Tuesday, August 18, 2009
Minimally Disruptive Medicine
A BMJ article describes the concept of "Minimally Disruptive Medicine" which seems akin to the concept of "Slow Medicine" as previously mentioned on this blog. The authors (two from the UK and one from Mayo Clinic in Rochester) state the relatively simple case for the need of such a concept: Physicians expect patients to respond to an individual therapy for a chronic disease as if each patient embodies the "average" patient in the clinical trial on which the therapy is based. However, just as patients often don't offer a textbook presentation of disease, their response to therapies (or lackthereof) will be impacted by many factors that often exclude subjects from those clinical trials. The "burden of healthcare" may result in the best laid plans backfiring. Patients may become unwilling or unable to comply with an overwhelming number of medications or provider visits because of cost, complexity, or just a sense that what the physicians are asking them to do is absurd. And the authors put it well:
This should be a routine but for some reason, I think I blush more easily when recommending that the recently added third antihypertensive be stopped when it's clearly not meeting the patient's goals of care than when I recommend that a patient be extubated because invasive ventilation isn't meeting their goals. Why? I think it gets back to the wishful thinking that clinical trials provide guidance for every clinical scenario. And so this orthodoxy leads to polypharmacy when perhaps the appropriate orthopraxy in this scenario should be minimally disruptive medicine.
Additionally, I can recall at least one time when a resident rotating with our team expressed reluctance about recommending the reduction of antihypertensive and diabetic therapies because the resident thought this was unrelated to the reason why we were consulted. I think we were able to adequately explain why this may be an appropriate PC recommendation, but I may pull this article out if I'm confronted with that scenario in the future.
The palliative care world has already put some thought into this issue, including an article co-authored by Christian and the aptly titled session at AAHPM 2008 Ending Prevention: When and How to Stop the Statin, Ignore the Blood Pressure, and Give the Patient a Cookie.
See Mayo endocrinologist and article co-author Victor Montori, MD describe the rationale in the video below (and also see their new blog).
Thanks to Dr. Greg Gramelspacher (Twitter: @ggramels) for alerting me to this article.
The work of being a patient includes much more than drug management and self monitoring. It also includes organising doctors’ visits and laboratory tests. Patients may also need to take on the organisational work of passing basic information about their care between different healthcare providers and professionals. In some countries, they must also take on the contending demands of insurance and welfare agencies. This means that although intensifying treatment often seems the solution to the patient’s problems, it adds to them. Advances in diagnosis and treatment thus have the paradoxical effect of adding incrementally to the work of being sick. Patients who cannot cope eventually experience iatrogenic outcomes and poorer quality of life, just as surely as do those who are affected by medical accidents or errors. Clinicians cannot respond adequately to this problem. They lack the tools to detect patients overwhelmed by the burden of treatment, and they lack strategies to lift these burdens.The authors propose four principles of minimally disruptive medicine which should guide health services research:
- Establishment of tools to identify overburdened patients
- Encouragement of coordination in clinical practice
- Acknowledgement of comorbidity in clinical evidence
- Prioritization from the patient persepective
This should be a routine but for some reason, I think I blush more easily when recommending that the recently added third antihypertensive be stopped when it's clearly not meeting the patient's goals of care than when I recommend that a patient be extubated because invasive ventilation isn't meeting their goals. Why? I think it gets back to the wishful thinking that clinical trials provide guidance for every clinical scenario. And so this orthodoxy leads to polypharmacy when perhaps the appropriate orthopraxy in this scenario should be minimally disruptive medicine.
Additionally, I can recall at least one time when a resident rotating with our team expressed reluctance about recommending the reduction of antihypertensive and diabetic therapies because the resident thought this was unrelated to the reason why we were consulted. I think we were able to adequately explain why this may be an appropriate PC recommendation, but I may pull this article out if I'm confronted with that scenario in the future.
The palliative care world has already put some thought into this issue, including an article co-authored by Christian and the aptly titled session at AAHPM 2008 Ending Prevention: When and How to Stop the Statin, Ignore the Blood Pressure, and Give the Patient a Cookie.
See Mayo endocrinologist and article co-author Victor Montori, MD describe the rationale in the video below (and also see their new blog).
Thanks to Dr. Greg Gramelspacher (Twitter: @ggramels) for alerting me to this article.
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7 Responses to “Minimally Disruptive Medicine”
August 19, 2009
Many thanks for this thoughtful and interesting commentary on our paper in the British Medical Journal. It demonstrates, very practically, the value of thinking about care through the lens of Minimally Disruptive Medicine.
August 19, 2009
sometimes i see our role in palliative care as being the voice that stops the madness in medicine. there is no purpose in continuing treatment that has no real benefit to the patient. it would be very much your role as a paliative care team in addressing the uselessness in continuing a third anti-HTN med for your patient. the resident should come away from the rotation understanding this.
August 20, 2009
One of the biggest challenges in my family med clinic is meeting a new patient who is "overburdened" by meds, specialists, labs and studies and trying to figure out where to start with them to make life easier. Usually, I start with the med list, as polypharmacy is easy to understand and patients usually hate taking a ton of meds. I tend to leave "polyspecialty" until I've established a rapport with them, and I try to consolidate their labs. It's awfully hard sometimes when they see multiple specialists, each of whom is ordering tests (often the same tests) and adjusting meds. I suppose this is where continuity in primary care can be helpful, or a truly integrated EHR.
August 20, 2009
Carl- Thanks for stopping by. Will be interested to see how the concept evolves.
Anon- Thanks for the support. There are certainly cases where it's beyond clear that such meds should be stopped, and in those cases, there's usually never a problem- just a matter of pointing out to the referring MD. And there are other cases (patients with "intermediate" prognoses) where I don't think we have enough evidence to guide us other than to say "this patient is likely dissimilar to the subjects in the RCT for the drug". Obviously, explicitly linking the recommendation (to reduce meds) with the issue of QOL/burden helps the PC consultant to avoid the appearance of straying away from the consulting maxim, "stick to the question you are asked." (As opposed to the tact of focusing ONLY on the lack of benefit of the drugs, which may be off putting for some referring MDs who may perceive you to be criticizing their management of HTN or DM, per se. Certainly some referring physicians won't be sensitive at all to this- know thy referral source...)
I certainly hope the resident mentioned and all residents who rotate with PC come away with the notion that medication lists should always be reviewed to make sure the benefits outweigh the burden.
Mike- Having a close relationship with an invested PCP (ie the captain of the ship) certainly can go a long way with a lot of these issues. May primary care rise from the ashes!
August 21, 2009
Thanks for helping to spread the word about this BMJ paper. It's interesting to me how much improvement could be made by the application of coordination and common sense; a blizzard of specialized knowledge won't help patients if they can't understand well enough to comply.
August 21, 2009
During my training, I spent time working in an academic medical center and a VA hospital. The contrast really highlighted some of the issues you brought up in your post. The integrated VA-wide medical record gives health care providers a big head start on accomplishing principles 1 and 2. It's easy to recognize which patients are starting to become overwhelmed with multiple meds and visits and to find out what's been happening at those other visits. That said, I think principle 4 is crucial to all of this; and just like discussing EOL preferences, finding out patients' perspectives on treating their chronic illness takes perseverance.
August 23, 2009
See another related post and comments at GeriPal.
http://www.geripal.org/2009/08/inappropriate-medications-in-hospice.html
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