Abstract
Managing medical complexity: co-morbidity
This competency is about aspects of care beyond managing straightforward problems, including the management of co-morbidity, uncertainty and risk and the approach to health rather than just illness.
In the final section on ‘diagnostics’, we move beyond the straightforward problems described in clinical management and look at some of the difficult areas where GP expertise comes into its own. It takes years of experience to master the competencies described here, but a basic ability to understand the concepts and apply them is required for licensing. The reason is that if they are not there even in rudimentary form, there is no foundation on which to build this vital area of expertise.
There are four major themes in the managing medical complexity domain, each represented by a competence progression, which we will discuss over the next three issues of the journal. In the first one, we will consider the management of co-morbidity. In the next issue, we look at uncertainty and risk and in the third article, health promotion.
The first progression, shown in Fig. 1, illustrates what managing co-morbidity means in behavioural terms.
The first competency progression of managing medical complexity.
Manages health problems separately, without necessarily considering the implications of co-morbidity
Doctors who perform at this basic level tend to be able to identify the patient's problem, but not to look beyond it when they come to develop the management plan. This competency overlaps with holistic care in which good GPs explore the impact of the patient's problem and try to understand physical, psychological and social aspects before discussing management with the patient. On top of this, in ‘managing complexity’, we also try to gauge how the problem impacts upon other ‘ongoing’ problems and how ongoing problems might have a bearing on the ‘current’ problem or problems.
The term ‘co-morbidity’ sounds like a complicated concept, but it is not and is often recognized by patients. For example, when we prescribe for an acute condition, it is quite common for patients to ask, ‘Will these be okay with my other drugs’?
Simultaneously manages the patient's health problems, both acute and chronic
At this level of performance, we are able to manage co-morbidity and are also able to manage more than one
problem in the consultation. Even more significantly, we understand the importance of thinking beyond the acute problem by checking for the presence of chronic disease both in the records and by asking the patient. In Table 1, we can see some examples of the impact of an acute condition on the chronic.
The interaction between acute and chronic problems
Tip: learning to manage co-morbidity
Do not forget to think about the past medical history. It pays dividends to spend a couple of minutes before the patient comes in just to look at the list of significant problems (particularly those coded as being active), the last two or three consultations and the medication the patient is taking.
An acute illness may be an exacerbation of a chronic disease. Therefore, patients with chronic disease are more likely to have acute illnesses than those patients without this background medical history.
However, acute illness is not always an exacerbation, although it is easy to make that assumption. For example, epigastric pain in a patient with peptic ulcer may be a manifestation of ischaemic heart disease. Of equal concern are the situations where the chronic disease can mask the ‘evolution’ of a serious problem. For example, the early signs of bronchogenic carcinoma may be misdiagnosed as exacerbations of chronic obstructive pulmonary disease. Chronic disease may also influence the ‘presentation’. Immunocompromised patients may have more severe local and systemic symptoms than might otherwise be expected.
Co-morbidities are often co-chronic, for example diabetics may also be hypertensive. Such patients are prone to polypharmacy and part of management is to streamline the medication to keep it as simple as possible and encourage concordance. Remember that co-morbidity is more common in the elderly, the deprived and in some ethnic groups.
Coping with multiple problems simultaneously requires us to identify the other problems going on, usually from the records, and discuss priorities with the patient. The ‘impact’ of one problem upon another and the ‘risk’ this creates along with the patient's ‘agenda’ usually dictate what needs to be done first.
Accepts responsibility for coordinating the management of the patient's acute and chronic problems over time
This competency falls within the ‘excellent’ category because ‘accepting responsibility’ may extend beyond the individual patient and include reviewing/improving the ‘systems’ in the practice that support acute and chronic problem management. This might include the establishment of clinics for chronic diseases and possibly (with Nurse practitioners) for acute conditions. It might also include a review of communication links so that:
an adequate summary of the patient's conditions is available at all times including on visits an adequate shared patient record is kept and key personnel such as the patient's usual doctor are routinely informed of significant developments.