Challenging Multi-Morbidity

Anna Luise Kirkengen, Thinking about guidelines:

I would like to depart from the most common situation in General Practice, namely: encounters with patients who are categorised as presenting multi-morbidity. This is how it is expressed in the medical language. I would try to change this formulation to something like: a GP’s encounter with a person suffering from what medicine conceptualises as a “number of different diseases”, either simultaneously or sequentially, in the same patient. The concept of “different” diseases does not apply when states of bad health are not strictly separable in terms of etiology, pathogenesis, treatment, and prognosis. Then the question is: on which level does medicine differentiate ethology or pathogenesis? If “two” diseases have a pathological characteristic in common, let us say inflammation, are these “two” diseases still “different” — and due to which criteria?

The inflammatory process may affect neuronal cells in one case and connective tissue in the other. This leads to different symptoms and impairments, but both states of illness can be “treated”, in the sense of slowed down or even blocked (though not healed), by the same chemical, namely Cortison, a substance counteracting inflammation — but, in the healthy body — also ignating inflammation. Now — as inflammation is the pathological property underlying “both types” of diseases, is inflammation to be regarded as CAUSAL? The next question is: what causes the physiological complex termed inflammation? In an evolutionary perspective it is the organisms response to being hurt, being traumatized. Next: does this connection strictly apply to acute, physical wounds/trauma alone? No, we have solid evidence that also experiential hurt or trauma can “cause” inflammation. Is this kind of causal relationship different from the other? …….

and so on and so on.

The nexus of multi-morbidity (as a medical construct or even artefact), causality (as to “level” of origin) and guidelines (specifically designed for each disease) is theoretically highly challenging yet the most common clinical reality in General Practice.