Upcoming MDM Workshop

MDM Conference Blog

You may have seen some buzz on social media about a course in Minimally Disruptive Medicine and Shared Decision Making that we are offering for the first time this year. We wanted to give you an inside scoop.

Should you attend? If you are a physician, nurse, or healthcare provider (quality improvement specialist, pharmacist, social worker, health coach, care coordinator, etc.) interested in applying principles of patient-centered care at the front lines, YES! If you are a researcher or patient advocate interested in these topics, YES! Here’s what will happen during our time together.

Tuesday, September 27th, we will officially open the conference in KER Unit fashion with a wonderful cocktail hour and welcome reception. Then, September 28th and 29th, each day will have: one opening plenary and closing talk, two large-group workshops, a small group breakout session. (Don’t worry we have coffee breaks, too!)

Everyone will get to participate in all four large-group workshops on: 1) ICAN in practice 2) actions for Minimally Disruptive Medicine in practice now 3) in-encounter shared decision-making, and 4) user-centered design to develop patient-centered care strategies. Every participant will get a chance to attend two small group breakout sessions designed to facilitate discussion with experts in each topic. These are opportunities for participants to go more in depth with ideas they discover during the plenary sessions and large group workshops and wish to dive deeper into content.

We have planned for plenty of time for you to network with experts and with other like-minded individuals across institutions through long lunches at nearby local restaurants, two planned networking opportunities, as well as more time for socializing and a sit-down dinner Wednesday evening.

We have put a lot of heart into this content and we want your input too! If you have a specific interest you would like us to cover during the course or any questions, please feel free to reach out to us by email at boehmer.kasey@mayo.edu or on Twitter @kerunit.

Where can we apply the MDM? An Experience in Family Medicine

I write these reflections as a senior medical student in Lima, Peru.  The clinical rotations were most attractive to me as they were packed with opportunities to face diagnostic challenges and craft treatments for complex health problems. This was fun, but more awaited me as I took on a rotation in the primary care center. I did not expect much would come of this, until it did.

My experience in ambulatory care involved patients not really heard or examined properly treated in ways that lacked clear scientific basis. I was surprised by how often patients were treated as a person in the family medicine clinic. Focusing beyond the disease, clinicians took time to hear the complaints and reasons for the consultation, to acknowledged the context of each person, and to discover the patient’s story, the complete one.

Loving Care

Without dividing the patient into specific organ
s and systems, I saw the value of a holistic approach. With this perspective, it is evident that the whole is not equal to the sum of its parts, but is enriched by their inter-relationship. The biological, psychological and social spheres of a person substantially influence each other and their health. Thus solutions require multidimensional thinking. For example, a patient with diabetes, hypertension, coronary heart disease, knee osteoarthritis and low back pain cannot achieve optimal health if abandoned at home with no interaction with others. The patient may also have negative ideas about their current living conditions. Family medicine takes these aspects into account and listens to the patient to propose comprehensive solutions, and the process of identifying and vetting them should be informed by the best available and pertinent research evidence. Medical decisions are not made for the patient, but with the patient, empowering patients and engaging in shared decision making (KER Unit SDM).

The new paradigm

Understanding the health needs and expectations of each patient, and understanding what problems the patient wants to solve and how it may affect other areas of the patient’s life is central to the practice of family medicine and of the medicine I would like to practice. I have found these principles in Minimally Disruptive Medicine (MDM), a humane, conscientious and comprehensive health care model that pays special attention to the work of being a patient. I see MDM as naturally fitting in the work of family physicians, and in my professional activities once I become a physician.

Christian Abelardo Siccha Sinti

Christian Siccha
6th Year medical student
Lima Peru

Helping to reduce the burden of taking 83 pills a week – A nurse’s perspective

I had a patient recently (a male in his late 60’s), whose treatment plan includes taking 83 pills a week! Pills he cannot easily afford and often neglects to take. I met with him to do a medication reconciliation recently and started by asking him what “matters to you”. He said “getting my house in order”. I asked what barriers he might have to doing that and he smiled and said “all these pills!” So that’s where we started. I helped him take all of the pill bottles out of pharmacy bags, new prescriptions ordered the week before, bottles in bags stapled shut and unopened. We went through a list together marking “morning, noon, evening, and night”. We talked through what the pills were for and when and how to take them. He verbalized understanding with teach back, a bit overwhelmed, but smiled as he said “a small fortune here!”. He was given a new, larger pill box, actually two, and a larger plastic tub for all his bottles. He left feeling “more in order” as he said. I wondered about getting him a security guard to protect the patient and ‘his loot’ on the way to the car!

