Minimally Disruptive Medicine, at your service

By Aaron Leppin, MD

I am not particularly mechanically oriented. I know very little about how my car works and what truly needs fixed and maintained. It is hard for me to fully appreciate the risks associated with rotating the tires vs. changing the oil vs. flushing the transmission, inspecting the spark plugs, repairing a dent, fixing a cracked windshield, replacing the brakes, and so on. What I know is that I do not have the time or the desire or the money to do every possible thing to my car at every possible opportunity to keep it in pristine condition. If I attempted, I am certain I would go crazy from the burden of it all.

Fortunately, my mechanic knows this. We have a partnership whereby I am loyal to his auto shop and trust in his guidance, and he provides a service that fits my life. He does what needs to be done on my car to meet my fairly straightforward expectations—that I have a safe and reliable vehicle that can get me where I need to go when I need to get there.

Squeezing out a few extra RPMs of performance or maximizing my fuel efficiency by a couple miles per gallon or removing an imperfection in the finish simply are not things I care to pursue unless he can ensure that the effort and resources required to accomplish these ends are minimal. In other words, these things simply do not mean enough to me that I would sacrifice my time, energy, or finances to make them happen. I have far more important objectives and goals for my life toward which I can direct those resources.

I’m sure there are people that care much more about their automotive performance than I do and for them a totally different approach would be necessary. And that is the beauty of providing a service. A service is flexible, it is responsive, and it is consumer-driven. No auto “service” shop will be in business long if it focuses its efforts on providing services that no one needs or wants. After all, people do not generally take their cars to the mechanic because they have an intrinsic desire to experience the process of it all; rather, they have specific areas where support is required that exceeds their own particular abilities, knowledge, or resources. The “service” shop helps meet those needs.

When we consider the implications of a service-first approach to health care, we often focus on quality metrics that reflect the patient’s experience of interaction with the health care system. This is certainly not wrong and is in fact an important part of what it means to be truly focused on patient goals. But, conceptually, the idea of a service shop view of our clinics, hospitals, and health systems should really extend far beyond the façade of experience and, in truth, be grounded in the actual substance of what it is we do. In that sense, we have to ask ourselves if the care we are providing is actually a service. And when it is not, what is our justification for making it anything else?

The U.S. Bureau of Labor and Statistics uses a simple classification scheme that dichotomizes the total of all American industry and productivity on the basis of a single consideration—namely, whether a field or sector is primarily “goods-producing” or “service-providing.” Healthcare and social assistance finds itself classified in Sector 62, within the service-providing group and cozily nestled between the feel-good fields of education services (Sector 61) and the leisure and hospitality sectors of arts and entertainment and accommodation (Sectors 71 and 72, respectively). This seems like an appropriate and desirable place for healthcare to reside, comfortably situated among the altruistic, the noble, and the joy-bringing.

At least in a theoretical sense, the ability for healthcare to remain justifiably classified as is depends on the idea that what it generates comes from and is directed by the demand and desires of the people it serves. And this too seems appropriate. After all, we would not say that we “produce” healthcare, but rather that we hope to “provide” it. Similarly, we would prefer not to say that we create a take-it-or-leave-it product available for consumption; but rather that we respond to the needs of patients. And, although I firmly believe in the genuinely good intentions and generally well-placed priorities of America’s healthcare policies and people, I think we all know we could do better. For all our best efforts, after all, there’s something about healthcare that occasionally makes it seem like a fraudulent servant, as something with good intentions but still driving to produce a product.

To the extent healthcare imposes itself on those it serves and becomes burdensome, pushy, and overbearing, it ceases to become a service at all—rather, it very much becomes a disservice. We do not often think of healthcare for what it is, or at least what it is intended to be fundamentally: a service provided to patients.

It may seem strange to think of one’s physician in the same light as one’s hairdresser or one’s pharmacist in the same way as one’s accountant—but should it? Perhaps not entirely. To the extent healthcare itself dictates the character and nature of its product, it becomes “goods-producing” and, according to the Bureau of Labor and Statistics, would better be lumped with the likes of the manufacturing or agricultural sectors.

New ways of thinking about healthcare are emerging that are seeking to empower patients with the negotiation tools they’ve always rightfully owned but not fully realized. Through the broadening reach of shared decision making, patient values and preferences are being called upon to dictate the application of healthcare in a way that is personalized and patient-driven. Furthermore, there is growing acceptance that clinical guidelines, often fail to guide the provision of service that meets the needs of some patients in some circumstances.

