Short films about polypharmacy

Short films to discuss polypharmacy? Why not.  The entries to the First Short Film Festival about Polypharmacy and Health are here. These are great, instructive, fun, reflective, and artistic. Which one is your favorite?  Why? Simplifying treatments, drugectomies, physician-assisted noncompliance, medication therapeutic management – all of these reflect the need to reduce the burden of treatment imposed by complex, often unnecessary, and frequently unsafe medication programs.

Burden of treatment

One of the key aspects of minimally disruptive medicine is the need to become aware of the burden that our treatments cause on people’s lives. This concept, of burden of treatment, relates to the distress (including suffering, interruption, inconvenience) caused by treatment-associated demands for time, attention, and work.  We know very little about it, but our international team is working toward clarity in this area.

Some important studies have been recently published and I bring them here for your attention:

1: Eton DT, Ramalho de Oliveira D, Egginton JS, Ridgeway JL, Odell L, May CR, Montori VM. Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study. Patient Relat Outcome Meas. 2012;3:39-49. doi: 10.2147/PROM.S34681. Epub 2012 Aug 24. PubMed PMID: 23185121; PubMed Central PMCID: PMC3506008.

2: Tran VT, Montori VM, Eton DT, Baruch D, Falissard B, Ravaud P. Development and description of measurement properties of an instrument to assess treatment burden among patients with multiple chronic conditions. BMC Med. 2012 Jul 4;10:68. doi: 10.1186/1741-7015-10-68. PubMed PMID: 22762722; PubMed Central PMCID: PMC3402984.

3: Jani B, Blane D, Browne S, Montori V, May C, Shippee N, Mair FS. Identifying treatment burden as an important concept for end of life care in those with advanced heart failure. Curr Opin Support Palliat Care. 2012 Nov 28. [Epub ahead of print] PubMed PMID: 23196381.

4: Shippee ND, Shah ND, May CR, Mair FS, Montori VM. Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. 2012 Oct;65(10):1041-51. doi: 10.1016/j.jclinepi.2012.05.005. Review. PubMed PMID: 22910536.

5: Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011 May-Jun;9(3):235-43. doi: 10.1370/afm.1249. PubMed PMID: 21555751; PubMed Central PMCID: PMC3090432.

6: Bohlen K, Scoville E, Shippee ND, May CR, Montori VM. Overwhelmed patients: a videographic analysis of how patients with type 2 diabetes and clinicians articulate and address treatment burden during clinical encounters. Diabetes Care. 2012 Jan;35(1):47-9. doi: 10.2337/dc11-1082. Epub 2011 Nov 18. PubMed PMID: 22100962; PubMed Central PMCID: PMC3241328.

The IHI and minimally disruptive medicine

I was pleased to learn recently that the podcast for the Institute for Healthcare Improvement called WIHI focused on Minimally Disruptive Medicine was among the top 10 most listened. My colleague Nilay Shah and I were invited to participate in this interesting and interactive forum and were delighted to learn, as is often the case, that the audience is quite to resonate with our diagnosis of the problem and contribute to a potential list of solutions. We ended up spending quite a bit of time discussing shared decision making as well, as part of the solution set.  The podcast and associated material is here.

New treatment guidelines consider patient characteristics

A recent article in the Wall Street Journal, Health & Wellness magazine, New Strategies for Treating Diabetes, discusses new guidelines for treatment of Type 2 diabetes which were published in June. The new guidelines suggest patient preferences and characteristics such as age and general health be considered by doctors when treating patients with Type 2 diabetes. The Shared Decision Making National Resource Center has promoted this consideration of patient preferences and individualized treatment plans. Patient decision aids, which are developed through the Center, give voice to the patient, as Dr. Montori points out as important in the article.

What patients want

An interesting article from was shared with us: “How much guidance do patients want with their medical decisions?”

Victor Montori, MD, comments:

While the surveys consistently show that not all patients would like to make the final decision about treatments, these surveys have two major flaws:  1) The majority of patients interview have never experienced a high-quality shared decision making interaction.  2) The decisions asked are infrequently described to the respondents of these surveys as being those in which there is no right or wrong choice.

Patients do not like to be asked to make a decision for which there is a technically correct choice. And who knows the right answer? The doctor. The decisions that are most amenable to shared decision making are nontechnical ones in which the options have trade offs that only the patient can seriously evaluate, with the help of a caring clinician. This last point is well illustrated in this piece.

We agree with the commentary writer that the context of primary care and healthcare in general is not conducive to shared decision making, and this is why this will require a patient revolution.

Medicina minimamente impertinente

Here is the video of my presentation in Spanish about MDM at the National Meeting of Primary Care Pharmacists in Bilbao, Spain in October 2011.

Aqui esta el video de mi presentación en español sobre Medicina Minimamente Impertinente en el Congreso Nacional de Farmacéuticos de Atención Primaria en Bilbao, España en octubre 2011.

Fuente: Irekia – Gobierno Vasco

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 (   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 (, 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.