I called the patient’s primary care physician and expressed my concerns over the number of pills this patient, who by the way also had early stages of dementia ( part of the new medications we took out of the unopened bags and bottles) was taking. The physician said he had no idea how many pills it added up to! The primary care physician said “I’ll take a look, but unfortunately each of his specialists feel strongly about what they are treating him for (diabetes, COPD, early onset dementia, urology and cardiac) and I’m not sure who might feel their medications are less important.” An appointment was set for a review of the patient’s med list with the primary care physician. The patient rescheduled this appointment, and the next appointment he ‘no showed’. Perhaps overwhelmed?

How difficult it is when the treatments for ‘optimal’ health supersedes living optimally! Such a burden we unfairly place on patients in healthcare sometimes. New meds to try, old meds we rely on.

I’m not giving up though. I will continue to help this patient lighten his load so he can run the way he desires, as much as he is able, in these next few years! Now, we just need to find out how to encourage him to get to his next appointment, but those barriers are another story!

Through all of my day, thinking about my patient’s priorities and ‘what matters to them’ has changed how I approach transitional care for my patients. I have “what matters to me” on my wall to remind myself to keep my needs and wishes in perspective too. I meet patients with their priorities and capacity in mind. It’s a start, but it’s making a difference in my nursing care!

IMG_5161

 

Renee’ Herman, RN, BSN, MHSA
High Risk Transitional Care Coordinator
Saint Luke’s Hospital

50 Courageous Years as a Diabetic Patient

I would like to thank the KER Unit for allowing Karen and me to be a part of the Diabetes Research Advisory Group for the last eight years.  I feel it has been a rewarding part of the relationship between the doctors and my care at Mayo Clinic.  I would also like to take this time to give a huge and sincere thank you to all the diabetic caregivers and family support we need for our chronic condition.

I have been Type 1 diabetic since age 5.  I never knew life without anywhere from 2 to 6 shots a day every day.  When I started in 1959, the only way of testing the sugar in my blood was by using urine test strips.  And then the only way of knowing when it was high was when it bright green.  This meant it was already too high and I needed to do something to get it down.  On the other end of the scale, I would go into reactions so we knew it was too low and I needed some sugar to bring it back up.  I started my day with a routine of checking my test strip and then sterilizing my syringe and needle before filling the syringe with the insulin the doctor had prescribed.  My sister has told me that she never came down the stairs to breakfast until after I was given my shot, because, she did not know if it was a screaming day or a crying day and the “doctor office smell” in the kitchen was not pleasant.

As the years went by, the insulin changed every few years and with it came changes and complication for my care.  I was told once that the old insulin would build up in my system, and as I changed to the updated insulins, the old insulin reserves would let go and send me into a  reaction.  I had this happen time and time again.  I have gone through every phase of insulin infusion there was up to 2005.  From the glass syringe with stainless steel needles, using an injection device to make the needle go in much faster to disposable needles to the pen and finally to the insulin pump for the last 7 years I needed the insulin.

I never knew life without my diabetic doctors and their staff.  I have been a part of Mayo since 1962 when I was transferred here for my brain tumor and diabetic care with Dr. Allan Frethrum on 9 Plummer.  I have ridden the ambulance too many times to count and have spent time in every hospital that was and part of Mayo.  I am proud to say that without my wonderful caregivers, wife family and friends, I now am a 50 plus year survivor of diabetes, cancer and a pancreas transplant.

On August 14th 2005, I received the greatest gift from a donor from Colorado of a pancreas.  I am now 10+ years as a normal everyday human being with no restrictions as to what I can and cannot eat.  I have the best care in the world right here at home and 30 minutes away at Mayo.  I am proud to also say that I have not spent 1 day in the hospital in over 10 years.  Thank you, Thank you, Thank you caregivers and Mayo.

Submitted by Gary Hahn
Gary Hahn Gary Hahn metal

Making a difference one clinician at a time

Submitted by Renee Herman

I wanted to start my day by sending you a “thank you!” for your work.  I have no awards to give you, live applause from the audience, or notations that reference your terrific work in journals. Today, from me, I can only give you the experiential, warm hearted “thank you!”

