What is Fit?
The single most important reason why it is important for a treatment to fit is that patients have the single largest stake in the treatment. It is the patient who will have to schedule the visits, take the medication, monitor his or her health, adjust his or her lifestyle, and deal with the effects of either the disease, the treatment, or both. These burdens of disease and burden of treatment must be managed using the resources of the patient and often his or her social community. The patient must have the capacity to cope with the demands of a treatment regimen in order for the treatment to help achieve a health goal. A good treatment fit with minimized treatment (and disease) burden are especially important for patients with at least one chronic disease, as the patient’s commitment to treatment can last a lifetime and the cumulative burden of disease and treatment can become very large.
The problem with many prescribed treatments is that the treatment must be used as directed in order to achieve the desired health outcome. Patient adherence, therefore, can be a major determining factor in whether a treatment will be able to achieve the doctor and patient’s goal. In addition to the decrease in benefit from treatment when adherence is low, additional side effects, complications, and doctor visits can result. Such consequences, which can result when disease management is poor, create an additional burden of disease and/or treatment for the patient, the community, and for society. Since adherence to treatments and the ability to cope with treatment burden can have a large effect on treatment outcomes, prescribed treatments should be chosen to fit a patient and to be minimally disruptive (or minimally burdensome) in order to allow for the best chance of reaching a health goal.
For a visual image of the way that I picture fit and minimally disruptive medicine, picture Venn diagram of three overlapping circles.
Each circle represents an important factor in choosing and implementing a treatment: on circle is the domain of the patient’s goals, on circle is the domain of the doctor’s goals, and one circle is the capacity of the patient to cope with or adhere to a treatment. At the intersection of all three domains is treatment that fits, and the practice of minimally disruptive medicine. In a perfect world, the doctor and patient would agree on all goals for treatment and disease management, and all of the possible treatments that would accomplish this goal would be within the capacity of the patient. In the real world, we must use different tools and ways of practicing medicine to determine the shared goal with as much agreement as possible between doctor and patient, and to find treatments that are within the capacity of the patient and can be accomplished using the patient’s available resources. This would mean working in the “zone” of treatment fit and minimally disruptive medicine, and allow the greatest chance of successfully achieving health goals.
Many different interventions have been developed which aim at improving health with the primary goal of increasing patient adherence and thus the efficacy of available treatment options. While many practices, including evidence-based and patient-centered medicine, include the aim to bring the doctor and patient to an agreed upon and effective treatment, specific tools have been developed to aid in setting these goals and prioritizing the characteristics of available treatments for the patient. These attributes include the efficacy of the treatment, various burdens of administration or monitoring of the treatment, side effects, cost in time, money, and resources, and access. Tools for helping to fit a treatment include decision aides, which give doctor and patient and systematic and inclusive approach.
Countless other interventions to improve treatment adherence address the issue of capacity by either increasing the patient’s resources available to use toward treatment (i.e. providing childcare, accompaniment to appointments, transportation, reminders) or by decreasing the burden of treatment to adjust for the patient’s capacity (i.e. scheduling fewer appointments, reducing costs, etc.) In some cases, treatment or outcome goals are adjusted so that the treatment necessary to accomplish them is within the capacity of the patient. Decisions to modify treatment or outcome goals must also take into account the possibility that while treatment burden may decrease as a result, the burden of disease increase in the short- or long-term as a result.
The practice and pursuit of finding a treatment that fits by shifting the doctor and patient goals as well as by addressing the patient’s capacity to cope with or adhere to a treatment is the practice of minimally disruptive medicine. In minimally disruptive medicine, the most important objective should be to treat or manage disease so that the patient has the best chance of leading the life that he or she wants with minimal disruption due to disease or treatment. I recently began the long journey of medical school because I want to spend my life helping others to address health problems in order to use time an energy towards other priorities, and in minimally disruptive medicine, I hope to find a fit.
— Hannah Fields, Mayo Medical School