By definition chronic diseases are diseases we cannot cure and at best can attempt to control symptoms and delay complications and progress. The care of patients with chronic diseases is consuming increasing general practice hours. They contribute to 60% of deaths globally and this figure is increasing on an international scale. It has been estimated that if the current trend persists, diabetes alone could consume the entire health care budget of western nations.
While much of our population lives longer they do not necessarily live with optimal health, being limited by their physicality, their pain, the psychological reaction to their problems and by current management itself.
Finding ways to effectively and efficiently prevent, manage and potentially cure these diseases is the challenge for the new generation of clinicians.
Not only do a majority of patients over 65 have at least one chronic disease diagnosis but many have two or more. In General Practice approximately 34% of patients seen have 3+ chronic disease diagnoses. Multiple morbidity significantly increases the complexity of patient care making it more challenging - although perhaps more professionally rewarding for us as GPs.
For the doctor the challenges are in the multisystem disease requiring multiple medications and management approaches when there are inevitably drug side effects, interactions between drugs and systemic disease which may affect drug efficacy and safety.
Management guidelines, evidence based and useful as they may be, most often address one specific diagnosis, so how does that apply when the patient has four or five? Coordination of management and ensuring continuity of care are vital in successful treatment.
And then there is the “care” word, so well used by Peabody in 1925 and still holding true today - “The secret of the care of the patient is caring for the patient”.
These are the patients that a GP gets to know well, thus deepening that special bond that is the doctor/patient relationship, deepening that connection which allows a very comprehensive understanding of the patient’s unique resources and needs, and requires that higher level of communication.
For the patient too there is a complexity - multiple referrals that consume time and money, multiple medications, multiple recommendations for lifestyle changes often conflicting and confusing.
This brings in the innovative concept of the patient centred medical home - a model local GP Tony Lembke promotes and champions – that attempts to optimise and rationalise management and most importantly, if there is to be success at all, to engage and empower the patient to take a central role in their own health care.
Wanted: orchestra conductor
Ever exponentially increasing, the level of medical knowledge has of necessity, caused a fragmentation in specialisation. Increasingly we are seeing the emergence of sub-specialties, and sub-specialties beyond them. There are cardiologists with amazing expertise and technical skills in the management of atrial fibrillation but who do not manage ischaemic vascular disease; orthopaedic surgeons who only perform knee replacements. Therein lies a problem. The human body is in itself not fragmented… mind, body and soul are one.
We have a conundrum. How does our patient with multisystem disease get the best care without this sense of each body system being managed by a different health care provider, and the risk that these are not communicating effectively with one another?
We need a conductor for this orchestra, a conductor. Traditionally this has been the role of the GP but with the increasing complexity of care GPs need to be properly funded and fully supported to coordinate a complicated care equation that is far beyond a 15-minute GP appointment. Without coordination, as in the tale of Humpty Dumpty…
“All the kings horses and all the kings men
Couldn’t put Humpty together again”
Valuing physician generalists
In our area we are blessed by having several highly competent physician generalists, but they are an aging, if not yet, a retiring breed. Few physician trainees are taking on this role, yet these clinicians are gold for GPs when it comes to problems in the complex management of patients with complicated, multiple morbidities.
Of necessity GPs have to take a holistic approach to patient care, but there are times when the wisdom and expertise of a generalist physician, bringing fresh eyes to our patients’ problems, are invaluable. I have always considered these clinicians to be the true masters and teachers of medical care. In fact, recently I watched in awe as such a physician taught a bunch of my students the nuances of neurological examination in differentiating the site of a CVA. He displayed true artistry.
It would be wonderful if in our work with medical students we could encourage those drawn to physician training to consider taking a generalist’s role. It is a difficult role requiring as it does multidisciplinary expertise, but the burgeoning numbers of patients with chronic and complex disease make it a vital role in today’s health care.
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One such local physician is Frank Wagner who has recently received a reward for long service to this rural region. “Everybody loves Frank” was the comment I heard more than once. As a GP I have always felt respected and valued by him, no problem I shared too small for him to assist with, never made to feel lesser than. Frank had already been working in Lismore for 8 years before I arrived in the area over 30 years ago. I had an immediate connection with him because we had both worked in New Guinea. Frank is so much more than a most knowledgeable physician generalist.
He has been a wonderful role model to several generations of doctors. He treats everyone from junior doctors to trainee nurses and all of his patients with utmost dignity and care, treating all as equals. He has shown us all what love looks like in medical care and set a standard which I believe has influenced the care at Lismore Base Hospital for many years.
* Local physician, Dr Frank Wagner , was recently honoured by the Northern NSW Local Health District in recognition of his award from the Royal College of Physicians.
Image: Humpty Dumpty under Creative Commons CC0 Link https://pixabay.com/en/humpty-dumpty-nursery-rhyme-nursery-34208/