Almost two years ago now, I accepted a position here in the heart of Kansas City (literally a bi-state city) at Saint Luke’s Hospital ‘on the Plaza”.  We are a part of a larger health care system, but this hospital is the heart of the system, in the heart of the city. My ‘title’ has changed several times, which tells you the changing dynamic of what I do.  Most recently, I wear the title of “High Risk Transitional Care Coordinator” which in its simplest description is a role whereby I identify or get referrals for those high risk, complex care, often chronically ill patients who are underinsured and under resourced. From May to December 2014, I received over 150 referrals, and this past year, had over 200.  These referrals came from all over the acute care setting, but also extended into the post acute care setting including several Patient Centered Medical Homes (PCMH) and Saint Luke’s Home Health Care and Hospice team.  In the acute care setting, I have had referrals from the Emergency Department where our high risk patients are some times first identified, to all inpatient units, including transplant units for heart, kidney and liver. Most often, the referrals come from frustrated staffs who just ‘don’t know what to do with this one’. So, they call me.  There are plans to expand this role into a ‘department’, but in this every changing healthcare environment, new programs like this one that was funded as a ‘pilot’ by a grant, often have as the number one question, “Where do we go from here?.”  So, for now, I am the “department” though I have  found great support by working with area ‘safety net clinics’, other community services, and terrific Community Healthcare Workers who often assist me.

In the midst of gearing up with information for this role, trying to understand my patient population so that I could give them the care and service my patients really needed, I found about your work at Mayo Clinic.  I’m a Minnesotan by birth and have visited Rochester since I was young (side note: it’s where I first learned about the power of illegal drugs from a video I saw at a Mayo learning center. It greatly impacted my life as a grade school child.). I watched Mayo Clinic grow from a ‘hospital/clinic’, to now a ‘health care system’ occupying city blocks! The strong feelings I have about Mayo’s reputation for quality and patient centered care set the stage favorably for you, even before I listened to you on an IHI radiocast.  Again, Mayo Clinic lived up to its reputation in my life and when I heard you talk about your work, it literally made me cry with excitement.  Finally, someone within the medical profession ‘gets it!’  I was seeing what your were describing in my patient population and right then, could name many of my patients who were really trying, but not succeeding, and suddenly it all made sense as to ‘why.’

Now, in working with my patients, I try to really hear them as they set out for me in their own words, what they can and cannot do to manage their own health care. Sometimes, they show me by what they are, or are not doing, what ‘really matters to them’.  It makes sense to me now and I can better explore with them their feelings of ‘never quite feeling like they are ‘measuring up to what they’ve been asked to do by their Doctor or health care team.  Some have even said to me, “It’s impossible!” and now, I can agree. When I ask patients “What Matters to You”, they often look at me and say, “No one has asked me that before”, and they go on to tell me. Interestingly, what seemed “impossible” for them, when broken down into ways that are manageable and meaningful to them, seem more “possible”.  I have story upon story of patients whom I have helped in the “transition” between the hospital and home, the “transition” off of home care and into the PCMH, and from ‘managed health care’ that was put upon them, to ‘self management’ of care that fits with their healthcare priorities.  From the End Stage Renal Disease patient who rides an electric wheelchair daily for 45 minutes to dialysis by bus because she wants to live independently in the only subsidized apartment she could find (we were able to get her a bed, which was what ‘mattered to her’ in her health care plan), to the Heart Failure patient who was illiterate and labeled ‘non-compliant’ (we helped him to log his weight daily because he could read numbers and his ‘self management ’ confidence rose significantly because he now had something he could do to show he was trying to follow his treatment plan, and that was what ‘mattered’ to him),  my ‘tool box’ of ‘helps’ and understanding, has been significantly aided by your work. We have long way to go to actually ‘do’ what your work has shown would actually transform the care of our complex care, chronically ill patients, but even in the basic ways I’ve applied your studies, I’m finding increased satisfaction in my work, less ‘burnout’ from ‘trying to make patients do it our way’, and positive outcomes in the lives of the patients I’m asked to help.

So, from the heart of a very grateful nurse (one who has been in the profession for greater than 35 years and is still learning!), I say “thank you.”  It’s cold here…and I know even colder there, but hopefully today, your heart will be warmed knowing you are making a profound ‘experiential’ difference in the lives of caregivers and patients. Thank you. Thank you.  Keep on!

Renee Herman

Renee’ Herman, RN, BSN, MHSA
High Risk Transitional Care Coordinator
Saint Luke’s Hospital

Minimally Disruptive Medicine

Submitted by Kasey Boehmer

Monthly, we meet to discuss MDM topics. While we often talk about patient capacity as one thing, last month we had an interesting discussion about three different types of capacity:

1) The capacity to fight, particularly when a diagnosis of a chronic illness is given, an acute exacerbation occurs, or another important life event occurs that interferes with the ability to care for an existing condition.

