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.