The patient voice – the need for a minimally disruptive medicine service
Posted: July 12, 2011 Filed under: MDM in practice, Reflections on MDM, Views from the frontline of care Leave a comment »We are working as a multidisciplinary team to develop a service offering for patients with multiple chronic conditions that will reduce the burden of treatment while pursuing patient goals in primary care. We are trying to learn as much as we can from other models such as PACE and Graded care. We are also learning as much as we can from our colleagues in multiple disciplines and in public health. And, of course, from our patients.
During an in-depth interview, one of our patients commented to the notion of a MDM service the following
I wouldn’t mind having like the whole team of doctors that I work with being able to sit down with them and look at the whole picture and decide a plan that would work out for all of my illnesses and how maybe I could avoid certain things or certain costs or just help me live better, period.
…I just think the biggest, most important thing in illness is having all the doctors be on the same page and know what is going on with you individually so that they can help you meet your best expectations and your best health.
Hi expectations we will have to satisfy if we are to make a difference to the workload/capacity balance of these patients. Onwards!!
A “cure” for overtreatment
Posted: May 13, 2011 Filed under: Reference material Leave a comment »The blog Bedside Manner recently echoed our sentiments about minimally disruptive medicine, yet making a novel point: it is not about less care, but about more patient-centered care.
Indeed, I have come to refer to this idea as ‘goldilocks’ medicine for that particular reason. It is care that is “just right” as it can only be defined by the patient-clinician dyad (ultimately a dyad of teams on each side really) with the right expertise and research evidence, the right understanding of the patient’s context, and the right consideration of the pertinent and informed values and preferences.
Goldilocks medicine is going to need not only changes in the environment of care (fundamentally changing the corrupt nature of healthcare delivery today), but also in clinician training and in shaping patient expectations for involvement.
Thank you, Julie Rosen, Executive Director of The Schwartz Center for Compassionate Healthcare, for bring up MDM in your blog!
The evidence for minimally disruptive medicine grows…
Posted: May 12, 2011 Filed under: Papers and presentations, Research on MDM Leave a comment »Katie Gallacher and the MDM Team have just published a typology of treatment burden in this month’s issue of Annals of Family Medicine (http://www.annfammed.org/cgi/content/full/9/3/235). The group have identified core components of treatment burden as reported by individuals with chronic heart failure and state that although further exploration and patient endorsement are necessary, the findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care.
Kurt Stange, Editor of Annals of Family Medicine, in this month’s editorial (http://www.annfammed.org/cgi/content/full/9/3/194), states that the group have identified factors that increase the burden on patients and agreed that the paper highlights targets for personalizing care. The important role for MDM, which aims to ease the burden of polypharmacy, improve the organization of care, and increase accessibility and continuity, all of which are reported as key issues, is therefore clear.
Prepared Patient Forum blogger resonates with Minimally Disruptive Medicine
Posted: May 12, 2011 Filed under: Reflections on MDM Leave a comment »Jessie Gruman resonated with “patient John” and the concept of minimally disruptive medicine. In this post, Gruman says:
There are few of us whose lives are not so full of responsibilities that we would not benefit from our clinicians’ recognition of the level of effort required of us when they recommend complicated changes to our daily routine. At a time when patient-centeredness in health care is a concern of policy makers and clinicians alike, Montori’s approach increases the likelihood that we will be able to act on our own behalf. In seeking to mitigate the treatment burden by recognizing both the demands of the treatment and the context in which each patient must meet those demands, this care is consistent with the Institute of Medicine’s definition of patient centered…
Read her whole post here
JAMA commentary attacks the notion of clinical inertia
Posted: May 11, 2011 Filed under: Papers and presentations, Reflections on MDM 1 Comment »I have discussed how nonadherence to therapy could be conceptualized as nonviolent resistance to medicine’s push to overdiagnosis and overtreatment, particularly in patients with multiple chronic conditions.
JAMA has published an important commentary by which the author’s essentially propose that what some have conceptualized as clinical inertia may be instead interpreted as nonviolent resistance of clinicians to healthcare push for more healthcare on patients. The authors say:
…clinical inertia may be a clinical safeguard for the drug-intensive style of medicine fueled by the current medical literature.”
Minimally disruptive medicine, thus, represents a solution, an assertive one, for both patients and clinicians that needs to overcome corruption of both the literature and the practice.
Minimally disruptive medicine – the cover story – April 2011 Minnesota Physician
Posted: May 11, 2011 Filed under: Papers and presentations, Reference material Leave a comment »In April 2011, Minnesota Physician published a cover story about minimally disruptive medicine. To read the article click here. We look forward to learn how Minnesota physicians and other health professionals think about minimally disruptive medicine as we try to develop and spread this model to help patients who are overwhelmed by their life and heatlhcare yet experiencing poor health and health outcomes.
Minnesota to be first in nation to embrace ‘goldilocks’ medicine
Posted: May 5, 2011 Filed under: MDM in practice, Reflections on MDM, Views from the frontline of care Leave a comment »This week marks the potential start of the implementation, evaluation, and eventual adoption of minimal,y disruptive medicine in Minnesota. Three events marked this week.
The first one involved the formation of a team that will be implementing MDM in a primary care practice. This iterative effort will involve identifying complex patients and figuring out what healthcare and the community can do to reduce treatment burden. This effort will be oriented by the application of the cumulative complexity model based on normalization process theory and the insights we have accumulated from interviewing patients.
