REPOST: Is healthcare careful? Is it kind? by Dr. John Mandrola

Is healthcare careful? Is it kind?

Research now indicates 50% of middle–aged people live with one chronic disease. Translation: half of middle-aged people are not healthy.(You don’t need a reference there. Just walk out into the world and look around.)

This new normal creates a challenge for caregivers. How will we care for the onslaught of chronic disease?

Surely not with the current model of care. What happens now is that doctors treat diseases–and even “pre-diseases.” We once had diabetes and hypertension and heart failure. We now have pre-diabetes, pre-hypertension and Stage A (no symptoms and no findings) heart failure.

Guidelines statements promote disease-specific numeric measures, such as blood pressure, glucose and cholesterol levels. Patients not at goal get more medication. Then guidelines spawn quality measures, which intensifies already burdensome care. Hit doctors with sticks, feed them carrots, the result is the same: more pills and procedures.

Here is the problem: People are not diseases. Guidelines are context blind. As the burden of healthcare overcomes the capacity (physical, mental, emotional and financial) of the patient, she makes choices of what to do. Said another way: life gets in the way of healthcare. No one wants to spend their life being a patient.

Dr. Victor Montori (@vmontori) is an endocrinologist at Mayo Clinic. His idea for making healthcare more effective is to shun disease-specific context-blind surrogates. Montori and his team have asked us to consider a minimally disruptive approach to healthcare. Quality care in their model happens when patients improve their ability to function–or enjoy life.

Their two new words in healthcare are work and capacity. Minimally disruptive care seeks to decrease the work of care while increasing the capacity of the patient to do the work.

This is not health policy gibberish. Think about it. We are losing the fight against chronic disease. When something is not working, you change the strategy.

Montori’s suggestions are simple: 1) Start by using the right language.Assess the burden of care and think about the patient’s capacity to do all that we prescribe. 2) Guideline writers must add context, otherwise guidelines will become irrelevant. 3) Use shared-decision making. If you have to treat 140 patients with a statin medication to prevent one heart attack (meaning 139 patients take the drug without benefit), it makes sense to incorporate the patient’s goals. 4.) Think about deprescribing,not just in the elderly, but in relation to decreasing the work of healthcare.

Here is a 45-minute lecture Montori gave to a group of primary care doctors. About half-way through the video, he describes a patient named John. John is real life. And once you hear John’s story, it is impossible to think we are on the right path.

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NAPCRG Plenary on Minimally Disruptive Medicine – audio is out!

The North America Primary Care Research Group hosts the foremost international annual conference on primary care research. In 2014, it took place in New York City on November 21-25. It started with a plenary by Victor Montori on Minimally Disruptive Medicine. The audio for that plenary has now been released and can be enjoyed on the Soundcloud website or App. The audience resonated with the message of Minimally Disruptive Medicine. A blog Victor penned discussed the upcoming talk as focused on a careful and kind approach to healthcare. The audience gave these ideas a standing ovation, but not all found the solution complete: Martin Roland for one thinks more primary care research to address the enormous needs of patients with multiple chronic conditions is needed. And that is what we are trying to do.

REPOST: Is Burden Of Treatment A Barometer Of Quality Of Care? from Carl May

Frances Mair and I have an Editorial in this week’s British Medical Journal that sets out some of the key problems around Burden of Treatment and multi-morbidity. That the BMJ should commission this editorial from us shows that the idea of Burden of Treatment is getting traction across the healthcare economy. And why shouldn’t it? The bug issue here is patient and carer workload – something that we know much less about than we should. The editorial comes hot on the heels of an important meeting sponsored jointly by the National Institute of Health Research and the Royal College of General Practitioners that sought to develop a strong research agenda on multi-morbidity. The key message that I took away from that meeting was that there was a real risk of turning multi-morbidity into a kind of new disease in itself – in the way that we often now hear chronic illness and long-term conditions spoken about in a quite undifferentiated way. In fact, the big problems here are at a system level, and they’re the problems that Frances and I discuss in our editorial. I was a plenary speaker at the RCGP NIHR Multimorbidity meeting and I’ve embedded my powerpoint presentation below.

Carl May’s blog

Multimorbidity, Burden of Treatment and Intervention Design from Carl May

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.

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.