A patient ¨pushes back against physicians¨? Minimally disruptive medicine brought about by patients
Posted: December 21, 2010 Filed under: MDM in practice, Reflections on MDM, Views from the frontline of care 1 Comment »This post in the Wall Street Journal highlights a point of view to which I keep arriving: clinicians may not be able to bring about changes in healthcare consistent with minimally disruptive medicine unless patients demand it. A real patient revolution will be necessary to help clinicians realize a future that — as I learned from Judt — they cannot make happen because the ideology of the healthcare industry does not allow them to imagine it. But patients may not yet be help by the same limitations. This WSJ post is therefore, to me, a manifestation of hope.
How I came naturally to minimally disruptive medicine!
Posted: December 20, 2010 Filed under: MDM in practice, Reflections on MDM, Views from the frontline of care Leave a comment »By Kevin Larsen, MD (Chief medical informatics officer, Hennepin County Medical Center)
I really love this concept since I first saw the opinion piece. I think I came to this naturally growing up with a brother who is a type 1 diabetic. In the early days of diabetes management it was maximally disruptive medicine – managing your life around your diabetes. Type 1 self management revolutionized this and when done right puts the patient in control of managing his/her own diabetes around their diet, lifestyle etc. I try to bring this approach to all of my patients conditions whenever I can.
Another aha! moment I had around this was at a site visit to a hospital in Panama. They had developed a program called “hospital at home.” Nearly all non-ICU patients had a one day stay or less in the hospital. The hospital arranged for doctors, nurses and therapists to go to the patients home, often multiple times a day to deliver care. They proved they had better outcomes with less falls, less delirium and it cost much less money. Plus patients loved it.
Minimally disruptive medicine finds a home in Minneapolis…
Posted: December 17, 2010 Filed under: MDM in practice, Reflections on MDM, Views from the frontline of care Leave a comment »Over the last few weeks it is exciting to see the concept of minimally disruptive medicine take off. At the IHI meeting, Maureen Bisognano highlighted it as an example of fresh thinking about patient-centered care. In Minnesota, Mark Linzer and his team at Hennepin County Medical Center are considering implementing an MDM clinic to help the myriad of patients with multiple chronic conditions, burdensome workloads and reduced capacity (mostly through poverty and its accompanying maladies).
Mark says:
I have been trumpeting the idea of an MDM (minimally disruptive medicine) clinic all day, from a morning meeting with the head of our EMR to a noon meeting with the director of our journal club and a leader in evidence-based medicine, and at an afternoon meeting with our health care reform work group where i spoke about MDM being the basis for the future of health care in our county (through an ACO). This concept has truly affected us! I believe i can find some willing partners for a pilot of an MDM clinic at Hennepin County Medical Center! The idea of doing MDM as a way of using only technology or medication for which there is excellent evidence of benefit and in a way that is minimally disruptive of the patient’s lifestyle, is one that is fascinating all of us right now!
This is really awesome and the MDM team at Mayo is very excited about the potential for this partnership, a fantastic opportunity to test Minimally Disruptive Medicine as a philosophy of care for patients with multiple medical conditions. Thanks Mark and a big ‘thank you’ to your team!
International group for the study of treatment burden
Posted: December 1, 2010 Filed under: Research on MDM Leave a comment »Frances Mair and her team in Glasgow, Carl May in Southampton, and the Mayo Team got together on December 1st via videoconference to launch a more vigorous collaborative.
We reviewed the ongoing work in Glasgow (CHF, stroke), and Mayo (patients with diabetes, multiple chronic conditions). Much more to come as we understand the conceptual underpinning of treatment burden, develop measures of treatment burden, and implement them in the context of care of patients.
Evidence 2010 and minimally disruptive medicine
Posted: November 5, 2010 Filed under: Papers and presentations 1 Comment »By Victor Montori
On November 1 and 2nd, clinicians, policymakers, and methodologists got together at the BMA House in London, UK for the Evidence 2010 meeting. The BMJ and Oxford’s Center for Evidence-based Medicine convened the meeting and it was a major success.
I had the opportunity to participate as a keynote speaker opening day 2. While I can summarize my presentation (the content and slides are elsewhere on this site), the colorful summary published in the BMJ does a much better job. You can read it here. The key paragraphs follow:
His strategy combines better explanations to patients of the benefits they may be missing, and giving them a chance to “choose their own poison” by taking them through the treatment options in a gentle conversation. A patient who has been given a choice is more likely to adhere to the treatment, whatever is chosen, he believes.
He also believes in “minimally disruptive medicine,” trying to devise a strategy that does not leave the patient spending hours each day organising his pills, arranging tests and appointments, and worrying about his disease. For a diabetic patient with multiple co-morbidities, doing this can turn into “a part time job” Dr Montori said.
Language needs to be changed, too. “LDL cholesterol is not a word” he asserted. “I have to talk to my patients about living longer, feeling better, and living unhindered by the complications of the disease. If I can’t do that, I shouldn’t be treating them.”
I am grateful to my colleagues at CEBM and BMJ for the invitation and I look forward to Evidence 2011. I will post an update here when the organizers post the video of the presentation online.