The second development involves the publication in Minnesota Physician of an article about minimally disruptive medicine. A similar piece will be published in their publication for patients. The dissemination of the concept I thing creates the space and mind frame for experimenting with care delivery models with an underlying approach to care, not just with an underlying approach to reimbursement. The former being much more exciting and motivating than the latter.
The third development took place April 4th 2011 in Saint Paul, MN. Möbius Inc convened a citizens meeting to discuss healthcare. I was in the first panel along with Dame Jo Williams and Sanne Magnan from ICSI. Sanne and I turned to do a 1-2 on healthcare as we know it, making a big push to redesign the system, reducing it’s footprint, and pursuing more health based on community action. Groups got together later in the day around their areas of passion. Our group started working right away looking for ‘bright spots’ (AA, diabetic bus, habitat for humanity), thinking about pilot projects; and job-creation schemes that will connect the isolated, connect existing resources to people that would benefit from these but does not know of them or of how to access them (e.g. Dial 211). We were able to present our findings to the Commissioner of Health and other officials. Citizens power was never so palpable, and that some of them rallied behind goldilocks care is just awesome. More to come soon!
Minimally disruptive medicine – the change must come from doctors
Posted: April 11, 2011 Filed under: Reflections on MDM 1 Comment »By Kate Gilbert (www.d1.org.au)
Minimally disruptive medicine acknowledges the lies that quickly become part of the doctor-patient relationship. As long as the relationship is about a doctor doling out treatment to a patient assumed to be a willing and able recipient, we are going to have a problem. ‘Non-adherence’ by the patient is one way to characterise the problem. Misguided folly by the health professional is another.
When I heard Victor Montori introduce Minimally Disruptive Medicine to an Australian audience last year (video available here: http://www.evertechnology.com/NMS2010/P4a/fHI.htm) I felt like I was listening to one of the most effective patient advocates I’d ever heard. And he’s not a patient, but a doctor! I couldn’t wait to share this new concept with other people with diabetes, and the enthusiasm spread quickly, spawning discussions about doctors’ incapacity to relate to patients, the stress and guilt caused by over-burdensome treatment regimes and more (see http://www.realitycheck.org.au/RCforum/viewtopic.php?f=1&t=8662).
I was reminded of Daniel Pink’s Four-Word MBA: Talk less. Listen more. (http://www.danpink.com/archives/2010/10/the-four-word-mba). This is strongly evident in developing the concept of MDM, and the same principle lies at the core of this new approach to medicine.
Victor isn’t the first person to acknowledge there’s a problem. Patient-centred care has been trying to get traction for ages. In my part of the world, ‘self-management support’ has received reasonable interest. But whilst I have followed this with interest, hoping it may reorientate the clinician-patient dynamic, it has had limited impact, and the medical profession has not embraced it. Perhaps an unfortunate side-effect of its name, self-management support is too often orientated towards the professional and his/her role so that even though it calls for change in that role, like most changes in health, few people implement it completely and we are too often left with people holding a strengthened view of their powers as a health professional to bring about transformation in their clients and limited real change in the relationship. Meanwhile, I pack out auditoriums whenever we put the topic of ‘Diabetes Burnout’ on the agenda – people with diabetes know the problem all too well and jump at the opportunity to hear and share in that discussion. Minimally Disruptive Medicine (MDM), in name and in practice, is very clearly oriented to the impact of care on the patient, and a promising place to start bring about critical change.
Montori’s early presentations on MDM have focused strongly on the rationale for a new approach, and only more recently is the next chapter emerging about what this new world might actually look like. The rationale he presents is irrefutable, clear and compelling. There wasn’t the zeal of a new fad (which always scares me off, I have seen a lot of fads come and go) but rather it has the passion of a new discovery that has to be shared. I am looking forward very much to Victor bringing this same clarity and passion to the solution: developing and spreading MDM as a new approach to medicine. Whilst I am delighted that Victor and colleagues are actively listening (there’s that word again) to patients and patient groups about our needs and views on MDM, and we can strongly support the rationale and be demanding of the change, the actual approach must come from within the doctors whose world will be changed.
Minimally Disruptive Medicine is an important truth, beautifully and intelligently executed.
More about reducing treatment burden – this time from burden “caused” by patients
Posted: March 14, 2011 Filed under: MDM in practice, Reflections on MDM Leave a comment »Dr. Michael Wolf and his team from Northwestern University have published an interesting article in the Archives of Internal Medicine looking at the complexity in medication intake. We had reported on a case like the ones explored in this study in our original Minimally Disruptive Medicine paper.
In this new study, the authors conclude that:
Many patients, especially those with lim- ited literacy, do not consolidate prescription regimens in the most efficient manner, which could impede adherence.
Although this study consisted of a simulated situation, it is indicative of patients approach to medicine use (without the assistance and input of other team members, such as a spouse which in my experience often assists with these tasks). In this study, patients with low literacy complicated their program!! This means that the patient unwittingly contributed to increase their own disruption.
Arguably, this happens because patients do not have the knowledge, skill, or self-efficacy to treat medicine schedules as they treat picking up the kids or brushing their teeth. These are activities they understand in their nature and consequence and as a result they can modify to make very efficient (like applying lean to your own life…lean consumption). But this is not available to these patients regarding the meds. As a result they overly complicate their routines! Fascinating, and a great opportunity for minimally disruptive medicine.
EVIDENCE 2010 talk about healthcare that fits the patient now available online
Posted: December 22, 2010 Filed under: Papers and presentations 2 Comments »My presentation on healthcare that fits during EVIDENCE 2010 is available here.
