It Ain't Easy Being a Patient

Minimally disruptive medicine, says the Mayo Clinic’s Victor Montori, is the kind of help today’s overwhelmed patients need

Peter Wehrwein

There’s no slacking off once you become a patient. Appointments bombard the calendar. There are phone calls to make and pills to take — and lots of them as the health problems multiply. So now there are trips to the pharmacy. Maybe there are lab tests or therapy sessions.

“All the work accumulates,” says Victor Montori, MD, an endocrinologist and shared decision-making expert at the Mayo Clinic. “It has to be implemented and it competes with the other things the patient needs to do.”

Victor Montori, MD

Victor Montori, MD, an expert on shared decision making at the Mayo Clinic, drums up support for minimally disruptive medicine.

And let’s not forget that the people doing this work are dealing with an illness, so they are probably also dealing with a draining combination of fatigue, pain, gastrointestinal distress, and assorted other woes. It’s a lot to ask. So Montori and others have proposed a new way of approaching health care that they’ve dubbed minimally disruptive medicine.

Great idea…

The concept, first proposed in a 2009 BMJ opinion piece, is for providers to work at striking a balance between the increasingly complex burden of treatment people assume when they are ill, and the capacity they have for handling treatment-related tasks and demands.

In some cases, minimally disruptive medicine might mean cutting back or simplifying treatments. In others, it might mean “capacity building” so people are better able to shoulder their treatment burden. Those capacity-building efforts could range from treating depression to arranging transportation to appointments to updating a prescription for corrective lenses so a patient could see better.

Montori says overwhelmed patients stumble into noncompliance: “They are not choosing to be noncompliant; they just don’t have the capacity to comply.” So, by his reasoning, minimally disruptive medicine would improve compliance, which presumably cascades nicely into better outcomes, lower hospitalization rates, and reduced costs.

The target population for the approach is people with several chronic diseases, but anyone with a complicated health situation would stand to benefit, Montori figures.

Carl May, a prominent British medical sociologist, wrote the BMJ article with Montori and Frances Mair, a British expert on primary care. May is known for his normalization process theories that offer explanations for how and why new technology gets adopted. Minimally invasive medicine reflects the flip side, in medical context: how and why people do not adopt new treatments.

You can also see traces of motivational interviewing in Montori’s formulation because of the emphasis on patient preference and tapping into intrinsic motivations. And, naturally, there’s a hefty dose of shared decision making, given his background, although shared decision making has tended to focus on major medical events such as surgeries rather than on sifting through the day-in, day-out tasks of keeping a chronic disease in check.

Maureen Bisognano, president of the Institute for Healthcare Improvement (IHI) in Cambridge, Mass., — the organization that gave us the “triple aim” — is enthusiastic.

“I think it is the next horizon in health care,” she says. “It is this wonderful way to say ‘I am the professional. I will take on the burden of redesigning health care so you can focus on your health.’ That is what I love about minimally disruptive medicine.”

…but hard to make happen

Sounds pretty good. But are there any takers? Montori concedes that adoption of minimally disruptive medicine “has been an extremely frustrating ride.”

Roadblocks loom for even minor adjustments that would reduce treatment burden just by making health care more convenient, he has found. For example, at Mayo, the system for scheduling appointments can’t synchronize the appointments of two people. As a result, if a couple wanted to save time and money by having their appointments on the same day at the clinic, it would be difficult to arrange. Another example: timing medication refills so that they occur on the same day, which would save multiple trips to the pharmacy. Pharmacy and payer rules and procedures stand in the way of that commonsensical bit of rescheduling.

The current zeal for performance measurement is another problem, says Montori. “When the patient is overwhelmed and you want to pull back a bit and let things play out, you don’t have a lot of flexibility in that environment,” he says. “You don’t want to look to your colleagues like you are a bad provider because your patients’ blood sugar or blood pressure levels are high because you are focused on the burden of treatment.”

So in the near term, he says, building up patient capacity is the more feasible strategy for putting minimally disruptive medicine into action. What that would mean would vary, but Montori mentions some now-familiar approaches — health coaches, for example — as well as some that aren’t so usual, such as mindful meditation. But isn’t this adding more treatment to treatment-besieged patients? As Montori points out, investing time and effort into solving one or two health problems can often make the rest of them easier to handle.

A quiet cultural change

Montori has been busy drumming up support for his ideas. In addition to articles in peer-reviewed medical journals such as BMJ, he gives talks and has a Web site, In medicine, if it can’t be measured, it doesn’t exist, so he has also been working with colleagues on ways to measure the burden of illness.

But shared decision making has been around a lot longer than minimally disruptive medicine, and getting shared decision making incorporated into medical practice has been slow going, says Jack Fowler, senior scientific adviser at the Informed Medical Decisions Foundation in Boston, a major promoter of shared decision making. “The rate at which it is practiced in routine medical care is not high — and that is what we are trying to change.”

Jack Fowler, PhD

“The contents are sound,” says Jack Fowler, PhD, of the Informed Medical Decisions Foundation, in regard to minimally disruptive medicine.

Despite Montori’s misgivings about slavish attention to performance measures, the right kind might provide the leverage needed to bring about the kind of change he is looking for. Increasingly, provider compensation is being tied to patient survey results, and today’s surveys are digging much deeper than the bland patient satisfaction surveys of yore.

Bisognano sees fertile soil for Montori’s ideas in today’s renewed efforts to manage health care costs and quality with value-based contracts and payment schemes like shared savings and episode-based payment. She notes that as many as half of all prescriptions go unfilled. Shift to a minimally disruptive medicine mindset and adherence would improve, she believes, because providers would be focused on removing the obstacles that people face in getting and taking those medications. Cost savings will follow if the medical management of chronic health conditions is improved

Bisognano also sees an opening for Montori’s ideas because being more sensitive to patient preferences and values should bear cost-savings fruit: “When patients describe what matters to them, in most cases, what they want is less, not more, and that is where the savings come in.” Payment that rewards providers for time spent engaging patients, not just prescribing to them, will also help, she says.

Ultimately, though, Montori says that American medicine needs an overhaul, a culture change. The goal should be to view health care as a means to an end. “We need to recognize people are living, not to be good patients, but to be good parents, good siblings, good spouses, good teachers, good coaches,” says Montori. “We need to get as much health back into their lives as possible. And then we need to get out of their way.”

Peter Wehrwein is a frequent contributor to Managed Care.

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