Minimally disruptive medicine. That’s a new buzzword for practicing medicine in a way that doesn’t overwhelm the patient.
Imagine that you have diabetes (well, if you didn’t, you probably wouldn’t be reading this) but also some gastric reflux, arthritis, high blood pressure, Hashimoto’s, celiac, high cholesterol, osteoporosis, and irregular heart beats. You’re a responsible patient, and you want to do what you can to minimize the damage from all these conditions.
But there can come a point at which trying to juggle all your medications, dietary requirements, medical appointments, blood glucose tests, and exercise needs as well as the financial costs of all your medications and the time needed to deal with insurance companies may be more burdensome than the diseases themselves.
Some of your medications have to be taken on an empty stomach, with no food for a certain time, and others have to be taken with meals. The diet recommended for one condition is contraindicated for another.
And when each of these conditions is being treated by a different physician, who doesn’t communicate with the others, the problem is compounded.
In such a situation, it may be tempting to give up, stop taking the expensive medications, revert to your former unhealthy diet, and just trust in luck. But that’s not a good solution.
That’s why in 2009 three professors, Carl May, Victor M Montori, and Frances S Mair, proposed the concept of minimally disruptive medicine, sometimes referred to just as MDM. Unfortunately, you can’t read the full text of the article without a subscription, but Dr. Montori kindly sent me a copy.
“The burden of treatment for many people with complex, chronic, comorbidities reduces their capacity to collaborate in their care,” they wrote, saying that to be effective, care must be less disruptive.
“We call for minimally disruptive medicine that seeks to tailor treatment regimens to the realities of the daily lives of patients.”
This makes a lot of sense. It’s not helpful to prescribe testing blood glucose levels five times a day if a patient has no insurance and can’t afford that many strips. It doesn’t even make sense to have a patient test blood glucose levels a lot if you don’t have time to teach the patient what to do with all that information.
“The epidemiological transition from acute diseases, where the emphasis was on cure, to chronic illnesses that instead require management also means that patients take on a lifetime burden. Poor adherence can lead to complications in professional-patient relationships, additional ill health and expenditure for patients and their families, and the waste or misallocation of healthcare resources.”
The burden of care can also lead to burnout. And if people suffer burnout from just one chronic medical condition, the stress of dealing with many conditions, especially if the patient is elderly and on a fixed income, can just be overwhelming.
The concept of MDM was proposed five years ago, and the Wall Street Journal had an article about the topic a year ago, but I hadn’t come across it until recently. Now I find there’s an interesting blog site on the topic.
And if you enjoy singing YouTube presentations, here is one on MDM. One recommendation on this YouTube presentation I disagree with is prescribing metformin only when A1c is over 8. Metformin is cheap and has several beneficial effects, although it can cause nausea or diarrhea in some people.
“We are also working to ensure we know what matters to patients. What patients really want is often not to have better blood pressure or lower cholesterol. What they usually want is to feel better, not die before their time, and be able to do what they need to do to fulfill their obligations and pursue their dreams. We must commit to work toward our patients' goals,” said Dr Montori of the Mayo Clinic in the Wall Street Journal article.
Right on, Dr Montori.
It’s refreshing to see a physician who understands the problems from the patient’s point of view. Conversely, I think we need to understand the problems from the physician’s point of view. When insurance companies allow physicians only a few minutes with each patient, there’s no way they can ferret out each patient’s real circumstances and needs. It’s faster to just write a prescription that might make sense for the average patient but not for this one.
Somehow, we need to figure out how to give our physicians more time to listen and to truly understand the needs of each individual patient. That means we need to figure out how to revise the medical insurance system that now has more power than the physician.
In the long run, MDM should lead to less patient burnout, which means fewer serious and expensive complications from chronic diseases. An extra 15 minutes of listening, at a relatively low cost, could save the system the costs of two weeks in an intensive-care unit at an astronomical cost to insurers and devastating effects on the patient.
Coincidentally, the New York Times reported today that diabetes complications have fallen sharply in the past 20 years. This suggests that we’re moving in the right direction. But we still have a long way to go.
Some physicians are experimenting with group appointments, which allow the physician to give the same information to several people at once and then use the extra time to answer questions. Quite often, several patients have the same questions, and this also saves time and means more time for individualizing treatment, “taking into account patient values and preferences . . . asking what is the effective yet least burdensome treatment programme for this patient with this set of conditions in this context.”
Others are experimenting with having a well-informed patient work with “newbies,” sharing what they’ve learned about how to make lifestyle changes and empathizing with the feelings everyone has when diagnosed with diabetes, while leaving medication advice to the physician.
There are probably other ways to help us all get MDM that will control our diabetes (and any other diseases) without consuming 100% of our time and income. Does anyone have any suggestions for this?
Published On: April 17, 2014