Minimally Disruptive Medicine - a concept borrowed from Dr Víctor Montori

At some point in life, our health enters bumpy-road or even roller-coaster mode. After age 60, most persons have some form of chronic ailment, mostly in the arenas of hypertension, heart failure, diabetes, arthritis, lung disease, kidney failure, some nutritional deficiency (or excess as in those who are overweight), not to mention the risk of developing some form of malignant disease, of which progressive ageing is the major risk factor. In our industrial, post-industrial and present information society, we’re all in collision course with the health sector, be it seeing doctors in their surgeries, visiting A&E, spending time in a hospital bed, getting tests, receiving home support and, of course, pill-popping our way into our individual futures, so as to keep all our ailments in check.

All this has tremendous consequences on all areas of our human existence. It is taxing on our time, our energy, our everyday expenses, our families and caregivers and on the national and global economy, with healthcare expenditures running anywhere between 10 and 20% of any national budget trying to keep up with demands. A good-intentioned effort by health systems and specialty societies is to design efficient, cost-effective and evidence-based guidelines, attempting to minimise excessive variation in care and runaway costs. Doctors, health systems and patients are nowadays bombarded by so-called ‘guidelines’ that are the result of genuine scientific fact, industry lobbying to promote certain services, devices or drugs (and some conflicts of interest in the mix, of course), political correctness (yes! – health ministers always use the word ‘protocols’ as a minimal percentage of their lexicon – just listen to the next interview on any of our local TV channels) and last but not least, doctors who boast they are knowledgeable of the latest issue of any guideline.

The problem is that guidelines are disease-specific. For example, the recent European or US guidelines for hypertension may differ slightly (understandable) but are applicable only in a vacuum where the other ailments any senior citizen is suffering from are ‘ignored’ – or relegated to ‘clinical judgement’ by the doctor if conflicting with the patient’s reality. This is piled up on the fact that some health systems reward providers for sticking to accepted guidelines, even if this means using two, three or more of them to cover all of the patient’s chronic diseases. No wonder that patients with more than one chronic condition need multiple checks, tests, follow-ups, medications – not to mention being labelled ‘non-compliant’ if found guilty of scoring low on abiding by the dogmas of conflicting recommendations.

The concept of minimally disruptive medicine was coined by Peruvian-born physician-diabetologist Dr Víctor Montori, who at present works at Mayo Clinic in Rochester, Minnesota. Diabetes is at the crossroads of metabolic, endocrine, cardiovascular and renal diseases, to mention the most common. His decades-long experience has shown that patients have their lives absolutely disrupted by what he calls ‘industrial medicine’, as doctors are required to abide within the system rather than to connect with what matters most to their patients. The reasons are manifold: restricted budgets (‘no money, no mission’), the need to see many patients in limited timeframes (productivity is valued more than connectedness), not counting the prizes of complying with the guidelines (P4P = pay for performance) and… penalisation ($) for not doing so. The consequence: patients are treated according to the guidelines directed at ‘patients like this’, rather than tailoring treatment to ‘like this patient’.

I recently read his book “WHY WE REVOLT” (Amazon, Kindle, 2017) where he makes excellent points on what his practice has taught him. He calls for a ‘patient revolution’, where care can be provided in ‘timeless’ mode, connecting patients with caregivers (physicians, nurses, technicians) at a deeper level, unhurried, unharried, unhassled and unharrassed (my words) by the constraints and pressures of industrial assembly-mode medicine. Care should not be disruptive of people’s lives. Evidence should be shared, discussed and what is to be done should be adapted, within ethical limits, to the reality of the patient, who should guide providers to what matters most to them. Scientifically-developed guidelines deserve a better ‘incarnation’ in patients’ lives and only a deeper and timeless relationship can do this. Patients should lead, followed by their professional caregivers and by the leaders of the healthcare organisations who have the will and means of transforming the present disruptive reality. In the end, we’re all going to become chronic patients someday, if we live enough.

How does TeleMedicine work?

I recently posted this article in The British Society Contact Newsletter (October 2018 issue)

Dr Jorge C Stanham MBE (a Spanish version will follow shortly)

Those who dare follow me on LinkedIn and my blog are already aware that I’m all for TeleMedicine. In fact, for more than 20 years, I’ve practised it with the tools of informatics and the Internet, be it e-mail, electronic health record messaging, SMS, WhatsApp – and (to my despair) via Facebook messaging. Plus, for the time-being, it’s all for free!

