Tuesday, 30 April 2013
When less could be more
Below is an extract from a Wall Street Journal article about 'minimally disruptive medicine'. The whole article can be read at: http://on.wsj.com/16gr9Dn It was published in early April.
I was reminded of the article when in conversation with a nurse about self-care management. She cited the example of an older man now living alone. His one contact with other people is at the pub. His consequent regular drinking was posing a problem for managing his diabetes. Simply telling him that his drinking was damaging his health wasn't changing anything. Nor was the evidence of his test results. His desire to combat his loneliness in the only way he knew how was outweighing what his test results were saying.
The Wall Street article describes reframing or changing the conversation between the clinician and patient. Diabetes is a complex, often frightening disease for people. To remain well, they are told about all the changes they are expected to make to the way they live. It can sound like a lot of demands with which people are expected to comply.
Doctor Montori starts from a different place. He starts with the question to the patient: 'What are your goals, hopes and dreams?' The focus then is on a conversation which identifies what help/intervention is needed to help the person achieve what they want to achieve. It isn't just about quality of care checks and results.
'As an endocrinologist, Dr. Montori specializes in diabetes, one of the most prevalent and costly of chronic diseases. But as director of the Health Care Delivery Research Program at the Mayo Clinic in Rochester, Minn., he focuses on innovative ways to improve care for all chronic illness, which taken together represents the leading cause of death and disability in the U.S.
Care for such diseases is often so complex, Dr. Montori says, it overwhelms patients and makes it hard for them to follow their regimens. His solution—minimally disruptive medicine—is gaining interest among health-care quality groups and policy makers. Here are edited excerpts from an interview with The Wall Street Journal:
WSJ: What is minimally disruptive medicine?
DR. MONTORI: It is health care designed to achieve the goals of patients while imposing the smallest possible footprint on their lives. Patients and clinicians can work together in deciding which treatments to take, prioritizing those most likely to help our patients achieve their goals and dreams. Then, we need to deliver these treatments in a way that is mindful of the work required and patients's capacity to get this work done.
For now, it is a four-pronged approach to the care of patients with many chronic conditions.
Like everyone else, we are working actively on care coordination.
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.
Then, we are implementing shared decision-making, using point-of-care tools that help with issues such as which medicine to take for diabetes or whether to take statins or aspirin to reduce the risk of heart attack.
Finally, we are working hard to understand patients' capacity. We are testing an approach to uncover patient's health literacy and resilience; their mental, physical, and financial health; the quality of their support network and of the environment in which they live. We want to know what resources they have which can be optimized to face the complexity of caring for their conditions.
Enhancing capacity and reducing workload can help patients access, use, and enact the care they need and want. This care will not be wasted.'