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Acute on Chronic Disease

As a medical student, high acuity cases initially scare you. Nothing like a patient decompensating on the ward while you are on call to get the adrenaline and anxiety going. Intubations, crashing patients, emergency surgeries, life-saving decisions are all big unknowns to a new medical student. Luckily, as you see more and more sick patients, you learn how to manage and treat these cases. In many ways, dangerous and life-ending diseases like DKA, toxic substance ingestion and sepsis are easy cases because they have “quick-fixes.” Either patients get better (most of the time) or things go downhill quickly and they end up in the ICU or the morgue.

What I’m learning now, and after speaking to several preceptors, is managing chronic disease is the real challenge in medicine. For example, it’s not the management of alcohol withdrawal in the hospital that’s hard, which is pretty routine. It’s the treatment that happens outside the hospital which is the big issue. How do you get people to maintain healthy lifestyles where they don’t smoke, drink in excess or eat bad foods. How do you manage an elderly man with 5 different comorbidities that requires 20+ meds in the community and make him self dependent. How do you treat diabetes when the person who has it has no idea how to measure their own sugars, interpret them and administer the right medication.

Intubating and ventilating a patient with pneumonia and hypoxia, though intimidating to the new learner, is quite a straightforward task. However, the challenge comes when you discover that the patient lives on the streets with diabetes, hypertension, liver cirrhosis, HCV and psychiatric illnesses (things that don’t immediately kill someone but may have long term consequences). How do you set up proper followup to prevent another pneumonia from happening?

I believe that will be a major challenge to all doctors who face an ageing population. We have to remember that we are dealing with complexity in another human being. Every doc should know how to manage high-acuity cases because in it works and saves lives. But what would be better is if our management of chronic diseases was given the same sex appeal and coolness factor as our fast paced medicine. Family doctors are under appreciated for the work they do at keeping patients out of the hospital and in their homes.

Ultimately, I would like to find a specialty/job that would allow me to do both high-acuity, hands on medicine and prevention/management of chronic diseases. I don’t think I can see myself as an emergency doctor with no continuity of care, even though I enjoy the quick pace.  Perhaps a combined family + 1 emergency residency would work out well. Cardiology and nephrology also has that variety. I still have some time to decide.

I just hope that our medical profession starts to put more emphasis on chronic diseases, that if left untreated would cause greater costs, morbidity and mortaliy. Yes, it’s cool to be a trauma surgeon, but that is ultimately a reactive specialty. For every trauma case, there is ten cases of unmanaged COPD and diabetes. What society really needs is proper followup for all the chronic diseases people have, the true burden of health care.

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  1. medrunner
    medrunner April 26, 2011

    Hey medaholic. Great post. I agree with you- chronic disease management isn’t as sexy as the acute cases, and that’s something that needs to change. I haven’t even begun my medical education, but I already feel that FM+ EM is a good option to keep my blood pumping.

    Hopefully, you can find your niche and help save the world one COPD case at a time.

    Keep it up!

  2. Anonymous
    Anonymous April 27, 2011

    I just learned what COPDs are today and then I came to your blog and felt so smart that I knew what you were talking about! 😀

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