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:
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:
  1. Establishment of tools to identify overburdened patients

  2. Encouragement of coordination in clinical practice

  3. Acknowledgement of comorbidity in clinical evidence

  4. Prioritization from the patient persepective
The overall concept has wide-reaching implications for the practice of medicine, but could these principles be any more aligned with the principles of palliative medicine? And what population might be more ripe for this type of research than a palliative care population? Consider a man who hasn't received much health care over the previous several years who is diagnosed with metastatic adenocarcinoma of the lung. Let's say his performance status remains good and he's expected to live for several months or even a year to two. He's in the hospital, and it's incidentally noted that his blood pressure is persistently mildly elevated as are his accuchecks. All of a sudden, he's not only faced with the prospect of chemotherapy, but he's also thrown onto a couple of meds to ensure tight BP and glycemic control. Of course, he's a little short of breath, and he may have a COPD component, so he's started on bronchodilators which are never stopped even though they may not be beneficial....and on and on. And then there's a palliative care consult to discuss "goals of care." Shouldn't the goals of care discussion include whether preventing stroke/MI or diabetic retinopathy over the next 10-20 years is really a realistic goal or whether this man (who is overwhelmed with a new diagnosis of cancer) and his family will really be capable or willing to take 6 other new pills throughout the day and monitor accuchecks?

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.