When Patients Manage Doctors


By Sumathi Reddy

One in four Americans lives with more than one chronic illness; three out of four among those 65 and older.

Managing those people’s health care is often difficult. Integrated health systems, such as Kaiser Permanente and Mayo Clinic, aim to ensure that treatment for one condition doesn’t interfere with care the patient is receiving for other diseases. Often, however, the responsibility of coordinating treatments falls on the patients themselves.

“Conflicts between medications, and doctors that don’t talk to one another, is a big and common problem,” said John Piette, director of the Center for Managing Chronic Disease at the University of Michigan School of Public Health. “People have difficulty managing both symptoms and side effects of multiple medications,” he added.

The Department of Health and Human Services (HHS) in July issued a free curriculum for training health-care professionals and others in how to care for patients with multiple chronic conditions. The curriculum includes strategies to help patients keep track of their own care by involving caregivers, for example. For patients who have a hard time taking numerous daily medications, doctors should tell them which drugs are most important, the curriculum recommends.

HHS has taken other steps to address the needs of patients with multiple chronic conditions since launching an initiative in 2010 to study the issue. The Centers for Medicare and Medicaid Services, an agency within HHS, began this year reimbursing health-care providers for time spent coordinating the care of those patients outside of regular office visits.

The department also seeks to ensure that people with multiple chronic conditions are included in clinical trials. “That’s important because we want to make sure that when drugs come on to the market that they are truly safe and effective for patients with multiple chronic conditions,” said Dr. Anand Parekh, HHS deputy assistant secretary for health.

For many patients, multiple chronic conditions, such as obesity and diabetes, are related, or what is called concordant. Other patients have completely separate conditions, such as epilepsy and cardiovascular disease, which are known as discordant.

Electronic health records can help doctors keep track of the varied care patients might be receiving, especially when they see multiple specialists at the same hospital or medical center. Patients shouldn’t necessarily rely on this, however, said Dr. Piette, who is also a senior scientist in the Veterans Health Administration. Ultimately, it is the patient who has to be “a proactive consumer of health care and in charge of managing their multiple conditions,” he said.

Sometimes different specialists give a patient conflicting advice. In this case, patients should write down as much information as possible when talking to each doctor and let them know about the apparent conflict, Dr. Piette said. Patients could also encourage the doctors to talk to each other if needed, he said.

Victor Montori, professor of medicine at the Mayo Clinic in Rochester, Minn., talks about the “work of being a patient,” which involves more than keeping up with one’s medications. Patients must also educate themselves about the health care they need, said Dr. Montori, who is also lead investigator of the clinic’s Knowledge and Evaluation Research Unit, which seeks ways to adapt care for individual patient’s needs.

Doctors who prescribe medications should be responsible for taking into account the patient’s various illnesses, Dr. Montori said. If clinicians don’t have the expertise to understand potential drug interactions, they should seek advice from a pharmacist, who is trained to deal with problems that arise when patients take many drugs, he said.

Dr. Montori recommends patients build their own version of a medical record by keeping a complete and updated list of medicines handy and bringing it to all doctors’ visits. And if the demands of being a patient become overwhelming, talk to the doctor, he said. For example, as a diabetes doctor, Dr. Montori might ask patients to check their blood sugar several times a day. When this is difficult for a patient to do, some checks can be eliminated in cases when they are less critical, he said.

He also recommends that patients who aren’t in an integrated health system seek out a “quarterback” to keep an eye on the big picture and help coordinate their care. Usually this is a primary care doctor or an internist, or in some cases the specialist who the patient sees the most. For a cancer patient, for example, the oncologist will often take on that responsibility. Family members can also help by keeping track of treatments for multiple illnesses.

Michael Munger, a family physician in Overland Park, Kan., said he regularly coordinates care for his patients, most of whom have multiple chronic conditions.

That part of the job, he said, means “getting the patient to the right care at the right time and making sure the information—past medicines, medical history—is available.”

Dr. Munger says he always starts visits by going over a patient’s medication list. “Most of my patients have it tucked in their purse or their wallet,” he said. “I have them pull that out so we can review it and make sure it’s current.”


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