Rethinking “Standard” Care for Multimorbid Adults
Curator’s Note: The article discusses the challenges of providing individualized care for multimorbid adults in a healthcare system dominated by standardized guidelines and metrics. It highlights the conflict between adhering to evidence-based protocols and considering the unique needs of patients who often face multiple chronic conditions, caregiving responsibilities, and quality of life concerns. The author emphasizes the importance of contextualizing guidelines, focusing on functional outcomes, and fostering shared decision-making with patients. By prioritizing goals that enhance independence and well-being over rigid metrics, healthcare providers can better integrate clinical recommendations with the realities of patients’ lives, ultimately improving their overall quality of care. This article was penned by Dr. Shiv Goel, a special medical doctor in internal medicine.
The EMR alert fired before I even sat down.
“Care gap: A1c above target. Statin not at recommended intensity. Hypertension uncontrolled.”
No hello yet. I had no time to ask how he was sleeping. I couldn’t ask whether he was still caring for his wife with dementia. I also didn’t have the chance to ask why he now used a cane he didn’t have three months ago. But already, the system had decided what our visit should be about.
In that moment, the familiar tension surfaced. The pull was between what guidelines tell clinicians to optimize and what payers want documented in dashboards and reports. Additionally, we needed to think about what the human being in front of us might actually need most that day.
When “Evidence‑Based” Becomes Too Narrow
Guidelines are built on populations, not people. They save lives, reduce unwarranted variation, and protect us from purely anecdote‑based care. But in adults with overlapping metabolic, cardiovascular, musculoskeletal, and mental health conditions, the clean lines of an algorithm quickly blur.
Many multimorbid adults in internal medicine share a familiar profile:
- Type 2 diabetes, hypertension, CKD, obesity, osteoarthritis, and often depression
- Eight to twelve chronic medications before any new “optimization”
- Real‑world constraints: caregiving duties, financial stress, poor sleep, limited mobility
Disease‑specific quality measures reward hitting targets: A1c below a threshold, blood pressure under a number, statin prescribed, screening boxes checked. These are useful. However, they can drift away from what patients actually value. Patients value walking to the mailbox without fear, getting out of a chair without pain, staying independent at home, and sleeping through the night.
If every guideline target is pursued for every condition, without context, we risk:
- Increasing pill burden and side effects
- Spending visits explaining lab minutiae while functional status quietly declines
- Meeting external definitions of “quality” while watching the quality of life erode
The Quiet Conflict: Payers, Metrics, and the Exam Room
Prompts for “medication intensification” appear when blood pressure is slightly above goal on a patient’s worst week of the year. Reminders pop up for yet another screening questionnaire. There is barely time to understand why current medications aren’t being taken.
From the system and payer perspective, standardized pathways and clinical quality measures are designed to:
- Ensure evidence‑based therapies are used consistently
- Prevent complications and reduce high‑cost events
- Enable population‑level tracking and accountability
At the bedside, the calculus is much more personal:
- Will a fourth antihypertensive improve function or increase falls in a frail older adult?
- Does aggressively tightening A1c bring real benefit for a patient with limited life expectancy? Or does hypoglycemia become the greater threat?
- Is today’s visit better spent closing a minor metric gap? Or is it better spent co‑creating a realistic plan for walking, sleep, and medication simplification?
The metrics live in dashboards. The tradeoffs live in the patient’s body and daily life.
Individualizing Care Without Going Rogue
Critiquing rigid, guideline‑driven care can feel uncomfortable, because the alternative is not “do whatever you want.” The goal is not to ignore guidelines, but to contextualize them.
A simple internal checklist can help:
- Clarify the primary outcome.
Ask what matters most right now: longevity, staying out of the hospital, pain reduction, independence, cognition, caregiver capacity. Functional outcomes are increasingly recognized as legitimate measures of care quality, especially in older adults. - Translate guidelines into probabilities, not commands.
This medication lowers the risk of heart attack or stroke by about this much. It can also cause these side effects. Given your priorities, how do we want to proceed together? - Simplify before adding.
For multimorbid adults, deprescribing or consolidating regimens can improve adherence, reduce adverse events, and make plans more realistic. - Document the reasoning explicitly.
When you choose not to intensify therapy despite a metric gap, note the patient’s goals. Document specific risks like falls, hypotension, and cognitive issues. Include the shared decision‑making process. Clear documentation helps align clinicians, patients, and reviewers.
This approach does not abandon evidence; it applies evidence within the reality of a particular life.
Function as a Vital Sign
When we treat function and quality of life as true outcomes—not afterthoughts—visit priorities change. Functional measures and patient‑reported outcomes are increasingly recognized by researchers and policymakers as essential indicators of healthcare quality.
Even without formal tools, clinicians can routinely ask:
- “What can you no longer do that you could do six months ago?”
- “If we could improve one thing about how your body works day to day, what would matter most?”
- “How do you feel the next day after following your current medication and lifestyle routine?”
When care plans explicitly aim at functional gains—stair‑climbing, walking distance, sleep continuity, less brain fog—patients often become more engaged. They become more consistent with behavior change. Functional improvements often lead to traditional outcomes. Better mobility supports metabolic health. Better sleep and stress regulation support blood pressure and glucose control. A clearer understanding of tradeoffs improves adherence.
Bridging the Gap in Daily Practice
For clinicians navigating this tension, a few working principles can help align guideline‑driven care with the lived reality of multimorbid adults:
- Lead with goals of care, not the problem list
- Use guidelines as maps, not handcuffs
- Respect metrics, but do not mistake them for meaning
- Make function and quality of life visible in your notes
- Protect time for honest, shared decision‑making
The patient behind that EMR alert eventually left without a perfectly “optimized” regimen. Instead, the plan focused first on fall risk. It also prioritized sleep and caregiver resilience. The approach to metabolic control was modest and jointly agreed upon. Over the following months, small but realistic changes occurred. Better sleep hygiene improved his condition. A simplified medication schedule was beneficial. Short daily walks had a positive effect. These changes shifted his function and well-being more than any single drug intensification would have.
The lab values improved modestly. His life improved meaningfully.
We are living in an era that is increasingly structured around standardized pathways and measurable “quality.” The task is not to choose between guidelines and patients. The task is to remember that guidelines describe what works on average. The real work of medicine is deciding what is right for the person in front of you today. This decision must be made transparently and compassionately.
About the author:
Dr. Shiv Kumar Goel, MD | Functional & Integrative Medicine | Author of Healing the Split
🌐 drshivgoel.com | 💼 @drshivgoel | 🎥 @vitalitymatrixwithdrg
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Dr. Shiv Kumar Goel — “The future isn’t something we chase. It’s something we become.”
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