Why we need more medical multi-tasking

You have a bad headache and deciding which specialist to go to is very likely to add to the pain. You can take your pick from a neurologist (for problems with the nerves in the brain), an ophthalmologist (eye strain), ENT (sinus), cardiologist (high blood pressure), neuromuscular dentist (correcting misalignments in the jaw), a gynaecologist (for menstruation-related migraines in women) and a psychiatrist (stress, anxiety), among others.

Very rarely would you consider going to a general physician, who can assess your overall health and point you in the right direction. But there are fewer and fewer GPs now, as most doctors prefer to specialise.

“People are complicated, and their medical problems rarely come neatly packaged as the single diseases that scientists and doctors study,” says the editorial this month in the journal Nature. Treating real-world illnesses require medical multitasking, and to improve health care, researchers need to study diseases in combination.

A person who is overweight is likely to have hypertension and high cholesterol, perhaps even diabetes. A person with diabetes may have chronic kidney disease. A person in chronic pain is likely to also have anxiety and depression. An inactive, obese person over 60 who enjoys a good meal is likely to have all of the above.

People are complicated, and their medical problems rarely come neatly packaged as the single diseases that scientists and doctors study, says the editorial this month in the journal Nature

Multi-morbidity affects men and women and doesn’t spare children. Evidence suggest that it is most common in women, people over 65 and the poor and marginalised, but is increasing in children and adults too.

An increasing number of people worldwide are suffering lifelong disability, and dying prematurely due to ineffective treatment of multiple health conditions, according to a report by the UK Academy of Medical Sciences released in April.

Health conditions that frequently group together include heart disease, high blood pressure, diabetes, cancer, depression, anxiety, chronic obstructive pulmonary disease (COPD) and chronic kidney disease. And it is unclear why some of these conditions cluster together, making it difficult to predict which patients may be most in need of preventive steps or increased care.

About 13% to 95% of people have more than one medical condition, termed ‘comorbidity’ or ‘multi-morbidity’. The range is so wide because researchers and countries disagree on the definition of multi-morbidities. As a result of this lack of consensus, most health services in the public and private sectors are not designed to care for patients with multiple illnesses.

Physical and mental health conditions often cluster together too. Poor mental health can lead to a poor quality of life, reduce physical health and lower life expectancy by a greater degree than having multiple physical illnesses, according to the UK report.

For example, people with Type 2 diabetes are at increased the risk of depression, and adults with depression are 37% more likely to develop Type 2 diabetes. However, the division between health services treating mental and physical conditions often means that people get treated for one but not the others.

People are living longer, but not healthier. For example, life expectancy in India has shot up by almost 8 years, from 58.5 in 1990 to 66.4 in 2013. But chronic diseases such as diabetes and lung ailments have added to the years people are living with illness, according to the Global Burden of Disease study released in August 2015. As the population ages and people live longer, the number of people living with multiple chronic diseases also goes up.

An overweight person is likely to have hypertension, high cholesterol, maybe diabetes. A diabetic may have chronic kidney disease. A person in chronic pain is likely to also have anxiety...

Healthcare systems and medical education need to review the increasing trend of specialisation when what is needed is people with expertise to recognise and treat a range of conditions, much like general practitioners are trained to do. Most private hospitals promote their super-specialists at the expense of general practitioners because they bring in more money from surgeries and expensive diagnostics, when what they should be doing is getting general practice better organised with each consultation being long enough for the comprehensive diagnosis of multiple conditions.

It’s not just hospitals that need to move away from being organised around treating single diseases or individual organs (different departments often work in silos). Clinical trials for drug development, too, need to start including patients with multiple conditions to fill significant gaps in knowledge about effective treatments of those with multi-morbidities.

Computational and laboratory tools that make sense of complex data sets have made it easier to study the complexities arising from diseases occurring in combination. What is needed is an overhaul in the way healthcare systems diagnose and treat people.