Do the Minnesota Community Measures’ ‘D5’ criteria for management of diabetes reflect a friendly contextualization of care for all people?

Mark Kaczor is a third-year student at the Mayo Clinic School of Medicine. As part of his clerkship in family medicine, Mr. Kaczor responded to a writing prompt meant to develop his thoughts about the role of a primary care physician. The prompt: “Do the Minnesota Community Measures’ ‘D5’ criteria (http://mncm.org/reports-and-websites/the-d5/) for management of diabetes reflect a friendly contextualization of care for all people? What are the risks and benefits of adopting guideline-driven care? Mark was asked to argue the hypothesis that guidelines are a force for evil. His answer follows:

While mulling over why D5 guidelines and those like them might be a force for evil, I happened to pull up the advertising poster for the D5 guidelines and read this: “Your goals may be different based on your individual needs. Talk with your doctor or health care provider about the D5 goals that are right for you.” At this point, I thought that any

Kaczor

argument I was crafting was surely sunk, as D5 calls for proper contextualization of care right on its’ poster. I then began inspecting the poster closely and noticed that that line, which pertains to something that we have all been agreeing over the last few weeks is pretty important,  was written in the smallest font, save for the copyright information, and positioned toward the bottom. While I do not want to read too much into artistic choices because I, myself, have no artistic instinct to speak of, I wonder if there is some dangerous parallel between how the idea of contextualization is treated on the D5 guideline poster and how well contextualization is performed in a clinical setting where guidelines and protocols are so adamantly promoted. To me, the line in question reads like the end of a drug commercial sounds: quickly and with no real deference to its subject matter.

Overall, I feel that how contextualization is presented on the D5 poster and the idea of pushing guidelines that are intended to generalize as much as possible creates a culture where contextualization, while mentioned frequently and lauded as a concept, hardly ever takes place. These guidelines are borne out of great intentions and adherence to them has, I am sure, produced some great statistics in whatever populations have been studied. Benefits of guidelines are numerous and include everything Lisa mentions. They are an effective safeguard against objectively poor care. I think one of the greatest risks that they pose, though, is a result of them being, by their very nature, somewhat anti-contextualization. I believe they aim to take some of the deep thinking out of medicine and successfully do so. The more providers are trained and encouraged to follow the guidelines, the less natural taking time to contemplate contextual factors feels. Proper contextualization is something that will always take deep thought. That is not to say that contextualization cannot take place while guidelines are kept in mind, but I think they do provide an additional barrier to something that is already done sparingly. Contextualization may always be the long-game when it comes to improving outcomes, but, like we have been discussing, it does do so, and there are so many more reasons to do it. As long as contextualization remains an afterthought when establishing guidelines, I do not anticipate the skill or frequency with which it is done will increase very much. I think guidelines are important and should exist, though, my belief is that our honest intention to contextualize patient care should be proudly presented at the top of the poster in the largest font.

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2 thoughts on “Do the Minnesota Community Measures’ ‘D5’ criteria for management of diabetes reflect a friendly contextualization of care for all people?

  1. In actual clinical practice, during an individual patient-doctor encounter, I doubt if there is much time for “deep” thinking for contextualization. Physicians tend to think on their feet, as it were, while engaging with a patient, and contextualizing established guidelines or treatment parameters as well as acquired clinical expertise comes almost as second nature.

  2. Excellent piece, thank you.
    “Performance measures are blunt instruments” -Dr. Rodney Hayward.
    And guidelines (a) are tracked by performance measures, (b) seem to functionally become “mandates” in clinicians’ minds, and (c) tend to make us treat all patients as an “average patient”: something none of us likely want. Dr. Montori’s book “Why We Revolt” articulates this well. I think guidelines can be helpful…IF ignored in individualizing care. That takes a strong, thoughtful clinician.

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