Category: Reflections on MDM

MDM in practice, Reflections on MDM, Views from the frontline of care

Minnesota to be first in nation to embrace ‘goldilocks’ medicine

This week marks the potential start of the implementation, evaluation, and eventual adoption of minimal,y disruptive medicine in Minnesota. Three events marked this week.

The first one involved the formation of a team that will be implementing MDM in a primary care practice. This iterative effort will involve identifying complex patients and figuring out what healthcare and the community can do to reduce treatment burden. This effort will be oriented by the application of the cumulative complexity model based on normalization process theory and the insights we have accumulated from interviewing patients.

The second development involves the publication in Minnesota Physician of an article about minimally disruptive medicine. A similar piece will be published in their publication for patients. The dissemination of the concept I thing creates the space and mind frame for experimenting with care delivery models with an underlying approach to care, not just with an underlying approach to reimbursement. The former being much more exciting and motivating than the latter.

The third development took place April 4th 2011 in Saint Paul, MN. Möbius Inc convened a citizens meeting to discuss healthcare. I was in the first panel along with Dame Jo Williams and Sanne Magnan from ICSI. Sanne and I turned to do a 1-2 on healthcare as we know it, making a big push to redesign the system, reducing it’s footprint, and pursuing more health based on community action. Groups got together later in the day around their areas of passion. Our group started working right away looking for ‘bright spots’ (AA, diabetic bus, habitat for humanity), thinking about pilot projects; and job-creation schemes that will connect the isolated, connect existing resources to people that would benefit from these but does not know of them or of how to access them (e.g. Dial 211). We were able to present our findings to the Commissioner of Health and other officials. Citizens power was never so palpable, and that some of them rallied behind goldilocks care is just awesome. More to come soon!

Reflections on MDM

Minimally disruptive medicine – the change must come from doctors

By Kate Gilbert (www.d1.org.au)

Minimally disruptive medicine acknowledges the lies that quickly become part of the doctor-patient relationship.  As long as the relationship is about a doctor doling out treatment to a patient assumed to be a willing and able recipient, we are going to have a problem.  ‘Non-adherence’ by the patient is one way to characterise the problem.   Misguided folly by the health professional is another.

When I heard Victor Montori introduce Minimally Disruptive Medicine to an Australian audience last year (video available here: http://www.evertechnology.com/NMS2010/P4a/fHI.htm) I felt like I was listening to one of the most effective patient advocates I’d ever heard.   And he’s not a patient, but a doctor!  I couldn’t wait to share this new concept with other people with diabetes, and the enthusiasm spread quickly, spawning discussions about doctors’ incapacity to relate to patients, the stress and guilt caused by over-burdensome treatment regimes and more (see http://www.realitycheck.org.au/RCforum/viewtopic.php?f=1&t=8662).

I was reminded of Daniel Pink’s Four-Word MBA: Talk less. Listen more. (http://www.danpink.com/archives/2010/10/the-four-word-mba). This is strongly evident in developing the concept of MDM, and the same principle lies at the core of this new approach to medicine.

Victor isn’t the first person to acknowledge there’s a problem.    Patient-centred care has been trying to get traction for ages.   In my part of the world, ‘self-management support’ has received reasonable interest.   But whilst I have followed this with interest, hoping it may reorientate the clinician-patient dynamic, it has had limited impact, and the medical profession has not embraced it.  Perhaps an unfortunate side-effect of its name, self-management support is too often orientated towards the professional and his/her role so that even though it calls for change in that role, like most changes in health, few people implement it completely and we are too often left with people holding a strengthened view of their powers as a health professional to bring about transformation in their clients and limited real change in the relationship.   Meanwhile, I pack out auditoriums whenever we put the topic of ‘Diabetes Burnout’ on the agenda – people with diabetes know the problem all too well and jump at the opportunity to hear and share in that discussion.  Minimally Disruptive Medicine (MDM), in name and in practice, is very clearly oriented to the impact of care on the patient, and a promising place to start bring about critical change.

Montori’s early presentations on MDM have focused strongly on the rationale for a new approach, and only more recently is the next chapter emerging about what this new world might actually look like.  The rationale he presents is irrefutable, clear and compelling.  There wasn’t the zeal of a new fad (which always scares me off, I have seen a lot of fads come and go) but rather it has the passion of a new discovery that has to be shared.   I am looking forward very much to Victor bringing this same clarity and passion to the solution: developing and spreading MDM as a new approach to medicine.  Whilst I am delighted that Victor and colleagues are actively listening (there’s that word again) to patients and patient groups about our needs and views on MDM, and we can strongly support the rationale and be demanding of the change, the actual approach must come from within the doctors whose world will be changed.

