Patients with multiple comorbidities

Patients with multiple illnesses present a considerable challenge to family doctors. Little research has been done on the care of these patients, who make up more than 50% of family physicians’ caseloads.^1,2 Clinical studies focus on a single disease and often exclude patients with multiple diseases, making decisions about the care of such patients difficult.² Most published guidelines address a single disease and few address the care of patients with comorbid illnesses.^3,4 Family doctors do not have the option of practising in 1-disease silos and must develop an approach for managing patients with multiple illnesses.

As the number of patients with multiple comorbidities grows, so does the need for medical education to address this issue. It has been suggested that family medicine residency programs will need to increase in length from 2 years to 3 years to better prepare trainees to care for patients with multiple chronic illnesses.⁵ A preliminary assessment of a survey we distributed to Canadian family medicine clerkship directors suggests that most programs do not include learning objectives related to multiple comorbidities in their curricula (W.E. Osmun, G.P. Kim, E.R. Harrison, L. Boisvert, unpublished data, 2014).

We have devised a simple method for teaching medical students and residents how to approach patients with multiple illnesses. Our method is low tech, requiring only slips of paper and a couple of bags. As such, it can be used virtually anywhere.

The preceptor or the learners write chronic illnesses on slips of paper. These go into a bag labeled chronic. The preceptors or learners then write common, acute illnesses on slips of paper, which go into another bag labeled acute. A whiteboard, a blackboard, or legal paper is then divided into columns labeled diagnosis, investigations, treatment, consultations, allied health, monitoring, other diagnoses, and family. The learners pull a diagnosis from the chronic bag (eg, type 2 diabetes mellitus). The learners then go across the columns and fill them in, considering the implications of the disease for the patient, allied health workers, and the doctor. In having to consider all the ramifications of the disease on the patient, the learner will appreciate not only the pharmaceutical options, but also what supports are available in the community; what consultations, if any, need to be considered; what laboratory investigations are necessary and how often they should be performed; and, very important and often overlooked, the effect of the disease on the patient and the family. Once this is completed another disease is pulled out of the bag (eg, depression) and the exercise is repeated, but in light of the initial disease. After pulling 3 or 4 chronic diseases out and addressing the multitude of implications, the preceptor can dip into the acute bag and throw, for example, an acute myocardial infarction into the mix. The patient’s care becomes very complicated very quickly, mirroring reality.^*

These sessions have been very well received by residents, students, and allied health workers. They are very interactive, as we go around the table asking for input from all—students, allied health workers, and staff doctors. All forms of technology are allowed to be used, from textbooks to the Internet. We have found that questions arise from these sessions that were not anticipated (eg, the validity of guidelines). As multiple websites with different points of view are accessed, we have to address controversies in care. In addition, and just as important, it allows us to explore the ramifications of care from a patient’s perspective—for example, depression as a result of chronic illness, its effect on care, and what resources are available for the patient in the community. Monitoring is a frequently overlooked aspect of chronic care, and this teaching method has allowed us to address, for example, the frequency of monitoring potassium and creatinine levels when a patient is taking angiotensin-converting enzyme inhibitors, what the recommendations are, how they change with the patient’s age, and what evidence, if any, supports the recommendations.

We have found this to be an excellent teaching tool, requiring little preparation on the part of the preceptor or student, yet providing some of the most dynamic learning and discussion of any sessions we have facilitated. We encourage family medicine preceptors to give it a try. And the best part is, it can be used multiple times and each session will be completely different!

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