Minimally Disruptive Medicine is a service-driven approach to care, co-created with patients (as is the best experience at any service), that makes sense for patients and meets their goals with evidence-based approaches, in a manner consistent with their needs and preferences. It is what patients would order for themselves at the drive-thru, it is what they would select from the produce aisle or the art gallery, and it is the part of their house they would choose to remodel if left to their own devices and were sufficiently informed.

Minimally Disruptive Medicine is minimally disruptive not because it is minimal, but because it is designed to naturally fit to the patient’s life.  In some cases, this may require maximal support and intervention, but that determination is made by the individual needs of the patient and the particular clinical situation, with the patient. MDM seeks to always support and never burden beyond what is necessary to achieve the patient goals.

As I have spent the last few months researching the merits of a Minimally Disruptive Medicine approach to care and growing in my own understanding and conceptualization of the construct, I’ve become familiar with some of Victor Montori’s favorite nicknames: “Goldilocks Care,” “Palliative Care for the Living,” “Geriatrics for the Young,” etc. Well, insomuch as I am qualified to propose another, how about: “Service With a Smile.” That’s what I get from my mechanic. Why should I expect anything different from my doctor and healthcare team?

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4 Comments on “Minimally Disruptive Medicine, at your service”

  1. Dr. Leppin, it was a stroke of brilliance to start off with the mechanic’s analogy here. It fits beautifully, as you carefully unfold in a common sense fashion how Minimally Disruptive Medicine can and should be integrated into care.

    I’m curious about where you and your MDM team stand on the ongoing discussion of whether patients should be considered “consumers” or not – as this shift might be the logical next step if a service-driven approach to health care is ever destined to happen. We’re comfortable being called consumers when it comes to our mechanics or hairdressers or other service providers – but how will physicians respond to such a shift?

    The Harvard Business Review waded in on this one, too, insisting that – unlike real consumers – even when patients are willing to be decision-makers, they just may not have the tools to do so. (FYI, my response to the HBR: http://myheartsisters.org/2013/01/27/why-the-harvard-business-review-is-wrong-about-patients/ )

    • Aaron Leppin says:

      Hi, Carolyn. Thank you for your thoughts! I really appreciated your take on the HBR’s stance about patients as consumers. I tend to agree with your perspective on this, although I suspect there’s some truth to both views. I think it may be that “consumers” is a word that is charged with some unpalatable meaning to some, but, in principle, I think the concept of patients as consumers mostly fits. The key distinction really comes back to your beliefs about how we should “treat” a consumer. I think the HBR’s authors seem to imply that there is some difference in the way healthcare would treat a consumer as opposed to a patient. That we’d necessarily lose empathy or concern and that we’d over-burden patients in an effort to empower them. That’s certainly not the way I would conceptualize what it means to be a consumer of health (i.e. in my view, the authors’ stance that our diabetes decision aids are the antithesis of what it means to treat a patient as a consumer isn’t really accurate).

      Furthermore, I’m not sure the authors’ central argument is based on entirely solid logic. Mostly, I don’t see how they establish that the claims that “patients don’t want to be there,” “patients aren’t equipped to be there,” and that “patients aren’t in it alone” is particularly unique. Even going back to the mechanic analogy, all of those statements and their corresponding arguments would be equally true. And yet no one seems to have a problem with us as consumers of auto service.

      I tend to think this “consumer vs patient” argument is mostly rooted in different thoughts about what the words actually mean. But that’s just my opinion!

  2. mark mcconnell says:

    This is a really nice post. I agree that the analogy of “auto maintenance” is spot on. Most of us “broker” our automobile care to someone we trust. Similarly, it would be nice for many people to “broker” their medical care to someone they trust. The problem is that many of us do not “trust” anyone in the medical profession as much as we trust our auto shop.

    That, I think, is the critical element missing in US healthcare these days.

    As to the issue of “consumer”: I do not believe that anyone in the US is a consumer of healthcare in the purest sense. PATIENTS do not make choices and “consume”: because they cannot possibly make choices based on costs: the information on “cost” is simply not available. DOCTORS are the “consumers”: they make the choices. This is not “good” or “bad”: it simply is what it is.

    I am idealistic but hope that we can move to:
    1. SIMPLER medicine: “Less is More” series in Archives of Internal Medicine and the “Choosing Wisely” campaign.
    2. Letting patients know (a) the cost of interventions and (b) the harms and benefits of those

    THEN patients will be consumers.

    • Aaron Leppin says:

      Can’t disagree with any of this, Mark! We’ll be putting up a post soon soliciting the sorts of things that should be involved in the practical delivery of MDM. “Choosing Wisely” is one resource we’ve identified and costs, harms, benefits should all be included through shared decision making. We’re interested to hear from folks on the front line on what they believe should be included in any MDM “toolkit.”


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