Minimally Disruptive Medicine

Reflections on MDM, Views from the frontline of care

The role of guidelines in Goldilocks medicine

We have been concerned about the role that guidelines could play in overwhelming patients. This leads to practitioners considering guidelines as mandates for quality, often overriding patient context and patient values and preferences. In the case of diabetes, there is a big concern that many guidelines reflect the interests of for profit interests on professional organizations that formulate these guidelines.

Last year, the VA, led by Pogach, Aron, McConnell and others, produced guidelines that take a different approach – a patient-centered one! To learn more about these guidelines, there is a very interesting discussion in this podcast.

In this podcast, Mark McConnell from the VA in LaCrosse, WI discusses with the Therapeutics Education Collaboration hosts about the evidence in support of diabetes control and how this should be translated in care that fits the life of patients with diabetes. A valiant effort indeed to reduce the way this care can disrupt people’s lives!

Reflections on MDM

Transferring complexity – how healthcare interrupts life

In working through minimally disruptive medicine, we are uncovering how the healthcare system has been developing habits — I think this is the right term — that essentially transfer complex work from the healthcare system to the patient.

Take appointment scheduling – some back offices have different schedulers for different types of appointments resulting in uncoordinated visits. A patient with whom we are currently working made more than 30 trips to the clinic, often times for one or two visits each time. This was particularly problematic because she could not drive. A family member ended up moving to town to help with this task…her life being disrupted by this “need”.

Take prescription refilling – some insurers do not enable pharmacies to refill prescriptions before a particular date even if this was the day that worked for this patient to ask for the refill. Some specialists will write their own prescriptions and these will get renewed at different times than those of others. Thus, the patient is left with multiple prescriptions refilled and renewed by different providers. One of our patients went to the pharmacy 43 times in a year to refill prescriptions!

Take e-health interventions. Many of the new technologies require patients to interact with machines and devices, often times in quite extensive ways. The designers of these technologies have not clearly acknowledged that the purpose of healthcare is to enable patients to pursue their life’s goals and dreams unhindered by health concerns (or by healthcare itself). Healthcare should get out of the way, not be “the way”.

More to come as we get deeper into ‘Goldilocks’ care.

MDM in practice, Reflections on MDM

Tailoring treatments to patient capacity

In a provocative piece, Slate magazine’s Darshak Sanghavi writes about “tiered medicine” and proposes that clinical protocols be titrated to patient capacity. This again approaches the notion of “Goldilocks” medicine we spouse in Minimally Disruptive Medicine. We have also discussed the need to have guidelines that appreciate this issue and that perhaps efficacy may need to have a secondary priority, particularly among patients who are overwhelmed with multiple chronic conditions.

MDM in practice, Reflections on MDM

Administrative disruption as a component of treatment burden and as opportunity for minimally disruptive medicine

I had a patient who told me that she was not experiencing any significant burden of treatment from caring for her type 1 diabetes. A minutes later she went on to tell of a tragicomic experience trying to get an Omnipod insulin pump: calls to diabetes clinician, educator, insurance company, Omnipod rep, plus their administrative assistants, voicemails, faxed forms requests, etc. This story made me think of this brilliant video by The Altons:

This video of Air Healthcare is based on an article by Jonathan Rauch in The National Journal Magazine here.

Clinicians need to be aware of what happens in their own front offices, back offices, and the administrative challenges patients face with access to them, their medicines, devices, and other components of their care. These disruptions may lead to poor treatment fidelity and outcomes. A minimally disruptive medicine approach would apply lean methods from a patient centered perspective to correct this situation. Thoughts?

MDM in practice, Reference material, Research on MDM

Who benefits the most from minimally disruptive medicine?

We are actively working to make MDM a reality in our primary care practice. A key step involves identifying patients who may benefit the most from MDM, or the most intensive form of MDM at least.

After some discussion we came out with this list (order does not necessarily implies importance)

Patient has a complicated treatment regimen and is overwhelmed by it (as judged by self report, nonadherence or other strong clue)
The current form of care does not meet the patient’s needs
The patient’s health is at risk of a health catastrophe if we do not take action
The patient is willing to invest in MDM work with the goal of achieving the patient’s goals for life and healthcare while reducing the burden of treatment (the imbalance in patient workload to patient capacity)

We will probably need to develop some criteria to flag charts in a busy primary care, yet all these require “conversation” – the healthcare team needs to become aware of the first one, needs to realize the second and third one, and needs to engage the patient for the last one.

