Dr. Jon Hallberg: Treating multiple morbid conditions

Almost three out of every four Americans older than 65 have more than one morbid condition. It's called multimorbidity. And a group of physicians published in the Journal of the American Medical Association suggest that these conditions should more often be treated as a group, rather than singly.

MPR's medical analyst Dr. Jon Hallberg discussed the impact of the study with Tom Crann of All Things Considered on Wednesday. Hallberg is a physician in family medicine at the University of Minnesota and medical director of the Mill City Clinic.

An edited transcript of that interview is below.

Tom Crann: Multimorbidity. What is it and how common?

Dr. Jon Hallberg: Morbidity, the core word there refers to illness as opposed to mortality, which is death. We often hear those two terms back and forth. But multimorbidity, having more than one ... chronic conditions. High blood pressure, for example, or high cholesterol, could be considered a morbidity.

Crann: And you see this fairly commonly in the clinic?

Hallberg: Clinic is always skewed because people coming in the door have insurance typically, and they are there for a reason. And a lot of people who are very healthy, we simply don't see. In the clinic setting, most people, especially over 65, as this article mentions, have more than one thing going on.

Crann: The common practice is a more discreet approach, right? In other words, treat high blood pressure? Well, here's a medicine for that.

Hallberg: We have these guidelines. We're scrutinized very carefully these days based on how we handle things such as depression, asthma, diabetes [and] high cholesterol. And so the guidelines really look at that condition by itself. It doesn't take into account that many people have other things going on.

Crann: The outcomes too are measured by individual disease and that's the way as doctors that you're often evaluated?

Hallberg: It's not only how we're evaluated, but it's also how we bill. I'll finish an encounter with a patient and I'll be looking at a bill trying to decide, what do I do?

It always strikes me that it's kind of odd to break down this visit that talked about a lot of different things in this discrete, one-by-one kind of ways.

Crann: Is that because oftentimes the discrete diseases actually are interrelated?

Hallberg: They almost always are interrelated. One example from the article you use, only 17 percent of people with heart disease have just heart disease. They almost always have other things going on such as diabetes or high-blood pressure or they smoke. In medicine things don't happen in nice tiny little boxes the way we wish they would.

Crann: They introduce this new word: a comprehensivist. Isn't that, as a primary care doctor, kind of what you are now?

Hallberg: It is, and it's very funny. I can speak especially as a family physician. Many times we don't want to be called that, or we haven't thought we wanted to be called that because it sort of implies that we're dealing with a boatload of things, all kinds of problems. And to me, gone are the days when you'd go to the family doctor for a sore throat or a bladder infection. We have better ways of dealing with it now.

The reality is that we're really good with dealing with these comprehensive problems. I think it actually elevates the profession. It elevates primary care a little bit to call us comprehensivists, rather than just generalists.

Crann: When we first talked about this, you said when you read the article that it got under your skin a little bit. Why?

Hallberg: One is this idea of rethinking of myself as a generalist ... or just a family physician, and becoming much more than that.

I've always thought that it seems, not ludicrous, but simple-minded in a way that we look at conditions as though they exist by themselves, and that we're sort of judged on that and how good the care is.

The reality is, the more conditions we treat like that, the more medications someone's on, we're losing the forest for the trees. We're losing sight of the patient and how they're doing. Maybe the thing we should be doing is thinking about what's best for the patient, not so much what's best for the protocol. And that's a big change in thinking.

Crann: Might that lead to a more realistic approach?

Hallberg: When you've got high-powered writers from high-powered institutions and a high-powered medical journal like JAMA [Journal of the American Medical Association], this can't help but enter the conversation.

Nothing happens quickly in medicine, so this is a very slow process. But I think that one of the reasons I like the article is you can just tell that this is just nudging the process in that direction.

Interview transcribed and edited by Jon Collins, MPR reporter.

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