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Editorial

Beyond diagnosis: rising to the multimorbidity challenge

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3526 (Published 13 June 2012)
Cite this as: BMJ 2012;344:e3526

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Re: Beyond diagnosis: rising to the multimorbidity challenge

21 July 2012

As has been pointed out, it is surprising that in an otherwise excellent editorial; Mangin and colleagues made no reference to the speciality of geriatric medicine; as a generalist, holistic approach to illness in older people is its defining characteristic.
When done properly, geriatric medicine comprises the identification of comorbidities in frail, older people; and the exercise of clinical judgment when to treat and to what extent.
The task is made the more taxing by the fact that many such patients are approaching the end of their lives; and many also have (often undiagnosed) dementia.
It is questionable whether primary care, as currently configured in the UK, has the sole answer to managing older people with multiple comorbidity; as they continue to appear in increasing numbers in MAU's up and down the country.
A collaborative approach between generalists in both primary and secondary care is surely required to properly address the needs of these patients.

Competing interests: None declared

Ray Hyatt, Consultant Physician and Orthogeriatrician

East Lancashire Hospitals NHS Trust, Haslingden Rd. Blackburn, BB2 3HH

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Re: Beyond diagnosis: rising to the multimorbidity challenge

20 July 2012

"Chronic illness is characterised by its variability"

Does that statement leap out at you? It should. Because we seem to have forgotten it.

Shifting the timescale under consideration changes the perspective, and changing the perspective to a longer duration one throws up a different set of problems and solutions.

When patients present acutely unwell, the disease picture is dominant. When a patient has acute asthma, is in the midst of a myocardial infarction, of suffering a seizure, the best approach is a disease management one. Who the person is who has this disease, at this moment, is not so relevant. We can identify what needs done and do it. Quickly.

However, scan out and consider the person who has had their problem for ten years. This person with asthma, or heart disease, or epilepsy will tell a unique story of their life with this illness. The pattern and course of the illness will be unique. The person's experience of it will be unique. It will have impacted on their relationships, their work, their interests and pursuits in a highly individual manner.

This means it is no longer relevant, or sensible, to focus on the disease. We need to focus on the person.

The authors make that point with great clarity - the care should be "based around the symptoms, values, and priorities of the particular person rather than particular diseases"

So, it's not just an issue of multiple comorbidities. It's the problem of chronic disease, or to change the perspective, the challenge of "living well".

Our health care is organised to deliver "disease management". A model which works in the Acute Sector. It doesn't in chronic care.

We need a whole person, individualised perspective focused on HEALTH not disease to address this issue of living well.

Competing interests: None declared

Robert Leckridge, Associate Specialist

NHS Centre for Integrative Care, 1053 Great Western Road, Glasgow

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A pithy summary of geriatric medicine!

1 July 2012

Prof. Mangin's analysis of medicine in general has beautifully captured the dilemma facing secondary care in the UK (and elsewhere) today.

The speciality of geriatric medicine has sustained emergency medicine in supporting the acute take, to the detriment of its speciality work [1]. Virtually all of the key points made in Mangin's paper represent the key elements of geriatric medicine, as seen by the British Geriatrics Society (BGS), our UK specialist body [2].

Sadly, because our work is inherently time-consuming (often focused on quality of life rather than other more easily measurable factors) and doesn't often involve the latest hi-tech gadgetry, it does not appear to be fully understood or valued by our professional colleagues or management - even though, in general, our patients and their family/carers value our input highly.

We do indeed spend time deciding NOT to undertake diagnostic and therapeutic interventions in our patients' interest. Our patients, in general, agree with our judgements as to what is important in their care [3]. Unfortunately, the qualitative outcomes of these interventions are very difficult to quantify in any way that is meaningful to managers.

Perhaps the BGS and Department of Health need to bite the bullet and spend time and money identifying how we can capture the relevant (and partly qualitative) information better? Without this, as arguably among the last generalists in the hospital - and given the current situation of many more acute medicine jobs than trained applicants - geriatricians will be destined to become even more the workhorses of the take, to the detriment of our core clientèle's needs elsewhere in the system (not least in designing and running services to prevent unnecessary admission [4])?

refs
1. www.bgs-england.org.uk/CurrentIssues/ConsultantChallenge.htm (accessed 30 Jun 12)
2. www.bgs.org.uk/index.php?option=com_content&view=article&id=35:gpgstanda... (accessed 30 Jun 12)
3. Setting priorities for measures of performance for geriatric medical services.
Roberts H, Khee TS, Philip I. Age Ageing. 1994 Mar;23(2):154-7.
4. http://www.gwentfrailty.org.uk/ (accessed 30 Jun 12)

Competing interests: I am employed as a geriatrician

Kit Byatt, consultant physician & geriatrician

Hereford County Hospital, Union Walk, Hereford HR1 2ER

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