Monday, 18 August 2014

Minimally Disruptive Medicine

"With regards to the chronic diseases, less can be more." The Wall Street Journal published that statement on the 8th of April last in an interview with Dr. Victor Montori, a diabetologist and Director of "Health Care Delivery Research Program" at a Mayo Clinic in Rochester. Dr. Montori told the journalist that one of the best strategies for the clinical management of patients with more than one chronic disease is to know how to slow down, namely how to give clinical practice some rest.

Reporter: What is minimally disruptive medicine?

Dr. Montori: Is the health care designed to achieve objectives of improved health for patients with various chronic conditions leaving the smallest possible footprint in their lives? To achieve this, patients and clinicians should jointly make decisions about which treatments are best suited to the patient’s lifestyle.

In this article published in the British Medical Journal in 2009, Carl May, Victor Montori, and Frances Mair christened the concept of "minimally disruptive medicine" applied to complex chronic patients. "It's about adjusting treatment plans to the realities of the daily lives of people suffering from various diseases," they say. "We must strive to rise above the kind of medicine that these patients receive too often – being referred to several specialists, which in turn provide uncoordinated recommendations and requirements that leads them to poly-pharmacy and iatrogenic caused by unpredictable interactions. In this practice, which the authors called "fractured medicine", patients feel more overwhelmed by the burden of treatment than by the weight of their diseases.

The 4 Principles of minimally disruptive medicine

To overcome "fractured medicine", the supporters of this way of doing things which is closer to the real needs of patients with complex health requirements, believe that the "minimally disruptive medicine" should be based on the following principles:
  1. One must know how to recognize the weight of the overload. To act rightly, one must first understand the magnitude of the problem. Has the patient understood the instructions given? Is the treatment being followed? What does the patient think about his/her treatment plan?
  2. Coordination of clinical practice should be promoted. The necessary clinical leadership to bring order to the "fractured medicine" can only be obtained from primary care units.
  3. EBM methodology should be extended to co morbidity. Clinical trials often exclude patients with co morbidity, but it's time to promote studies that contain at least the most frequent combinatorial pathologies.
  4. Should prioritize from the patient's perspective. If the patient can not, or will not, face a heavily overloaded treatment, nor is willing to bear the risks of interactions, then the time has come to listen. As doctors, don’t doubt that this is very helpful.
The practical part

In this other work which is much more up to date and also published in the BMJ by two professors at Cambridge, practical advice is being offered on how continuity of care for complex chronic patients can be provided. I think that nowadays with the widespread development of specific programs for chronicity, some of these recommendations may be helpful. If you already have them in mind - so much the better.
  • It is very useful that complex chronic patients have a reference doctor and a nurse.
  • In scheduling visits, these reference professionals should be chosen "by default".
  • The references must have a (non-variable) cover of two or three other professionals for when they are not available. The patient should know and accept this.
  • Patients should be able to schedule visits online and make inquiries via e-mail.
  • Patients must be informed that having this exclusive access means that sometimes they must have patience and wait to be served.
  • The compliance with these recommendations must be assessable and appropriate incentives for professionals must be developed.
Finally, if you want to know more about it, I have selected a video where Dr. Victor Montori explains the approach of "minimally disruptive medicine" from the program that he leads at the Mayo Clinic.

Jordi Varela

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