In the past half century or so, medicine has changed the complexity of the human population as it has never been seen in the past. Think about it, there are people walking around today that fifty years ago, wouldn’t even be alive. This evolution in medicine has not only brought about transformation in the human population, but it is also changing the approach of how clinicians need to treat these complex patients.
Traditional medicine has always focused on a single cause for a particular disease, without any consideration towards multiple risk factors and co-morbidities (a concomitant but unrelated pathologic or disease process). For this reason, clinical practice guidelines may not be able to address a particular patient’s needs if the patient has more than one medical issue that they are dealing with simultaneously.
My concern is that clinical outcome studies may not give a true representation of the type of patient many of us are seeing in our practices. This is because patients with multiple co-morbidities or multi-morbidities are on the rise, as diseases that were once considered death sentences are now seen as manageable. However, in many clinical trials, patients with other illnesses are usually excluded from these trials. Unfortunately, those of us in clinical practice do not have the luxury of excluding patients with multi-morbidities making these clinical trials/guidelines inadequate to manage patients.
Interestingly enough, the United States has been, for decades, in the forefront of dealing with multiple co-morbidities as opposed to the rest of the world, and is probably the leading cause of increased healthcare costs here in the United States, as opposed to other countries. However, the rest of the world is catching up to us at a rapid rate as medical technology and poor dietary habits become more available throughout the world.
For instance, it is predicted that by 2030, over fifty percent of the obese patients in the world will be from China and India combined. Also, right now, the rapidest growth in obesity is not here in the U.S. but is occurring in Europe and Asia, mostly due to the rapid expansion of fast food markets in those areas.
The question now becomes: How do we manage this new type of patient?
The first thing is for clinicians to have a better understanding of how multi-morbidities can affect a patient simultaneously. This is going to require better history taking and a better understanding of how disease processes work. In addition, the clinician is going to have to be aware of poly-pharmacy and drug-drug interactions. This can be accomplished by listening and establishing a dialog with the patient. Unfortunately, many clinic guidelines do not allow for this, but it must change if we are to be successful.
Second, it is my belief that there should be more emphasis on case studies where complex patients are described and how the clinician or clinicians successfully treated that patient. I believe this because in my thirty years of practice, no two patients have ever presented the same way or responded exactly the same way.
Thirdly, there needs to be a change in the medical education system with a better understanding of how all these multi-morbidities will impact a patient. This will not be easy to test considering that testing has always been driving towards a more traditional single-disease approach. Regardless, it must be done if we are to succeed.
As I have said before, the human race is evolving, and medical technology has been a major factor in this evolution. The old model of medical management is no longer able to help many patients, so it is now time for medicine to evolve to meet this new challenge.
Andrew Pugliese is an infectious disease physician who blogs at Sinusitis Blog. He can be reached on Twitter @SinusBlog.