2) The capacity to cope with both the work of patienthood and life. In some ways this is tied with normalizing the work of being a patient in light of competing priorities: making sense of it, planning it and enrolling others for help, enacting the work, and appraising its worth.

3) The capacity to thrive, which consists of the ability to author ones own story and make a meaningful life with and in spite of living with chronic illness. This capacity may follow the first two.

We discussed that these may be sequential but people may also move backwards and forwards between these phases during different points in their journey with chronic illness.

Finally, we briefly discussed the differences and similarities between the Chronic Disease Self-Management Program (CDSMP) and Capacity Coaching, which are both components of a minimally disruptive approach to care. CDSMP deals more with self-management and the capacity to cope with the complexity of chronic illness. Capacity coaching, aims to foster the patient¹s capacity to thrive. It helps people decide what story they want to write, and then asks questions to help them consider if that story is reasonable and how they might get there.

ICAN Tool

Submitted by Kasey Boehmer

We have had many clinicians ask us what using the ICAN Discussion Aid is like in busy practice. We have had questions about what value it adds to the clinic visit from both the patient and clinician perspective, as well as how long it takes. I sat down to talk with Dr. Summer Allen in this brief interview and pose some of these questions.  Dr. Allen shares her first-hand perspective regarding ICAN from her participation in the development process and from using it in her practice.

 

 

A patient’s story

Submitted by Kasey Boehmer

A couple of weeks ago, I had the opportunity to catch up with a member of a family who have all together struggled with their own chronic health conditions. Their story resonated deeply with me, as it highlighted both the incredible amount of work they have taken on to manage their conditions and get the best care, as well as how this work drew on capacity that they could have better spent on the things where they find joy. This patient was kind enough to summarize the story and allow me to share it:

Caring for a 21-year-old daughter with complex, chronic conditions that have required years of finding the right specialists and other medical practitioners.  Drug and other regimens have been exhausting for her, her mother and me.  I, too, suffer from different complex and chronic conditions that are similarly exhausting.

That we are both successful, high-functioning individuals does not ameliorate our struggles in any way, other than we are more adept at working with our medical teams (which have created on our own, owing to the lack of a Mayo model despite “world-renowned” medical institutions in our area).

My wife, who has to care for both us, has had to neglect her own medical needs from time to time as a result of her attention to me and my daughter, and the costs associated with our care.  We have a son who is perfectly healthy, but he has had to bear the burden of having two family members draw down multiple family resources:  cognitive, emotional, behavioral, and financial.

In essence, we have had to create your own Minimally Disruptive Medicine. We have able to do so because we are both professionals, with strong networks of physicians and other health professionals, and with highly flexible work schedules as contrasted with most patients and caregivers.  Nonetheless, even with these capacities, our chronic care needs have detracted from using those resources for other things that we love, value, and enjoy doing, including our careers. Wouldn’t it be nice if the healthcare system created MDM for everyone, so that we and others didn’t have to marshal so much of our capacities for making it happen?

Bringing health and health care issues to the forefront

Submitted by Madge Kaplan

Every now and then, as IHI’s Director of Communications and the host and producer of WIHI, I get the opportunity to bring forward issues health and health care improvers are particularly wrestling with. These are issues born of one of the hallmarks of quality improvement – innovation – but they can easily fall between the cracks and fall off schedules because sometimes the implementation requires a fundamental change in mindset and attitude among health care providers most of all. Victor Montori’s leading edge work on Shared Decision Making (SDM) and Minimally Disruptive Medicine (MDM), and the contributions from his team, fits into a tension we often come back to on WIHI: whether health care is serious about getting to know and respond to the needs and real lives and contexts and experiences of patients or pay lip service to the same while going about its own business.

I’m hopeful it’s the former. IHI’s “What Matters” initiative, which shares many of the same principles as MDM, is gaining traction; Don Berwick’s recent call for an Era Three for the health care quality improvement movement, has reminded many of the centrality of the provider/patient relationship that must be protected especially in the midst of health care transformation; and there are new concepts such as “co-production” that are helping to frame this brave new world of doing with patients rather than doing to them.

So, let’s be optimistic that the several hundred who tuned into the live broadcast of the January 28 WIHI with Dr. Montori, Kasey Boehmer, and Dave Paul from the KER Unit at Mayo, along with IHI’s Andrea Kabcenell, are going to think differently about the next discussions they have with patients with chronic conditions. It was also a treat to have Dr. Montori live in the WIHI studio, so much so we did some additional videotaping and produced these equally inspiring clips. Let’s keep the conversation going!

Madge

 

Madge Kaplan is the Director of Communications for the Institute for Healthcare Improvement.