I look forward to your thoughts and ideas on who would benefit the most from MDM?

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

The patient voice – the need for a minimally disruptive medicine service

We are working as a multidisciplinary team to develop a service offering for patients with multiple chronic conditions that will reduce the burden of treatment while pursuing patient goals in primary care. We are trying to learn as much as we can from other models such as PACE and Graded care. We are also learning as much as we can from our colleagues in multiple disciplines and in public health. And, of course, from our patients.

During an in-depth interview, one of our patients commented to the notion of a MDM service the following

I wouldn’t mind having like the whole team of doctors that I work with being able to sit down with them and look at the whole picture and decide a plan that would work out for all of my illnesses and how maybe I could avoid certain things or certain costs or just help me live better, period.

…I just think the biggest, most important thing in illness is having all the doctors be on the same page and know what is going on with you individually so that they can help you meet your best expectations and your best health.

Hi expectations we will have to satisfy if we are to make a difference to the workload/capacity balance of these patients. Onwards!!

Reference material

A “cure” for overtreatment

The blog Bedside Manner recently echoed our sentiments about minimally disruptive medicine, yet making a novel point: it is not about less care, but about more patient-centered care.

Indeed, I have come to refer to this idea as ‘goldilocks’ medicine for that particular reason. It is care that is “just right” as it can only be defined by the patient-clinician dyad (ultimately a dyad of teams on each side really) with the right expertise and research evidence, the right understanding of the patient’s context, and the right consideration of the pertinent and informed values and preferences.

Goldilocks medicine is going to need not only changes in the environment of care (fundamentally changing the corrupt nature of healthcare delivery today), but also in clinician training and in shaping patient expectations for involvement.

Thank you, Julie Rosen, Executive Director of The Schwartz Center for Compassionate Healthcare, for bring up MDM in your blog!

Papers and presentations, Research on MDM

The evidence for minimally disruptive medicine grows…

Katie Gallacher and the MDM Team have just published a typology of treatment burden in this month’s issue of Annals of Family Medicine (http://www.annfammed.org/cgi/content/full/9/3/235). The group have identified core components of treatment burden as reported by individuals with chronic heart failure and state that although further exploration and patient endorsement are necessary, the findings lay the foundation for a new target for treatment and quality improvement efforts toward patient-centered care.

Kurt Stange, Editor of Annals of Family Medicine, in this month’s editorial (http://www.annfammed.org/cgi/content/full/9/3/194), states that the group have identified factors that increase the burden on patients and agreed that the paper highlights targets for personalizing care. The important role for MDM, which aims to ease the burden of polypharmacy, improve the organization of care, and increase accessibility and continuity, all of which are reported as key issues, is therefore clear.

Reflections on MDM

Prepared Patient Forum blogger resonates with Minimally Disruptive Medicine

Jessie Gruman resonated with “patient John” and the concept of minimally disruptive medicine. In this post, Gruman says:

There are few of us whose lives are not so full of responsibilities that we would not benefit from our clinicians’ recognition of the level of effort required of us when they recommend complicated changes to our daily routine. At a time when patient-centeredness in health care is a concern of policy makers and clinicians alike, Montori’s approach increases the likelihood that we will be able to act on our own behalf. In seeking to mitigate the treatment burden by recognizing both the demands of the treatment and the context in which each patient must meet those demands, this care is consistent with the Institute of Medicine’s definition of patient centered…

Read her whole post here

Papers and presentations, Reflections on MDM

JAMA commentary attacks the notion of clinical inertia

I have discussed how nonadherence to therapy could be conceptualized as nonviolent resistance to medicine’s push to overdiagnosis and overtreatment, particularly in patients with multiple chronic conditions.

JAMA has published an important commentary by which the author’s essentially propose that what some have conceptualized as clinical inertia may be instead interpreted as nonviolent resistance of clinicians to healthcare push for more healthcare on patients. The authors say:

…clinical inertia may be a clinical safeguard for the drug-intensive style of medicine fueled by the current medical literature.”

Minimally disruptive medicine, thus, represents a solution, an assertive one, for both patients and clinicians that needs to overcome corruption of both the literature and the practice.