Minimally Disruptive Medicine is an important truth, beautifully and intelligently executed.

 

MDM in practice, Reflections on MDM

More about reducing treatment burden – this time from burden “caused” by patients

Dr. Michael Wolf and his team from Northwestern University have published an interesting article in the Archives of Internal Medicine looking at the complexity in medication intake. We had reported on a case like the ones explored in this study in our original Minimally Disruptive Medicine paper.

In this new study, the authors conclude that:

Many patients, especially those with lim- ited literacy, do not consolidate prescription regimens in the most efficient manner, which could impede adherence.

Although this study consisted of a simulated situation, it is indicative of patients approach to medicine use (without the assistance and input of other team members, such as a spouse which in my experience often assists with these tasks). In this study, patients with low literacy complicated their program!!  This means that the patient unwittingly contributed to increase their own disruption.

Arguably, this happens because patients do not have the knowledge, skill, or self-efficacy to treat medicine schedules as they treat picking up the kids or brushing their teeth.  These are activities they understand in their nature and consequence and as a result they can modify to make very efficient (like applying lean to your own life…lean consumption).  But this is not available to these patients regarding the meds.  As a result they overly complicate their routines!  Fascinating, and a great opportunity for minimally disruptive medicine.

MDM in practice, Reflections on MDM, Views from the frontline of care

A patient ¨pushes back against physicians¨? Minimally disruptive medicine brought about by patients

This post in the Wall Street Journal highlights a point of view to which I keep arriving: clinicians may not be able to bring about changes in healthcare consistent with minimally disruptive medicine unless patients demand it.  A real patient revolution will be necessary to help clinicians realize a future that — as I learned from Judt — they cannot make happen because the ideology of the healthcare industry does not allow them to imagine it.  But patients may not yet be help by the same limitations.  This WSJ post is therefore, to me, a manifestation of hope.

MDM in practice, Reflections on MDM, Views from the frontline of care

How I came naturally to minimally disruptive medicine!

By Kevin Larsen, MD (Chief medical informatics officer, Hennepin County Medical Center)

I really love this concept since I first saw the opinion piece. I think I came to this naturally growing up with a brother who is a type 1 diabetic. In the early days of diabetes management it was maximally disruptive medicine – managing your life around your diabetes. Type 1 self management revolutionized this and when done right puts the patient in control of managing his/her own diabetes around their diet, lifestyle etc. I try to bring this approach to all of my patients conditions whenever I can.

Another aha! moment I had around this was at a site visit to a hospital in Panama. They had developed a program called “hospital at home.” Nearly all non-ICU patients had a one day stay or less in the hospital. The hospital arranged for doctors, nurses and therapists to go to the patients home, often multiple times a day to deliver care. They proved they had better outcomes with less falls, less delirium and it cost much less money. Plus patients loved it.

MDM in practice, Reflections on MDM, Views from the frontline of care

Minimally disruptive medicine finds a home in Minneapolis…

Over the last few weeks it is exciting to see the concept of minimally disruptive medicine take off.  At the IHI meeting, Maureen Bisognano highlighted it as an example of fresh thinking about patient-centered care.  In Minnesota, Mark Linzer and his team at Hennepin County Medical Center are considering implementing an MDM clinic to help the myriad of patients with multiple chronic conditions, burdensome workloads and reduced capacity (mostly through poverty and its accompanying maladies).

Mark says:

I have been trumpeting the idea of an MDM (minimally disruptive medicine) clinic all day, from a morning meeting with the head of our EMR to a noon meeting with the director of our journal club and a leader in evidence-based medicine, and at an afternoon meeting with our health care reform work group where i spoke about MDM being the basis for the future of health care in our county (through an ACO).  This concept has truly affected us!  I believe i can find some willing partners for a pilot of an MDM clinic at Hennepin County Medical Center!  The idea of doing MDM as a way of using only technology or medication for which there is excellent evidence of benefit and in a way that is minimally disruptive of the patient’s lifestyle, is one that is fascinating all of us right now!

This is really awesome and the MDM team at Mayo is very excited about the potential for this partnership, a fantastic opportunity to test Minimally Disruptive Medicine as a philosophy of care for patients with multiple medical conditions.  Thanks Mark and a big ‘thank you’ to your team!