Healthcare is notorious for being the latecomer to every bandwagon that has changed the way humans manage information and connect, especially when it comes to the physician part of providing the services. When doctors do get involved in a change, it has already happened in administration, accounting, marketing and even diagnostic services. I frequently refer to the Greek mythological character Procrustes, who had a lodge for visitors and travellers, but had only a one-size-fits all bed model. For those shorter than the bed, he’d stretch the poor host to reach the bed size and for those longer, he’d cut off whatever exceeded the bed’s limits. Medicine as practised, is enormously Procrustean: we rely on the one-on-one and face-to-face model, which means that we strive to fit a doctor and a patient in that time-space singularity called an office visit: never remote and always at the same time. Consequence: assembly-line-industrial-model medicine, leading to queues, waiting lists, unneeded emergency room visits and even, losing precious time. This single-tool model is the consequence of expanding what was possible in the middle of the 20^th and forcing it on the multidimensional modes of relating people and professionals of the 21^st century. A Continuous Quality Improvement (CQI) pioneer once said: “Every system is designed to produce the results that it gets.” Many cite Einstein’s ‘insanity trap’: you cannot get out of a problem using the same resources that got you into it.

So, back to TeleMedicine. The ‘tele’ part is the first (and defining) key: the service is provided from a distant location ie, the patient and the provider/doctor are not located in the same place. With this concept in mind, we enter the second key: the service can be provided at the same (synchronous) or at a different (asynchronous) time. Let’s remember the old-fashioned phone call to or from the doctor: this would be ‘tele’ (at a distance) and synchronous (at the same time). Expand this to Skype and we add video (sounds more like the present, doesn’t it?). Think about e-mail: its ‘tele’ and asynchronous. Interfacing the two models would be chatting (‘tele’ and nearly synchronous) as can happen with SMS or WhatsApp. (Why this isn’t happening in a generalised way will be explained later.) To start, there are three types of Telemedicine:

1.       Synchronous. Just like the good old phone call, the patient and the provider interact over the internet, usually in view of each other (like Skype). Recently, I’ve been aware that some psychiatrists and psychotherapists follow up on their patients using synchronous audio-video technology, with good results and a high degree of satisfaction. That this type of TeleMedicine is well-suited for mental health if probably a reflection that a physical exam is not needed, or that it has been performed previously by another doctor and not relevant to the problem at hand.

2.       Store-and-forward. This is, by definition, asynchronous. E-mails would be typical of this interaction: information is recorded, saved/stored and sent/forwarded to the doctor/provider, who’ll respond and give recommendations or requests for further info. Receiving results from a lab on a patient’s mobile phone app, which is then forwarded to the doctor, is just another form. Consultations, second opinions, sending images and lab test results to remotely (even across the globe) located professionals or clinics, is store-and-forward. Sending everyday diagnostic images from North America or Europe to highly trained radiologists in India for interpretation, shortens the turnaround time for reports, making use of the different day/night time zones.

3.       Remote patient monitoring. The world, both in developed and in developing countries, has to face the fact that providing services to remote locations, to a progressively ageing and home-bound population, plus the burden of chronic, non-communicable diseases, cannot be handled with the present tools of Procrustean medicine. Self-care and monitoring with wearables or trusted diagnostic home devices, produces information that can be managed remotely (tele) in asynchronous or synchronous modes and by non-physician healthcare professionals. Even the younger ‘worried well’ population will feel secure with this type of relationship with their healthcare providers.

So why isn’t TeleMedicine happening in a widespread way? Some point at doctors as the main bottleneck, as we (doctors) are already hard-worked and have our hands (and minds) already full with the Procrustean model of assembly-line medicine. Besides, most TeleMedicine services are not reimbursed (payed for) – so why offer it, having to work longer? – even if it’s maybe notoriously beneficial for some patients. Many cite confidentiality and cybersecurity issues (true) and the liability of a regulatory vacuum and how to document the doctor-patient interactions in the electronic health record. Although many cite that physical examination cannot be reliably performed over the internet (this may change), in fact many follow-ups, most medication refills and follow-up tests can be done safely, without forcing patients to book, wait and see their doctor personally, for every single issue.

In a nutshell: Telemedicine saves time, the need for displacement and can be as reliable as traditional one-on-one and face-to-face medical practice, or even better, when used flexibly and in addition – or in place of – what we’re doing now. We only need to start thinking outside of the box, like the CQI improvement author and Einstein said.