Caring for people with chronic disease: is muddling through' the best way to handle the multiple complexities?

It is stated everywhere that chronic care poses one of the biggest challenges for the future of medicine. Critical analysis however suggests that these statements are oversimplistic and based on limited, and at times, spurious assumptions. This paper highlights some basic realities: epidemiology shows that at any time, 80% of people experience good enough health, and that only 0.8% require tertiary medical care; most people with chronic conditions experience a stable illness trajectory; true multi-morbidity is a pattern of advanced age; ageing and the physiological decline of our organ systems is a slow and steady process starting at the age of 30; and, as our health declines in a variety of patterns with disease and ageing, our psycho-socio-semiotic care needs increase dramatically. I argue that managing the complexities associated with chronic disease care successfully requires an equally complex management approach, muddling through, defined by Lindblom as making decisions based on successive limited comparisons. Our patients rightly expect that we make these decisions in their best interest. Individual health care professionals and health care policy makers firmly need to put the patient at the centre of the health care system.