Reflections on MDM

Designing the ecosystem to make the work easier

by Victor Montori

While in London, I had the chance of reconnecting with J. Paul Neely, a brilliant designer with whom I had the pleasure of working when he was at Mayo as part of the SPARC Innovation Program.  He is a Masters student at the Royal College of Art and he thought his peers would enjoy learning about our work.  After I presented my talk, a team that is intent on designing out medical error showed their efforts to redesign the hospital bays to ensure health professionals wash their hands.

After much discussion, it become clear that both sets of projects were not about designing a solution, or a system of solutions, but rather they were about redesigning the ecosystem in which the work occurs — the work of being a chronically ill patient or of being a health professional —  and engineering that ecosystem to make that work easier, minimally disruptive.  Ohh!! Love it when ideas from different backgrounds, disciplines and foci have a chance to collide and reproduce!  Thanks J. Paul!

Reflections on MDM, Views from the frontline of care

Challenging my colleagues

By Victor Montori

I am often on the road discussing minimally disruptive medicine with colleagues elsewhere. For some reason I never hear disagreement with the basic statements of concern (we are responsible for some of the non adherence by virtue of our endless and uncoordinated demand for more work on chronically ill patients with multiple comorbidities). When I suggest something needs to be done about this, e.g., reject disease specific quality and performance measures, work for integrated care around patient needs, assess and reduce treatment burden, I get a sense of impotence, of inability to create change, to truly advocate for the patients’ interests. Why do you think this is the case?

When patients opt out of their medical care, we think it is because they may be ignorant about the implications of disease and the effects of treatment.  This intentional noncompliance sounds to me as a target for improved communication and education.  Even shared decision making.  If patients make informed choices about what to do and what not to do, that is not noncompliance.  That is informed patient choice.  An exercise of people’s values and preferences with full understanding of the opportunity costs of taking and not taking action in their specific context. This is sometimes confused, but some folks understand it – e.g. this article in LA Times.  The focus of my attention, however, is poor treatment fidelity – poor follow-through with an agreed upon plan of action.

Poor treatment fidelity can be caused by our transferring to patients the demands for optimal care we feel as part of misguided performance improvement campaigns, by poor care coordination, and by blindness to the burden of treatment and to the (limited or shrinking) capacity that patients and family have available or able to muster to implement treatments.  It is this reality that is within our reach and, as I indicated in the first paragraph, it is something about which I find professionals feeling impotent.  Why?

My colleague Barbara Koenig pointed me to this article by the late historian Tony Judt commenting on the work of Czeslaw Milosz and specifically on The Captive Mind.  The key phrase Judt offered that seems pertinent to this discussion is: “Above all, the thrall in which an ideology holds a people is best measured by their collective inability to imagine alternatives.”  Is the impotence I have observed the result of this inability to imagine alternatives?  Can minimally disruptive medicine offer these?

MDM in practice, Reflections on MDM

How negative studies can help with minimally disruptive medicine?

By Victor M. Montori, MD, MSc

Harlan Krumholz is a healthcare hero.  He has actively campaigned against the corruption of healthcare and has received attacks aimed at him personally and professionally.  He has formed a cadre of rigorous researchers in cardiovascular outcomes research who meet regularly. He is now the editor of the leading journal in this space.   He is an independent thinker, a productive researchers, and a supportive and loyal mentor to his peers and students.  The opportunity to express my admiration comes from the publication of Harlan’s op-ed in the Washington Post that directly relates to the topic of this blog.

For minimally disruptive medicine to take place, clinicians and patients need credible research evidence about what works, how much interventions are able to accomplish in terms of patient-important goals and outcomes, and what are the harms and costs to pay to get those benefits.  Both positive and negative trials (the latter referring to those who find conclusions of no difference between a new intervention and no intervention, placebo, or the standard of care) are essential to this mission.  However, negative trials are less likely to be published which furthers the notion that most of medicine’s treatments on average are effective.

Harlan’s Op-Ed makes a strong case for supporting, publishing, and celebrating negative trials.  And this is important for minimally disruptive medicine and to answer the question that patients ask: “is there something that we can stop doing?”  For many of my patients with diabetes taking pills this means that they can stop checking their blood sugars using finger sticks.  We know this from well conducted research showing marginal, if any, benefit.

Clinicians and patients in the US are enthusiastic tinkerers and are in the lookout for exciting new opportunities to improve their health.  As a result they are often attracted to new potentially effective therapies.  Publication of only positive trials contributes to sell those therapies; hiding of negative trials distorts the record, misleads clinicians and patients, and corrupts healthcare.

Thanks Harlan for raising this issue, and for all you do for patients.