This OSP Journal of Case Reports section is a vignette almanac whose purpose is to provide a record of the emotional climates of the general practitioner, expressed as metaphors of landscapes, geographical features, atmospheric data, lunar phases, sunrises and sunsets, beginning and end of the seasons of the year, winds, tides, etc., when dealing with different clinical cases, with the aim of achieving a greater understanding of what we are and what we do as doctors, and then achieving greater empathy. Here, a vignette of a case of polypharmacy and multimorbidity is presented. This situation creates an emotional climate in the doctor that suggests the patient seems to be a sand spit; an accretionary feature formed by littoral drift, consisting of a long narrow accumulation of sand or gravel that forma una barrier that blocks the mouth of a lagoon or a river.
Emotions; Polypharmacy; Multimorbidity; Metaphor; General Practitioner
[Accretionary feature formed by littoral drift, consisting of a long narrow accumulation of sand or gravel, lying generally in line with the coast]
Vignette
Frank, 68 years old, comes to the doctor's office to repeat his medical prescriptions. He is being seen by internal medicine, pulmonology, digestive medicine, traumatology...
Frank has lived alone since his separation from his marriage. He comes to the doctor's office in a wheelchair.
Over the last few years, numerous health problems have accumulated and become associated: hiatal hernia, high blood pressure, osteoporotic L2-L3 crush fracture, spondyloarthrosis, generalized disc disease L1 to L4, moderate sleep apnea, depression, renal colic, flare of ulcerative colitis with moderate-severe activity requiring ileostomy, avascular necrosis of the left femoral head, acute myocardial infarction, severe focal restenosis within the stent, bilateral bronchiectasis, chronic rhinitis, benign prostatic hypertrophy...
And its treatment is: amlodipine, bempedoic acid, ezetimibe, clopidogrel, allopurinol, acetylsalicylic acid, inhaled salbutamol, formoterol, glycopyrronium bromide, inhaled beclomethasone, nasal fluticasone furoate, tamsulosin, dutasteride, doxazosin, calcifediol, ivabradine...
The general practitioner (GP) knows that life expectancy has improved significantly in recent decades thanks to medical practice based on advances in science. Greater specialization on the part of medical teams providing care has contributed to improved clinical outcomes. However, the proportion of patients who have two or more medical conditions at the same time, i.e. multiple health problems, is constantly increasing. This is called multimorbidity, and generally involves the prescription of numerous drugs, or polypharmacy.
The GP wonders how to address this multimorbidity [1].
Perhaps by looking for the problems with the most energy around which the rest revolve. This requires a comprehensive assessment and maintaining a risk/benefit balance of drug treatments. Certain drugs could increase the treatment burden without adding greater quality of life or survival.
Multimorbidity [2, 3] and polypharmacy [4-9], situations that are increasingly frequent, are accumulating in greater and greater quantities, becoming a barrier that blocks the patient's passage to situations of less risk or better health. The GP imagines Frank as a sand spit. It is an accretionary feature formed by littoral drift, consisting of a long narrow accumulation of sand or gravel, lying generally in line with the updrift coast, with one end attached to the land and the other projecting into the sea or across the mouth of an estuary or lagoon. A spit can develop into a barrier that temporarily blocks the mouth of a lagoon or a small river. Sand spits are a ubiquitous feature of sandy coasts with prevailing oblique wave incidence and associated strong littoral drift. Sand spits usually develop where the coastline bends away from the incident waves.
The successive re-entry of Frank's multimorbidity and polypharmacy cause waves that crash against the beach, gradually forming a tongue of sand that forms an increasingly larger beach relief, in a zigzag pattern, in front of the coasts or the shores of the lakes. This is complemented by longshore currents, which transport sediment through the water along the beach. These currents are caused by the same waves that cause drift.
- Turabián JL, Pérez Franco B (2016) A way of helping Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems. Semergen 42: 38-48. [Crossref]
- Skou ST., Mair FS., Fortin M (2022) Multimorbidity. Nat Rev Dis Primers; 8: 48. [Crossref]
- Willadsen TG., Bebe A., Køster-Rasmussen R (2016) The role of diseases, risk factors and symptoms in the definition of multimorbidity - a systematic review. Scand J Prim Health Care 34: 112-121. [Crossref]
- Varghese D., Ishida C., Patel P., Haseer Koya H (2024) Polypharmacy. In: StatPearls. Treasure Island (FL): StatPearls Publishing. [Crossref]
- Halli-Tierney AD, Scarbrough C, Carroll D (2019) Polypharmacy: Evaluating Risks and Deprescribing. Am Fam Physician 100: 32-38. [Crossref]
- Turabian JL (2019) Polypharmacy is an Indicator of Bad Practice and Low Quality in General Medicine. J Qual Healthcare Eco 2: 000130.
- Turabian JL (2019) Reactions Adverse to Drugs and Drug-drug Interactions: A “Wonderful” Spiral of Geometric Growth Produced by Multimorbidity and Polypharmacy. J Community Prev Med 2: 1-5.
- Turabian JL (2020) Polypharmacy: volume or value, quantity or quality? The high quantity originates low quality. There is no adequate and valuable Polypharmacy. General medicine and Clinical Practice
- Turabian JL (2021) Hypothesis and Practices to Avoid Polypharmacy in Family Medicine. Ejmscr; 1: 1003.
