Alderson, D

Atherton, F

Atherton, J

Calderwood, C

Goddard, A

MacEwen, C

Marshall, M

Marx, C

McBride, M

Powis, S

Reid, W

Stokes-Lampard, H

Whitty, CJM

English

UCL Discovery

Rising to the challenge of multimorbidity OPEN ACCESSWe need to combine generalist and specialist skillsChristopher J M Whitty chief medical officer for England 1, Carrie MacEwen chair 2, Andrew Goddardpresident 3, Derek Alderson president 4, Martin Marshall chair 5, Catherine Calderwood chief medicalofficer for Scotland 6, Frank Atherton chief medical officer for Wales 7, Michael McBride chief medicalofficer for Northern Ireland 8, John Atherton co-chair 9, Helen Stokes-Lampard former chair 5, WendyReid medical director 10, Stephen Powis national medical director 11, Clare Marx chair 121Department of Health and Social Care, London, UK; 2Academy of Medical Royal Colleges, London, UK; 3Royal College of Physicians, London,UK; 4Royal College of Surgeons, London, UK; 5Royal College of General Practitioners, London, UK; 6Scottish Government, Edinburgh, UK; 7WelshGovernment, Cardiff, UK; 8Department of Health, Belfast, UK; 9Medical Schools Council, London, UK; 10Health Education England, London, UK;11NHS England, London, UK; 12General Medical Council, London, UKLife expectancy has improved remarkably over the past fourdecades thanks to improved medical and public health practicebased on advances in science. Greater specialisation in medicalsciences and by the clinical teams delivering care has contributedto improved clinical outcomes, and many more people areenjoying life relatively unaffected by disease from earlychildhood through to beyond retirement age.The proportion of patients who have two or more medicalconditions simultaneously is, however, rising steadily. This iscurrently termed multimorbidity, although patient groups preferthe more intuitive “multiple health conditions.”1 In high incomecountries, multimorbidity is mainly driven by age,2 and theproportion of the population living with two or more diseasesis steadily increasing because of demographic change. Thistrend will continue.Multimorbidity is, however, not restricted to older citizens.Being less advantaged socioeconomically accelerates theprocess, so in deprived areas multimorbidity occurs earlier inlife.3 Children or young adults with serious congenital oracquired impairments often have multiple physical or mentalillnesses,4 and the interaction between mental and physical healthmakes each harder to treat.5 Certain periods of life, includingpregnancy, increase the probability that multiple conditions willpresent simultaneously. Although this transition is happeningmost rapidly in industrialised countries, it is already increasingin middle income countries and will become a global problem.6The multimorbidity trend presents challenges to the entiremedical profession, from general practice and community careto acute and long term hospital settings. Greater specialisation,especially for hospital based doctors, has improved our abilityto treat single diseases, but unless we react to the increase inmultimorbidity it will disadvantage the increasing proportionof patients with multiple seemingly unrelated diseases.Treating each disease in a patient as if it exists in isolation willlead to less good outcomes and complicate and duplicateinteractions with the healthcare system.7 Training from medicalschool onwards, clinical teams, and clinical guidelines, however,all tend to be organised along single disease or single organlines. As a result, a single patient may take multiple drugsrecommended by different guidelines and see several specialiststreating subcomponents of their overall health problem inisolation. Medical science is also disease based. Clinical trialsstill often exclude people who have more than one condition.Good vertical integration exists from bench to bedside for asingle condition or disease, but there is little or no horizontalintegration between diseases that often coexist.8 This will requirean intellectual shift and rethinking some elements of ourresearch, training, and practice in virtually every discipline.Cluster medicineThe shift includes moving from thinking about multimorbidityas a random assortment of individual conditions to recognisingit as a series of largely predictable clusters of disease in thesame person. Some of these clusters will occur by chance alonebecause individuals are affected by a variety of commonlyoccurring diseases. Many, however, will be non-random becauseof common genetic, behavioural, or environmental pathwaysto disease. Identifying these clusters is a priority and will helpus to be more systematic in our approach to multimorbidity.Correspondence to: C Whitty chris.whitty@dhsc.gov.ukNo commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2020;368:l6964 doi: 10.1136/bmj.l6964 (Published 6 January 