Friday, April 3, 2009

You Can Have Lice and Fleas at the Same Time

Today, a friend told me this wonderful quote: "You can have lice and fleas at the same time." He says it is from Sir William Osler, a Canadian physician (1849-1919), who some refer to as the most influential physician in history.

The point of the quote – you can have more than one issue at the same time – echoed an eye-opening recent article in the New York Times "Treating an Illness Is One Thing. What About a Patient With Many?"

Here are some of the highlights:

Many people have multiple chronic conditions
Two-thirds of people over age 65, and almost three-quarters of people over 80,
have multiple chronic health conditions, and 68 percent of Medicare spending
goes to people who have five or more chronic diseases.

Some further data (from the Jan-Feb 2009 issue of Health Affairs): "In 2005, 133 million Americans were living with at least one chronic condition. In 2020, this number is expected to grow to 157 million. In 2005, sixty-three million people had multiple chronic illnesses, and that number will reach eighty-one million in 2020". Elsewhere in the same issue, a table showed that in 2005, amongst working age Americans (ages 20-65) 12% or over 21 million had three or more chronic conditions.

Multi-morbidity is neither well understood nor well managed by the medical community
Yet people with multiple health problems – a condition known as multimorbidity
– are largely overlooked both in medical research and in the nation's clinics and
hospitals. The default position is to treat complicated patients as collections of
malfunctioning body parts rather than as whole human beings. ...

And treating one disease in isolation, [Dr. Mary Tinetti, Yale] added, can make
another disease worse. In controlling diabetes, for example, doctors often seek to
reduce levels of a blood-sugar marker called hemoglobin A1C. "But we know that
for some people with complicated diabetes, that's not always the best move,"
Dr. Tinetti said. ...

... patients with multiple diseases are routinely shut out of drug trial. 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. "We often don't know what the real safety or efficacy is for patients
with multiple illnesses," said Dr. W. Douglas Weaver, president of the
American College of Cardiology. ...

Because so little research includes complicated patients, physicians have little
scientific evidence on which to base their care. ... "We're so far away from
having perfect evidence about how to help patients with complex health
problems," Dr. Cynthia Boyd [Johns Hopkins] said.

Why this doesn't get more attention
In a medical system geared toward individual organs and diseases, there is no
champion for patients with multiple illnesses – no National Institute for Multi-
morbidity, no charity Race for Multimorbidity Cure, no celebrity pressuring
Capitol Hill for more research.

And that, sadly, is the underlying issue. The focus on the "glamour diseases" – diabetes, cancer, HIV/AIDS, Parkinsons, etc. – and the competition amongst their advocates seems to keep us from addressing the real issue: the health and well-being of the person.

No comments: