When a patient comes to us, he or she is hiring our services to accomplish something in his or her life. I always find it an intriguing question to wonder, “What is this patient hiring us to do?” In other words, “What is the patient’s job to be done?”
To me, the concepts of Minimally Disruptive Medicine, Contextualizing Care, Shared Decision-Making, Patient-Centered Care, Individualized Medicine, etc. are all different but similar ways of helping us understand the patient’s “job to be done” and customizing our arsenal of tools, skills, and knowledge to help him or her fulfill that job.
In a way, a patient encounter is a negotiation. In negotiations, people often make the mistake of immediately trying to gain as big a possible piece of a fixed pie that they can. In reality, however, it is usually far more beneficial to first ask questions of one another to grow the pie before divvying it up. Growing the pie, however, requires the patience, dialogue, and trust to understand one another’s priorities as well as the ability to align those priorities to create maximum value for each party. It requires debunking an often innate assumption that the pie is fixed in the first place.
Furthermore, in medicine the negotiations are rigged. As providers, we wield all the authority in making the plans but we often forget that we have none of the power in implementing them.
Each of us, as providers, has a default set of assumptions at baseline. Baseline assumptions, however, are often overlooked even though they have profound influences on results. A look back to the launch of Space Shuttle Challenger on January 28, 1986 reveals a painful lesson about default assumptions. In an emergency conference call on the night of January 27, engineers and executives of Morton Thiokol (manufacturers of the solid rocket boosters) told NASA managers and flight controllers that they were concerned because the overnight temperatures were going to be colder than they had ever planned for or had data about and they were concerned that elastic o-ring seals on their boosters may not function properly during liftoff at such cold temperatures.
NASA leaders, however, had already made “launch” the default assumption in their mind. George Hardy, Manager of the Solid Rocket Booster Project, reportedly responded to Thiokol’s request to delay the launch with, “I am appalled. I am appalled by your recommendation”. Millions of people watched on TV the next morning as the Challenger exploded a little over one minute into flight, later determined to be a result of the failure of the elastic o-ring seals.
In medicine, “launch” is often our default. With a few easy clicks of the computer, we can engage sophisticated technologies, armies of staff and services, novel treatments from around the world, and cash flows that can bury our patients in economic turmoil, none of which we have to pay for or experience ourselves. The pain, inconvenience, and expense of what we enact we rarely see or even have time in clinic to ponder. Furthermore, when the rocket explodes, we aren’t in the cockpit.
Minimally Disruptive Medicine is, from my understanding, an umbrella term that encapsulates a number of focused and targeted strategies for providing services and treatments that are aligned with our patient’s own unique “job to be done” and are simple, easy, and convenient for that particular patient to participate in and adhere to.
Contextualizing care is a process of empathizing with each patient to understand where our assumptions as providers may be false and to attempt to determine that individual patient’s expressed and even unexpressed needs, desires, and limitations. Knowing an individual’s context and status in life helps us remedy our false assumptions and thereby gain a more accurate understanding of a patient’s priorities and how our care can be optimally aligned with those priorities.
The very name “Minimally Disruptive Medicine” starts with the assumption that care will be disruptive and that our job as providers is to minimize that disruption. However, Ritz-Carlton’s mission is not, “Avoid bothering our guests too much.” Their mission is actually quite long, but the final line is, “The Ritz-Carlton experience enlivens the senses, instills well-being, and fulfills even the unexpressed wishes and needs of our guests.” It is ambitious but inspiring for employees. I am not sure I am inspired by making something less awful for my patients; I think we have a long way to go in how we frame the care we provide. I believe in the pursuit of MDM and respect and look up to Dr. Montori and the entire KER team. MDM has obviously been highly successful at getting out the message that care, especially chronic care, is extremely disruptive to patients and needs to be redesigned. Moving this from discovery to translation to application at large scale, however, is another story. A 2015 “Minnesota Physician” article on MDM discussed that a 22-chapter implementation guide for MDM was in the works. I haven’t found that manual yet, but a 22-chapter implementation guide sounds frighteningly complex when the overall goal is to reduce complexity.
Every time I hear or read Minimally Disruptive Medicine, it is impossible for me not to also think about a completely different but similarly-named and ironically applicable theory, that of Disruptive Innovation. Disruptive Innovation is a theory that “explains the process by which complicated, expensive products and services [such as medicine] are transformed into simple, affordable ones. It also shows why it is so difficult for the leading companies or institutions [like Mayo Clinic] in an industry to succeed at disruption. Historically, it is almost always new companies or totally independent business units of existing firms that succeed in disrupting an industry.” (From Innovator’s Prescription by Clayton Christensen, page 3).
To me, a more rapid and effective approach to achieve the goals of MDM would be a Disruptive Innovation approach, something that would seem radical and unviable to the “leading companies and institutions” like Mayo Clinic. A Disruptive Innovation solution may likely be centered around a new baseline, one where the default assumption will be that a patient does not want any healthcare services or treatments and only through discussion of each patient’s unique priorities would you begin to build a thorough and individualized plan from scratch that encompassed every aspect of a person’s life. I can quickly envision a vertically integrated approach to “healthcare” that coordinates and organizes all the important elements of people’s lives, including food, fitness, financial services, education, career navigation, child care, etc.
Of course, doing something like this requires fundamentally restructuring the entire way in which we deliver and ensure “health”, “healthcare”, and “medicine.” This is why I am an advocate for Disruptive Innovation as a “build from scratch” rather than “rebuild what we’re already doing” model. In healthcare, we must sit in the cockpit with our patients. To do that, however, we must restructure everything, including, and perhaps most importantly, who pays us, when they pay us, why they pay us, how they pay us, what they pay us, and what they pay us for.
John Schupbach is a student at the Mayo Clinic School of Medicine, recent graduate of Harvard Business School, and Founder and CEO of Squalor to Scholar. He plans to complete his residency in Emergency Medicine and eventually to engage in practice redesign efforts globally. He wrote this response to a writing prompt as part of his Family Medicine clerkship.