Special Focus: Patient Compliance
n the April 2011 issue of Minnesota Physician, we showed how the structure of health care is organized to optimize quality markers that may have little relevance to patients and their lives. Particularly in patients with chronic disease, health care activities can occupy a large footprint and become an unnecessary burden. We showed how the workload of being a patient is added to the workload of being a person and that, in many cases, patients lack the resources and capacity to carry out this work. When workload and capacity are imbalanced, patients exhibit a clinical syndrome that can be thought of as “structurally induced nonadherence.” In the 2011 article, we used the example of a fictitious patient, John, who is fired from clinical practice because of an inability to meet quality markers for his diabetes. What appeared to John’s clinician as “noncompliance” was actually the result of
Minimally disruptive medicine 2.0 Avoiding structurally induced nonadherence By Aaron Leppin, MD, and Victor Montori, MD
a complex life and context that John was not supported to handle. John ultimately prioritized the parts of his life that were most meaningful and pressing to him—a family in crisis and a tenuous employment situation. Health care failed John because it was not sensitive to his context. Indeed, because of its rigid design, the only options it provided to him were maximum and infeasible care or no care at all. What John needed was a new and more appropriate form of care, something
we call minimally disruptive medicine. Minimally disruptive medicine (MDM) is an approach to care that is sensitive to the complex contexts in which patients exist. Providing MDM requires us to assess the workload imposed on patients (i.e., tests, treatments, self-management activities) and the capacity they have to carry it out (i.e., support, functional abilities, finances). When imbalances in these factors are found, clinicians must wisely respond by
reducing the workload and/ or by augmenting the capacity. This amounts to stopping or modifying treatments and enhancing the capabilities and resources patients and caregivers have to access and use heath care, and to enact necessary self-care. In 2011, MDM was primarily a concept to which we’d given much thought. But that was it. We have spent the last three years, in concert with outstanding stakeholder support and the input of numerous Minnesota physicians and health sytems, developing a method for making MDM a clinical reality. The objective of this article is to provide an update on our progress and answer some key questions of interest to Minnesota physicians. Does MDM work? For the practice of MDM to be of value, it must ultimately improve patient health and wellness and facilitate the
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Minnesota Physician March 2015