The patient sitting across from Dr. Arun Veera has diabetes, hypertension, and depression. She’s been prescribed three medications, told to check her blood sugar twice daily, and referred to a nutritionist. The clinical targets are clear. The medication choices are evidence-based. Yet six months later, her A1c has worsened, and she’s missed two follow-up appointments.
This scenario plays out in primary care offices across the country, and Veera, a board-certified family medicine physician with 14 years of clinical experience, says it reveals a fundamental flaw in how medicine approaches chronic disease. “We’ve gotten really good at asking what the right treatment is,” he says. “We haven’t asked whether this particular patient can actually do it.”
The missing variable, Veera argues, is patient capacity—the real-world cognitive, emotional, and logistical bandwidth a person has available for health management at any given point in their life. Depression narrows it. Caregiver responsibilities consume it. Financial stress depletes it. Yet most care plans are built as if capacity is infinite.
IMAGE: UNSPLASH
The Burden Stack Problem
When a patient has multiple chronic conditions, each one adds its own set of requirements: medications to remember, appointments to schedule, symptoms to monitor, lifestyle changes to implement. Veera calls this the “burden stack“—the accumulated weight of everything a person with chronic illness is expected to manage daily.
“Each condition gets evaluated in isolation,” Veera explains. “The endocrinologist asks if the diabetes medication is appropriate. The cardiologist asks if the blood pressure target makes sense. But nobody’s asking what it feels like to live with all of these requirements simultaneously.”
The burden stack becomes especially problematic when depression enters the picture. Research consistently shows bidirectional relationships between depression and chronic physical illness, with depressive symptoms linked to poorer self-care and increased complications. But depression doesn’t just make adherence harder—it fundamentally changes how people relate to the future and their capacity to plan.
“Depression changes cognitive bandwidth,” Veera says. “It affects memory, concentration, and executive function—exactly the capabilities chronic disease management requires most. When we layer a complex care plan on top of untreated or undertreated depression, we’re essentially asking someone to carry more than they can hold.”
Rethinking Noncompliance
The traditional response to missed doses and skipped appointments is to label it a compliance problem and add more education or more frequent monitoring. Veera suggests this misses the point entirely. When the treatment burden exceeds a patient’s current capacity, disengagement is a rational response, not a character flaw.
“We’ve medicalized what is often a practical problem,” he says. “Someone who stops taking their medications isn’t necessarily stubborn or poorly educated. They might be overwhelmed, depressed, or dealing with side effects they can’t tolerate on top of everything else they’re managing.”
This reframing has immediate clinical implications. Instead of assuming patient failure when plans don’t work, it suggests looking at plan design. Was the regimen too complex? Were the goals too ambitious for someone dealing with multiple conditions? Did depression or anxiety narrow the patient’s capacity below what the plan required?
Capacity-First Care In Practice
Treating capacity as a clinical variable means assessing it before designing treatment plans, not discovering it when plans fail. Veera describes this as a fundamental shift in how primary care visits are structured.
“Start with a workload inventory,” he suggests. “Before adding anything new, understand what this person is already carrying—medically, personally, and professionally. Then design a plan that fits their current bandwidth, not their theoretical maximum.”
In practice, this might mean simplifying medication regimens before optimizing them, consolidating appointments and lab draws, or focusing on one achievable change rather than multiple simultaneous interventions. It means treating depression and sleep problems as upstream variables that affect everything else, not secondary conditions to be referred out.
“Depression isn’t a side diagnosis when someone has diabetes,” Veera emphasizes. “It’s a primary determinant of whether the diabetes plan will work at all.”
The Economics Of Ignored Capacity
The current approach has measurable costs. Patients with untreated depression and chronic physical illness show higher rates of emergency department visits, hospitalizations, and overall healthcare utilization. They’re more likely to develop complications and less likely to achieve treatment targets.
From a health system perspective, this creates a perverse cycle: quality metrics measure whether targets are met, not whether plans are achievable. When depression undermines adherence and worsens outcomes, the response is often to intensify rather than simplify treatment—adding more medications, more frequent monitoring, and more specialist referrals.
“We’re optimizing for the wrong endpoint,” Veera argues. “Success shouldn’t just be hitting clinical targets. It should be designing sustainable plans that patients can actually live with.”
A Different Definition Of Quality
Veera’s argument ultimately challenges how medicine defines quality of care. Current metrics focus heavily on biomarkers and adherence rates. A capacity-centered approach would also measure whether treatment plans are sustainable, whether patients remain engaged with care over time, and whether people report that their healthcare feels manageable.
“Quality has to include fit,” he says. “A perfect plan that nobody can follow isn’t actually perfect. It’s a mismatch waiting to happen.”
This perspective becomes increasingly important as the U.S. population ages and multimorbidity becomes the norm rather than the exception. CDC data suggests that roughly half of American adults now live with multiple chronic conditions. Many of those same patients are also managing mental health symptoms, caregiving responsibilities, and economic pressures.
“The patients walking into our clinics today aren’t the same patients our systems were designed for,” Veera concludes. “They’re more complex, dealing with more conditions, and often have less margin for error. If we keep designing care as if everyone has unlimited capacity, we’ll keep being surprised when it doesn’t work.”
For Veera, the solution isn’t revolutionary—it’s foundational. Before asking whether a treatment is clinically appropriate, ask whether it’s humanly achievable. The first question isn’t “What does the guideline recommend?” It’s “What can this person actually do right now?”
In an era of precision medicine, perhaps the most precise thing physicians can do is match treatment intensity to patient capacity. The alternative is continuing to design excellent plans for hypothetical patients while the real ones slip through the cracks.
COMMENTS