Research now indicates 50% of middle–aged people live with one chronic disease. Translation: half of middle-aged people are not healthy. (You don’t need a reference there. Just walk out into the world and look around.)
This new normal creates a challenge for caregivers. How will we care for the onslaught of chronic disease?
Surely not with the current model of care. What happens now is that doctors treat diseases–and even “pre-diseases.” We once had diabetes and hypertension and heart failure. We now have pre-diabetes, pre-hypertension and Stage A (no symptoms and no findings) heart failure.
Guidelines statements promote disease-specific numeric measures, such as blood pressure, glucose and cholesterol levels. Patients not at goal get more medication. Then guidelines spawn quality measures, which intensifies already burdensome care. Hit doctors with sticks, feed them carrots, the result is the same: more pills and procedures.
Here is the problem: People are not diseases. Guidelines are context blind. As the burden of healthcare overcomes the capacity (physical, mental, emotional and financial) of the patient, she makes choices of what to do. Said another way: life gets in the way of healthcare. No one wants to spend their life being a patient.
Dr. Victor Montori (@vmontori) is an endocrinologist at Mayo Clinic. His idea for making healthcare more effective is to shun disease-specific context-blind surrogates. Montori and his team have asked us to consider a minimally disruptive approach to healthcare. Quality care in their model happens when patients improve their ability to function–or enjoy life.
Their two new words in healthcare are work and capacity. Minimally disruptive care seeks to decrease the work of care while increasing the capacity of the patient to do the work.
This is not health policy gibberish. Think about it. We are losing the fight against chronic disease. When something is not working, you change the strategy.
Montori’s suggestions are simple: 1) Start by using the right language. Assess the burden of care and think about the patient’s capacity to do all that we prescribe. 2) Guideline writers must add context, otherwise guidelines will become irrelevant. 3) Use shared-decision making. If you have to treat 140 patients with a statin medication to prevent one heart attack (meaning 139 patients take the drug without benefit), it makes sense to incorporate the patient’s goals. 4.) Think about deprescribing, not just in the elderly, but in relation to decreasing the work of healthcare.
Here is a 45-minute lecture Montori gave to a group of primary care doctors. About half-way through the video, he describes a patient named John. John is real life. And once you hear John’s story, it is impossible to think we are on the right path.
h/t Carolyn Thomas of the Heart Sisters Blog.
5 replies on “Is healthcare careful? Is it kind?”
You are correct.
I have said this for years now. The issue with healthcare is not necessarily the docs, who truly want to help patients. The issue is the system which is run not by the docs and patients involved, but by a morass of third parties who have different interests.
If you truly want to see change like you described in your post, then you need to change the system, take it back from the third parties, and truly focus on the individual patient’s objectives.
I think pre-diabetes is a great diagnosis. It gives the doctor an opening to refer the patient for lifestyle education. The doctor doesn’t have time for this. But, a “healthtrainner” like myself who is educated in nutrition and exercise science can counsel the patient in several one hour sessions. An exercise program can be established or critiqued and a 5 day diet diary can be reviewed and tweaked.
No drugs involved and the benefits priceless. “This is your precious we are talking about here”. “Do you want to slow down the aging process, or accelerate it”.
Thx Ken… Good point.
Except, the problem with over-diagnosis is over-treatment. Take a look at this video: https://www.youtube.com/watch?v=l3pVadh4yzM
Ken, pre-diabetes is not a “great diagnosis”. Please take the time to watch Dr. Montori’s video. I’m thinking you may have missed his entire point about the futility of “education”.
Your solution is a good one, engage a professional to help with nutrition, etc., but I believe the message in the video is that the patient is challenged to be the dominant decision maker due to constraints such as work and capacity. I am not in medical field and just a consumer interested in good health habits. I believe the message in the video was for the primary care doctor/service provider network to be more involved in helping to manage the patient and yes, a coach such as yourself would be a good solution, except pushing ownership to the patient to make it happen is not working. The mayo clinic example provided of “call back tomorrow (on 10th day vs 11th day from depletion of meds to refill) was glaring. The slide on heart attack and statin effectiveness was a good one that I have never had presented to me. i think that is the focus of the presentation. My PC should have a conversation about that type of data versus writing me a prescription for a statin which is an easy step for both parties and sends me on my way. FYI: I refuse to take the statin because I am educated and with no signs of disease, the side effects are not attractive to me. But the PC office is not where I developed my education and I think that is the point of the video. Patients need the doctor and other touch points in their healthcare management/provider food chain to become more involved in the coaching. Not sure how feasible that is, but after seeing the video, I sure am wondering why my PC just defaults to a prescription. Many thanks for reading my post.