Need for a Minimally Disruptive Medicine toolkit

By Nathan Shippee

MDM needs a toolkit for people who are interested. This is not my idea originally—I’m just a messenger. As a junior researcher fortunate enough to be involved in minimally disruptive medicine (MDM), I’ve been able to collaborate with and learn from great people like Victor Montori, Frances Mair, Carl May… the list goes on.

Yet, for all our efforts, MDM remains a good concept, but one with arguable impact. Our research has shown that treatment burden is a real and measureable thing; that managing chronic conditions is complicated and work-intensive; and that medicine needs to recognize the balance between the demands placed on a patient and his or her capacity to handle those demands (see the MDM blog’s Jan 9th post for a bibliography). However, what have these realizations done for patients?

At Mayo (at least while I was there), there was mixed success (Victor mentioned this here). In trying to merge MDM into primary care, for instance, MDM-interested people were able to help some patients in simplifying medications, lab tests and diet, but also encountered barriers, such as problems in changing all the forms patients are asked to complete (especially when they visit multiple specialties at the clinic) or the way visits are scheduled to consolidate them and improve convenience.

We’ve been contacted by providers at other clinics who have read some of this work. Some have had interest in tools to measure the complications in patients’ lives; others have been interested in provoking culture change by educating their colleagues about the difficulties and challenges that patients face.

People at the core of MDM have discovered that it may be impossible to change how medicine is delivered at a given clinic or practice due to institutional inertia, difficulty in getting professionals to buy in, and so on.

Instead, there is a different idea: to provide a toolkit for people interested in MDM and its implementation, built upon existing evidence and collected findings, suggested scales  and new measures, and more, in order to promote a broader impact for MDM on common practice and pm patients’ lives.

Therefore, here is a teaser for what might become a dominant theme in MDM: it is time to create an MDM toolkit—a clearinghouse, go-to place, or whatever one might call this single source for tools that help make MDM to be useable and to have an impact.

Initially, such tools might include:

  • background and literature developments supporting MDM, including bibliographies of recent papers (like the one on the MDM blog);
  • ways to build knowledge and motivate and culture change, such as presentation slides, conceptual model outlines, graphs, and other material to promote MDM concisely and directly;
  • shared decision making tools to improve the involvement of patients’ informed preferences in medical decisions; and
  • survey items or measurement approaches people can use to assess and track healthcare-related overburden and workload-capacity imbalances among patients. Later, based on widespread testing of these tools and focused intervention studies, we might add validated screening tools, field-tested and evidence-based components for building MDM interventions, and updates to our conceptual models and statistics about the solutions to patient overburden, healthcare-related disruption, and lack of support for patients.

This toolkit may sound ambitious, but it is reachable. Developing individual tools that can be picked up for free, piecemeal, and used in practices may be the most far-reaching, and yet also most feasible, approach to ensuring that the promise of MDM reaches its intended beneficiaries—patients.

We welcome your thoughts. What would you add or take out of the toolkit?

Challenging my colleagues

By Victor Montori

I am often on the road discussing minimally disruptive medicine with colleagues elsewhere. For some reason I never hear disagreement with the basic statements of concern (we are responsible for some of the non adherence by virtue of our endless and uncoordinated demand for more work on chronically ill patients with multiple comorbidities). When I suggest something needs to be done about this, e.g., reject disease specific quality and performance measures, work for integrated care around patient needs, assess and reduce treatment burden, I get a sense of impotence, of inability to create change, to truly advocate for the patients’ interests. Why do you think this is the case?

When patients opt out of their medical care, we think it is because they may be ignorant about the implications of disease and the effects of treatment.  This intentional noncompliance sounds to me as a target for improved communication and education.  Even shared decision making.  If patients make informed choices about what to do and what not to do, that is not noncompliance.  That is informed patient choice.  An exercise of people’s values and preferences with full understanding of the opportunity costs of taking and not taking action in their specific context. This is sometimes confused, but some folks understand it – e.g. this article in LA Times.  The focus of my attention, however, is poor treatment fidelity – poor follow-through with an agreed upon plan of action.

Poor treatment fidelity can be caused by our transferring to patients the demands for optimal care we feel as part of misguided performance improvement campaigns, by poor care coordination, and by blindness to the burden of treatment and to the (limited or shrinking) capacity that patients and family have available or able to muster to implement treatments.  It is this reality that is within our reach and, as I indicated in the first paragraph, it is something about which I find professionals feeling impotent.  Why?

My colleague Barbara Koenig pointed me to this article by the late historian Tony Judt commenting on the work of Czeslaw Milosz and specifically on The Captive Mind.  The key phrase Judt offered that seems pertinent to this discussion is: “Above all, the thrall in which an ideology holds a people is best measured by their collective inability to imagine alternatives.”  Is the impotence I have observed the result of this inability to imagine alternatives?  Can minimally disruptive medicine offer these?