2020) Page 1 of 2EditorialsEDITORIALS on 3 March 2020 by guest. Protected by copyright.http://www.bmj.com/BMJ: first published as 10.1136/bmj.l6964 on 6 January 2020. Downloaded from All doctors know the clusters of disease around smoking,diabetes, HIV, or obesity. Known clusters affect multiple organswith multiple pathological processes. The cluster around diabetesis a good example, with the common serious disease affectingthe heart, nervous system, skin, peripheral vasculature, and eyes.Diabetologists already provide care for the cluster of multiorgandiseases around diabetes, and some specialties, such as geriatricsor general practice, have multimorbidity at their heart. For most,however, training and service organisation are not optimised toface a multimorbidity dominated future.Bringing together the undoubted benefits of specialism with amore systematic approach to the realities of dealing with patientswith multiple diseases is possible but will not happenspontaneously. It is possible and desirable to have both aspecialist and a generalist skill set; a specialist without generalistskills will be ill equipped to deal with many of their patients.Osler’s aphorism, “Care more particularly for the individualpatient than for the especial features of the disease,” isincreasingly important. A holistic professional approach isessential. The shift back to maintaining generalism in themedical workforce, including initiatives such as Shape ofTraining, should accelerate and be given a greater focus in theselection, training, and reward of our future workforce.Continued increases in healthy longevity depend on this differentmodel. Clustering of diseases, and how we might better tacklemanagement of coexisting physical and mental health problems,should be embedded into medical training and continuousprofessional development, including for specialists. Medicalschools, the royal colleges, guideline groups, the GeneralMedical Council, and the governments of the UK need to worktogether with the whole profession to tackle this. The patternof health and disease in our population is changing, and as aprofession we must respond.Competing interests: We have read and understood BMJ policy on declaration ofinterests and have no relevant interests to declare.Provenance and peer review: Commissioned; not externally peer reviewed.1 Hardeep A. Multimorbidity: understanding the challenge. A report for the Richmond Groupof Charities. 2018. https://richmondgroupofcharities.org.uk/sites/default/files/multimorbidity_-_understanding_the_challenge.pdf2 Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology ofmultimorbidity and implications for health care, research, and medical education: across-sectional study. Lancet 2012;380:37-43. 10.1016/S0140-6736(12)60240-2 225790433 Schiøtz ML, Stockmarr A, Høst D, Glümer C, Frølich A. Social disparities in the prevalenceof multimorbidity. A register-based population study. BMC Public Health 2017;17:422.10.1186/s12889-017-4314-8 284869834 Dunbar P, Hall M, Gay JC, etal . Hospital readmission of adolescents and young adultswith complex chronic disease. JAMA Netw Open 2019;2:e197613.10.1001/jamanetworkopen.2019.7613 313395475 Gaulin M, Simard M, Candas B, Lesage A, Sirois C. Combined impacts of multimorbidityand mental disorders on frequent emergency department visits: a retrospective cohortstudy in Quebec, Canada. CMAJ 2019;191:E724-32. 10.1503/cmaj.181712 312667866 Zhang R, Lu Y, Shi L, Zhang S, Chang F. Prevalence and patterns of multimorbidityamong the elderly in China: a cross-sectional study using national survey data. BMJ Open2019;9:e024268. 10.1136/bmjopen-2018-024268 314273097 Guthrie B, Payne K, Alderson P, McMurdo ME, Mercer SW. Adapting clinical guidelinesto take account of multimorbidity. BMJ 2012;345:e6341. 10.1136/bmj.e6341 230368298 Academy of Medical Sciences. Multimorbidity: a priority for global health research . AMS,2018.Published by the BMJ Publishing Group Limited. For permission to use (where not alreadygranted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissionshttp://creativecommons.org/licenses/by-nc/4.0/This is an Open Access articledistributed in accordance with the Creative Commons Attribution Non Commercial (CCBY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this worknon-commercially, and license their derivative works on different terms, provided theoriginal work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2020;368:l6964 doi: 10.1136/bmj.l6964 (Published 6 January 2020) Page 2 of 2EDITORIALS on 3 March 2020 by guest. Protected by copyright.http://www.bmj.com/BMJ: first published as 10.1136/bmj.l6964 on 6 January 2020. Downloaded from 

Rising to the challenge of multimorbidity

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Rising to the challenge of multimorbidity

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