and not to worry’. He is not sure what’s going on.

H is aware that he worries about his health – he must have been seen by different GPs over a dozen times in the last 6 months. He had some investigations for his prostate earlier in the year and ended up on more tablets; and has been to the ‘chest pain clinic’ but was told he didn’t have angina, but they didn’t explain why he gets chest pain. He has been to Accident and Emergency department twice in the last two months, but they just give him pain-killers and send him away. His family says that he is irritable and needs to see a doctor. H doesn’t want to bother the GP with how he feels, or his problems sleeping; he worries that all the doctor will do is add another tablet, and he certainly doesn’t want that.

Ill-prepared for multimorbidity

Presently, health care workers have limited guidance and experience when approaching care decisions for patients with multimorbidity. Medical training and clinical care has been largely informed by evidence and guidelines for single systems or diseases.

Current clinical practices are increasingly specialized, with healthcare professionals often basing treatment decisions on relatively narrow aspects of an individual’s health problems. As such our medical care system is particularly ill-prepared to deal with patients with multimorbidity. As our global population ages, and the number of patients with multimorbidity rises, it is imperative that we adjust our healthcare system to effectively care for them.

With this in mind, BMC Family Practice launches a new special issue: Impact of comorbidity and multimorbidity on primary care practice, in which we explore how comorbidity and multimorbidity have changed clinical practice.

In the first three published articles, researchers examine the complex healthcare needs of patients with multimorbidities, and how general practitioners can refine their treatment of these patients to promote better and more consistent management and self-management of the illnesses. We wish to continue this focused exploration on comorbidity and multimorbidity in primary care practice. To contribute to the discussion, please find instructions on how to submit to the thematic series on the journal homepage.

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