Month: December 2017

Submitted by Paige Organick, Nataly  Espinoza Suarez, M.D., Anjali Thota and Bjorg Thorsteinsdottir, M.D.

An 84 year old woman, whom I will call Amy, went to the hospital 4 years ago to receive a pacemaker. The surgeons botched the surgery, and subsequently told her she’d have, at most, 2 years to live. Four years and many procedures, interventions, and subsequent infections later she is still going strong. She carries a bag for her PIC line and cares for her husband, who is 94% blind, on dialysis, has had cancer, and is recovering from leg surgery. Amy and her husband live alone in their own home. If there ever was a couple in need of minimally disruptive medicine (MDM) to decrease their treatment burden, it is this couple.

After the prolonged hospitalization, Amy was dependent on a high risk heart medication that kept her hooked up to a cardiac monitor and essentially confined to her hospital room. Fortunately, she was invited to participate in the Palliative Homebound Program of the Care Transitions team at the Mayo Clinic. The multi-disciplinary team works on the Palliative Care homebound program; in theory, they assist seniors over the age of 60 with high risk medical conditions transitioning in and out of the hospital, focusing on palliative care and in-life transitions. But it seems they do much more than that, working on fall prevention, simplifying medications, and coordinating with nursing home staff, social workers and physicians to best aid the patient in their own home. Dr. Thorsteinsdottir and a Nurse Practitioner regularly visit Amy and her husband in their own home, and in return they freely call her personal cell phone whenever they have even the smallest question.

The team freely uses the basic concepts of MDM and the accompanying theories, even though they never call it by name. They acknowledge that imbalances occur between the patient’s capacity to perform cognitive and physical actions and the workload they were assigned by their various clinicians. This imbalance causes a burden of treatment, meaning that the patient feels overwhelmed, saddled with or stressed over some aspect of their therapeutic treatment. The Care Transitions team seeks to right this imbalance of overwork on the patient’s behalf. Nurses call regularly to assess coping, ongoing need and co-ordination of necessary appointments. Dr. T and Nurse practitioners come to Amy’s home to visit with the couple, relieving much of the burden of dealing with multiple appointments. Advice from subspecialty physicians is mostly sought via clinician to clinician phone calls. This means that, to get the most care, Amy didn’t have to navigate busy downtown Rochester, deal with finding parking, then walk the long distance up the ramp and into the clinic, which she said made her too tired.

Having Dr. T come to her home made care not only easier, but also more effective. It helps Dr. T and the nurses see the home environment and identify fall risks and other hazards, and better get to know and understand the patients on their own terms. This creates holistic care where clinicians better understand their patients, their values, and how to create medical values that align with that of their clinicians. A big focus of MDM, and the Care Team, is to understanding the patient’s needs and values. For example, some may not mind getting up early in the morning to drive their spouse to dialysis; Amy can’t stand it. No matter what, this is a burden of treatment for the couple. However, Dr. T and the Care Team understands the couple well enough to figure out an alternate bus Amy’s husband can take so Amy doesn’t have to wake up so early, decreasing  Amy’s burden of her husband’s treatment, making her more happy, free, and less tired.

The Care Transitions team implicitly practices MDM, looking to simplify medical care for their patients. This indicates that the concept of MDM could be more widespread than previously believed, making it challenging to track and accurately assess how many care teams use MDM. This creates wide implications for how researchers ought to understand and track the spread of MDM. Knowledge of the term does not indicate use of the theories and philosophies behind it, and thus cannot be the sole way researchers look for other clinics using MDM, form collaborations, and provide resources for “MDM” clinics.

Deeyar Itayem is a third-year student at the Mayo Clinic School of Medicine. As part of her clerkship in family medicine, Ms. Itayem responded to a writing prompt meant to develop her thoughts about the role of a primary care physician. The prompt: “The ideas behind MDM or contextualized care ask us to respect the needs and circumstances of the patient before us as we construct our care plans. But that puts us in a weird spot, yes? Because just as MDM is this decade’s push, last decade’s push was evidence-based medicine: the idea that, through science, we can find a ‘best’ way to handle a problem, a ‘best’ treatment. It becomes our job to apply the evidence with less and less spin to it, if we dedicate ourselves to EBM purity. With that in mind, what is your opinion of the Minnesota Community Measures’ “D5” criteria (http://mncm.org/reports-and-websites/the-d5/)? What are the risks and benefits of adopting guideline-driven care? Do the D5 measures reflect a friendly contextualization of care?” Ms. Itayem’s response follows:

My first day with Dr. Lillie in clinic, we began with a meeting to discuss diabetes management of her panel. To ensure that patients were meeting goals, the team of nurses and panel assistant hovered over pages that were covered in colors that were intuitive – green was good and patients were meeting all the goals, red was bad and patients were not meeting the goals. Even listening for a minute or two, you could pick up on the dilemma: Anyone whose HgbA1c was above 7% was automatically in the red.  Despite significant improvement in HgbA1c from 11% to 8.9%, this particular patient was still in the red and was not budging. The Minnesota Community Measures D5 criteria set the rules of the land, another checklist that was initially hard for me to swallow. We have had so many lectures on the importance of checklists, and I can see how useful it can be to measure all diabetes patients with 5 simple measurements. But a part of me cringes at the simplified boxes. You can easily review the green and red boxes in the panel to make sure patients don’t fall through the cracks. However, the colored boxes didn’t tell the whole patient’s story. There was no disclaimer that described the socioeconomic reality of the patient, no blue box on the side to say that depression plagued this patient, no asterisk to report the significant improvements.

Immediately after the D5 meeting, Dr. Lillie sent me in to talk to my first patient who happened to be one on the panel. I walked in to introduce myself to find the patient with the D5 sheet in hand, all the boxes neatly filled out. “Green. Green. Red. Green. Green,” I said in my head. Our conversation initially centered around the numbers, how her cholesterol was “good,” daily aspirin intake was exactly as recommended,  her A1c was sooo close to 7% but red, etc. The conversation went easier as the goals were mutually agreed upon. But then I asked her to put the D5 checklist aside for a second to tell me how things were going. How was eating and exercising? How was she enjoying her days of retirement? Did she feel safe where she lived? Those were more the difficult conversations.

My experience thus far with the D5 criteria has been generally positive in that it gives patients specific measurable goals to make diabetes management tangible and the goals clear. To attain any health improvement, the importance of clear goals have been drilled into us through our “Motivational Interviewing” class. But as simple as you drill it down, diabetes is complex and the lives of the patients it consumes are likewise more involved than 5 checkboxes. The fact that it standardizes diabetes care is admirable, but it doesn’t replace the medicine that we’ve learned. What worries me is how my patient viewed it as a substitute to our conversations about her own goals. Once she hits all of the 5 goals on D5, is she done? Instead of teaching our patients how to make their own goals and crafting a culture of self-improvement, we’ve replaced that beautiful process with 5 rigid boxes standardized across the state.

Upon further research, I found websites touting D5 criteria scores for specific clinics in Minnesota. Physicians are being held accountable for their patients attaining 5 specific goals. My question is – do these scores reveal more about the physician’s worth or do they tell us more about the population they serve? Just as standardized test scores are used to assess a school’s success even though many factors play into that score. It is the same discussion. Are standardized tests important? Of course. Should a student’s score matter more than their improvement or the context of the score in their life? Hmmm.

Looking forward to navigating the checklists to come in my career. Hopefully, their implementation will help my patients receive better care, but I cannot help but cringe at the way they simplify the intricate patient lives. I hope we continue to treat patients instead of their diseases.