In April 2011, Minnesota Physician published a cover story about minimally disruptive medicine. To read the article click here. We look forward to learn how Minnesota physicians and other health professionals think about minimally disruptive medicine as we try to develop and spread this model to help patients who are overwhelmed by their life and heatlhcare yet experiencing poor health and health outcomes.
MDM BLOG
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!
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.
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.
My presentation on healthcare that fits during EVIDENCE 2010 is available here.
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.
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.
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!
Frances Mair and her team in Glasgow, Carl May in Southampton, and the Mayo Team got together on December 1st via videoconference to launch a more vigorous collaborative.
We reviewed the ongoing work in Glasgow (CHF, stroke), and Mayo (patients with diabetes, multiple chronic conditions). Much more to come as we understand the conceptual underpinning of treatment burden, develop measures of treatment burden, and implement them in the context of care of patients.
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.
Minimally Disruptive Medicine 