Health and Psychology

The New England Journal of Medicine just published an article on the need to develop guidelines on treating patients with multiple illnesses also known as co-morbidities.  No kidding.  The average person starts getting multiple medical conditions around age 50-65.  Some people start much earlier.  The difficulty is that the current system of medical treatment is disease specific and specialty specific.  

Here's the problem with treatment by disease.  Dr. John sees patient Barbara.  She coughs often, is sometimes short of breath, and her left shoulder bothers her.  Dr. John tests her for diagnosis.  She has inflammation in her shoulder, arthritis and bursitis, a chronic cough, and some abnormalities on her electrocardiogram that require further tests.  So she needs to be seen by specialists.  She's referred out to a cardiologist, pulmonologist and rheumatologist.  Each of these doctors will prescribe separately and will follow guidelines for treating the particular disease they are responsible for.  So Barbara is now diagnosed with chronic obstructive pulmonary disease, chronic emphysema, congestive heart failure, hypertension, osteoarthritis, bursitis, and mixed connective tissue disease.  She is prescribed a total of 12 medications designed to treat the various conditions she's been diagnosed with.  

• The medications cause side effects.
• With more than 4 medications being prescribed there is no research on the combination of medications or their synergistic or opposing effects and side effects.  
• There's little coordination between the physicians.
• None of the physicians are responsible for the patient as a whole.
• There's little thought to the overall risks and benefits.
• No one focuses on quality of life.
• No one asks Barbara what she wants for her life.

As time goes on, the conditions worsen.  The cardiologist thinks she should have surgery to open the blood vessels to her heart.  Stents are put in to help with blood flow, despite the worsening condition of her lungs and the enlarging of her heart to accommodate the limited oxygen supply.  Barbara feels better for a couple of months.  She notices that she is starting to fall.  She is on multiple antiinflammatory medications increasing the risk for bleeding episodes, heart attacks, and strokes.  She is losing mobility.  Treatment of her heart worsens her mobility problems.  Treatment of her joints and muscles worsens her heart and lungs.  Within a few years other organs are involved.  She has kidney problems, bowel problems and diabetes.  She is now additionally being followed by a gastrointestinal specialist, a nephrologist (kidney doctor) and an endocrinologist for her diabetes.  She's also found to have a thyroid disorder.  She's prescribed another 1/2 dozen medications.  Her mobility worsens.  Despite surgery, she has a heart attack and a stroke.  She needs a wheelchair or walker.  She needs assistive living.  She can't care for her dog and has to give him away.  She becomes depressed.  Barbara died after a long period of disability.

If someone talked to Barbara and asked her what she wanted for her life she would have said she wanted to:

• Live in her own home independently
• Take as little medication as possible
• Be as productive as possible
• Be able to care for her dog.