Evidence 2010 and minimally disruptive medicine

By Victor Montori

On November 1 and 2nd, clinicians, policymakers, and methodologists got together at the BMA House in London, UK for the Evidence 2010 meeting.  The BMJ and Oxford’s Center for Evidence-based Medicine convened the meeting and it was a major success.

I had the opportunity to participate as a keynote speaker opening day 2.  While I can summarize my presentation (the content and slides are elsewhere on this site), the colorful summary published in the BMJ does a much better job.  You can read it here.  The key paragraphs follow:

His strategy combines better explanations to patients of the benefits they may be missing, and giving them a chance to “choose their own poison” by taking them through the treatment options in a gentle conversation. A patient who has been given a choice is more likely to adhere to the treatment, whatever is chosen, he believes.

He also believes in “minimally disruptive medicine,” trying to devise a strategy that does not leave the patient spending hours each day organising his pills, arranging tests and appointments, and worrying about his disease. For a diabetic patient with multiple co-morbidities, doing this can turn into “a part time job” Dr Montori said.

Language needs to be changed, too. “LDL cholesterol is not a word” he asserted. “I have to talk to my patients about living longer, feeling better, and living unhindered by the complications of the disease. If I can’t do that, I shouldn’t be treating them.”

I am grateful to my colleagues at CEBM and BMJ for the invitation and I look forward to Evidence 2011.  I will post an update here when the organizers post the video of the presentation online.

 

 

Normalization Process Theory and minimally disruptive medicine

by Victor Montori

I have just spent a glorious week with colleagues in the UK who are all pioneers in formulating a sociological theory of work called Normalization Process Theory.  We were brought together by the very generous Carl May, the convener of this group and key intellect along with Tracy Finch, Tim Rapley, and several others behind NPT — all “eminent, esteemed, and lovely”.

I was given the opportunity to share some notes about fitting healthcare to the patient using shared decision making and minimally disruptive medicine and how we were using NPT to support this work.  My presentation is here:

During these proceedings, the official website (which is curated by the developers as opposed to the otherwise accurate wikipedia page version) for NPT was launched, including the very useful NPT Toolkit, currently in beta.

The NPT toolkit boils down the theory into 16 questions.  The point of working thru these questions is not to reach an answer, but to think through — while addressing these questions — the process by which an intervention, a study, a treatment will become implemented, enacted, embedded, i.e., normalized, into existing routines.  The questions are challenging and invite thoughtful discussion.  I want to start using these with patients to uncover the work of adhering to complex medical regimens.

The developers are anxiously waiting for users to provide feedback and promise to be responsive.  Since this is the theory underpinning minimally disruptive medicine, my enthusiasm for a toolkit that will make it more accessible to practical people is very high.

The other attractive feature of the toolkit is the resulting report.  While this gives a sense of “destination” — when I say above that the “journey” is where the value lies, the plots suggest the notion of footprint that I have found so critical to understand healthcare in the lives of patients.

Go explore the site and post comments there and here.

Minimally disruptive medicine talk on YouTube

The great folks at the Mayo Center for Innovation have published last year Transform symposium talks on youtube.  These include the first public presentation about Minimally Disruptive Medicine and Maggie Breslin’s classic on the power of conversations in healthcare.

What has happened in the last year?  Our international research team continues to work hard to define the concept of treatment burden for patients and caregivers and make it measurable, we are looking into clinical visits video recordings to explore the nature of these conversations, and we are working with partners to further consider these goals in initiatives such as the patient-centered medical home.  Lots to do!

Minimally disruptive medicine at the Transformation Symposium at Mayo Clinic

We had the opportunity to present on Minimally Disruptive Medicine at the Innovation Symposium (Transform) at Mayo Clinic on September 14 2009.  The video of the presentation by Victor Montori is here (scroll down to find it). 

Another member of our team had an AWESOME presentation as well — in fact the majority of the presentations of this symposium brilliantly organized and conducted by David Rosenman, my friend and colleague, were incredibly good and illuminating.   Maggie Breslin closed the symposium with a passionate call for meaningful conversations in healthcare.  Plain true and brilliant.  You can find that video at the same website.

Enjoy!

Minimally Disruptive Medicine in the BMJ

The article is out!  You can review it here.

The BMJ frontmatter says:

A man being treated for heart failure rejects the offer to attend a specialist clinic because in the previous two years he has made 54 visits to similar clinics for consultant appointments, diagnostic tests, and treatment. According to the authors of this analysis paper, this case and others highlight the need for minimally disruptive medicine that seeks to tailor treatment regimens to the realities of patients’ daily lives.

A theoretical underpin

How things become part of routines

Carl May and others have developed a theory that explains how complex interventions get to be part of the routine work of complex systems.

While initially motivated by the need to implement tele-medicine in the established health systems, this theory, called the Normalization Process Theory, is robust enough that we can use NPT to illuminate our  understanding of the processes that hinder or promote the normalization of treatment programs in the daily routines of patients.

To learn more about NPT you can visit here.

MDM discussed at EBM mecca

Coinciding with the June 2009 How to Teach Evidence-based Clinical Practice workshop at McMaster University, Victor Montori was invited to present Medical Grand Rounds.

His presentation Patient Disobedience challenged EBM to consider its application to patients with multiple medical conditions and poor treatment adherence, and introduced the concepts of FIT and Minimally Disruptive Medicine.

The slide show (without performance) is available here.