The New York Times has a really nice piece on the sure-to-increase problem of comorbidity in treating patients, particularly older ones, with chronic disease. Personally, what I found most interesting was the fact that such a common problem is not just overlooked, but excluded in research looking at therapeutic efficacy:In a medical system geared toward individual organs and diseases, there is no champion for patients with multiple illnesses — no National Institute on Multimorbidity, no charity Race for the Multimorbidity Cure, no celebrity pressuring Capitol Hill for more research.Now, this is for a good reason (its very difficult to do controlled studies using patients with multiple conditions, and would be even more difficult to interpret the result of any such studies) but it would seem that, given the increasing need, such multifactorial research could, and should, be done.
And because studies involving uncomplicated populations are cheapest and easiest to interpret, patients with multiple diseases are routinely shut out of drug trials. A 2007 study found that 81 percent of the randomized trials published in the most prestigious medical journals excluded patients because of coexisting medical problems.
Thoughts? Particularly from current or future internists, who deal with this stuff every day?
2 comments:
(Alright, here comes the representative 'current or future internist'...)
This is a very good article, in that it brings to the attention of NYTimes readers something that is being discussed all the time in academic centers. While I like to think that we're all aware of our patients' comorbidities, that's clearly not true. Being an internist, it's particularly disconcertnig to notice how various specialists' notes don't reference the OTHER specialists (and that's where, as the article references, everyone needs a 'coach' to keep the team together...that coach being ideally the internist rather than the patient).
And this is where geriatricians have got it right. Like the article said, "What is best for the disease may not be best for the patient." I remember coming across this idea really well demonstrated in a great article by Atul Gawande (yes, another Atul Gawande article): The Way We Age Now (http://www.newyorker.com/reporting/2007/04/30/070430fa_fact_gawande?currentPage=all).
But that's easier said than done. Are you really not going to anticoagulate that elder patient with unsteady balance when the literature says you should? Ideally we internists should develop the sort of relationship with our patients where we can explain the risks and benefits of our medical decisions to patients so that we're not terrified of getting sued on those occasions when we go against 'The Recommendations'. But that would require a whole lot more than 15 minutes every few months.
So what's the answer? Probably more time with patients, more streamlined computer records (come on, stimulus package!... see NEJM article this week on 'Stimulating the Adoption of Health Information Technology'). That way we can see the whole person and tailor our treatment accordingly.
Speaking of which...my 4:30 patient just arrived in the waiting room, wouldn't want blogging to cut in on precious patient time...
This was too long for a comment, I'm making a BLOG POST!!!
Post a Comment