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.

3 thoughts on “REPOST: Is healthcare careful? Is it kind? by Dr. John Mandrola

    1. Guideline panels can produce strong or conditional recommendations, according to the GRADE approach ( Strong recommendations can be linked to quality of care measures and should apply to >95% of patients no matter what. Strong recomendations (and quality measures linked to these) are therefore rare. Yet, we have a lot of “must” “should” recommendations, i.e., strong recommendations, that do not apply to every patient for reason of context (comorbid or sociopersonal). So this must stop. Most guidelines should provide conditional recommendation. These recommendations are the subject then of shared decision making. if there is a pertinent quality measure then it should point toward doing shared decision making. If a panel insists on issuing strong recommendations then they should be explicit about context, e.g., we recommend that all patients with type 2 diabetes, who are young, have no complications, do not live alone, are not employed in high risk occupations or that involve travel, and who place a low value in preventing the symptoms of hypoglycemia and place a high value in the potential benefits, albeit uncertain, of tight glucose control, should try to bring their Hba1c to < 7%.

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