Designing the ecosystem to make the work easier
Posted: November 2, 2010 Filed under: Reflections on MDM 4 Comments »by Victor Montori
While in London, I had the chance of reconnecting with J. Paul Neely, a brilliant designer with whom I had the pleasure of working when he was at Mayo as part of the SPARC Innovation Program. He is a Masters student at the Royal College of Art and he thought his peers would enjoy learning about our work. After I presented my talk, a team that is intent on designing out medical error showed their efforts to redesign the hospital bays to ensure health professionals wash their hands.
After much discussion, it become clear that both sets of projects were not about designing a solution, or a system of solutions, but rather they were about redesigning the ecosystem in which the work occurs — the work of being a chronically ill patient or of being a health professional — and engineering that ecosystem to make that work easier, minimally disruptive. Ohh!! Love it when ideas from different backgrounds, disciplines and foci have a chance to collide and reproduce! Thanks J. Paul!
Normalization Process Theory and minimally disruptive medicine
Posted: October 23, 2010 Filed under: Papers and presentations, Reference material Leave a comment »by Victor Montori
I have just spent a glorious week with colleagues in the UK who are all pioneers in formulating a sociological theory of work called Normalization Process Theory. We were brought together by the very generous Carl May, the convener of this group and key intellect along with Tracy Finch, Tim Rapley, and several others behind NPT — all “eminent, esteemed, and lovely”.
I was given the opportunity to share some notes about fitting healthcare to the patient using shared decision making and minimally disruptive medicine and how we were using NPT to support this work. My presentation is here:
The NPT toolkit boils down the theory into 16 questions. The point of working thru these questions is not to reach an answer, but to think through — while addressing these questions — the process by which an intervention, a study, a treatment will become implemented, enacted, embedded, i.e., normalized, into existing routines. The questions are challenging and invite thoughtful discussion. I want to start using these with patients to uncover the work of adhering to complex medical regimens.
The developers are anxiously waiting for users to provide feedback and promise to be responsive. Since this is the theory underpinning minimally disruptive medicine, my enthusiasm for a toolkit that will make it more accessible to practical people is very high.
The other attractive feature of the toolkit is the resulting report. While this gives a sense of “destination” — when I say above that the “journey” is where the value lies, the plots suggest the notion of footprint that I have found so critical to understand healthcare in the lives of patients.
Go explore the site and post comments there and here.
Challenging my colleagues
Posted: September 21, 2010 Filed under: Reflections on MDM, Views from the frontline of care | Tags: change, fear, minimally disruptive medicine, nonadherence, poor treatment fidelity, treatment burden 2 Comments »By Victor Montori
I am often on the road discussing minimally disruptive medicine with colleagues elsewhere. For some reason I never hear disagreement with the basic statements of concern (we are responsible for some of the non adherence by virtue of our endless and uncoordinated demand for more work on chronically ill patients with multiple comorbidities). When I suggest something needs to be done about this, e.g., reject disease specific quality and performance measures, work for integrated care around patient needs, assess and reduce treatment burden, I get a sense of impotence, of inability to create change, to truly advocate for the patients’ interests. Why do you think this is the case?
When patients opt out of their medical care, we think it is because they may be ignorant about the implications of disease and the effects of treatment. This intentional noncompliance sounds to me as a target for improved communication and education. Even shared decision making. If patients make informed choices about what to do and what not to do, that is not noncompliance. That is informed patient choice. An exercise of people’s values and preferences with full understanding of the opportunity costs of taking and not taking action in their specific context. This is sometimes confused, but some folks understand it – e.g. this article in LA Times. The focus of my attention, however, is poor treatment fidelity – poor follow-through with an agreed upon plan of action.
Poor treatment fidelity can be caused by our transferring to patients the demands for optimal care we feel as part of misguided performance improvement campaigns, by poor care coordination, and by blindness to the burden of treatment and to the (limited or shrinking) capacity that patients and family have available or able to muster to implement treatments. It is this reality that is within our reach and, as I indicated in the first paragraph, it is something about which I find professionals feeling impotent. Why?
My colleague Barbara Koenig pointed me to this article by the late historian Tony Judt commenting on the work of Czeslaw Milosz and specifically on The Captive Mind. The key phrase Judt offered that seems pertinent to this discussion is: “Above all, the thrall in which an ideology holds a people is best measured by their collective inability to imagine alternatives.“ Is the impotence I have observed the result of this inability to imagine alternatives? Can minimally disruptive medicine offer these?
Minimally disruptive medicine talk on YouTube
Posted: September 10, 2010 Filed under: Papers and presentations, Reference material Leave a comment »The great folks at the Mayo Center for Innovation have published last year Transform symposium talks on youtube. These include the first public presentation about Minimally Disruptive Medicine and Maggie Breslin’s classic on the power of conversations in healthcare.
What has happened in the last year? Our international research team continues to work hard to define the concept of treatment burden for patients and caregivers and make it measurable, we are looking into clinical visits video recordings to explore the nature of these conversations, and we are working with partners to further consider these goals in initiatives such as the patient-centered medical home. Lots to do!
Patients or consumers?
Posted: August 31, 2010 Filed under: Reflections on MDM Leave a comment »This is a great blog post focused on the issue of terms. A patient endures, much more than healthcare. Clearly, context matters. Recommended reading for sure.
