We need minimally disruptive medicine
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2803 (Published 11 August 2009) Cite this as: BMJ 2009;339:b2803
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Dear Editor,
As a working GP, occasional patient and occasional carer, this
article struck a particular chord. In an era of increasing sub-specialism
it was refreshing to hear the authors take a step back and question the
complexity, industry and outcome of continually 'doing things to
patients'.
How though do we measure the impact or utility of such research? I
left a copy of the article with someone who has no medical background
but is caring for a relative with Alzheimers. She had an appointment
with an old age psychiatrist later that week and was wearily anticipating
another round of investigation, referral and potentially 'disruptive'
treatment. Instead she was overjoyed to encounter an empathic, supportive
and non-directive young doctor who recognised that both patient and carer
were becoming overwhelmed and responded appropriately.
Disruptive medicine often results from doctors misunderstanding
patient expectation, the contribution of colleagues and the consequence of
action. Perhaps the culture shift that the authors call for may come from
a shared inter-professional understanding that, to quote John Donne "no
man is an island entire of itself...because I am involved in mankind"
Competing interests:
None declared
Competing interests: No competing interests
May, Montori and Mair have identified a growing problem for people
with chronic conditions and a useful set of principles for helping resolve
it. They have not, however, mentioned treatment accessibility and
usability, a significant and increasing obstacle to adherence to treatment
regimens that could quite easily be removed.
All too often, the pharmaceutical industry seems oblivious to the
need for patients to be able to access and manipulate treatments. Evidence
of this is to be seen in the inexorable drive towards the provision of
pills, tablets and capsules in blister packs, which runs contrary to
patients’ interests. The problems posed by blister packs are often
exacerbated by the use of pills too small easily to be seen or handled.
Like increasing numbers of people, my step-mother is elderly,
determinedly independent, and has macular degeneration and moderate
arthritis in her fingers. She has been prescribed digoxin for arrhythmia,
taking two tablets daily to make up the total dose. The tablets are less
than 5mm in diameter. I watched recently when she insisted on accessing
them herself, waiting for a full five minutes as she wrestled with the
blister pack, becoming increasingly agitated and frustrated, and losing
one pill on the floor before eventually I intervened.
I myself have good eyesight and am reasonably dextrous. Even so,
trying to extract (5mm diameter) coversyl 2mg tablets and 25mcg thyroxine
tablets from blister packs is a frustrating chore. I have had capsules
break apart when being pressed out of blister packs. And I encountered a
pack recently on which the backing foil was so thick that it had to be cut
on three sides of each capsule before the capsule could be released.
Many less determinedly adherent patients would stop taking such
treatments rather than continue to wrestle with tiny pills and nigh-
impenetrable packaging.
The Association of the British Pharmaceutical Industry says that
blister packs facilitate the provision of patient information leaflets
with all medication, that they meet the requirement that medications
should be presented in as tamper-proof and as child-resistant a form as
possible, and that they make counterfeiting more difficult. That is
misleading. In reality, the regulations leading to the growth in the use
of blister packs were introduced solely for the benefit of the industry.
All of those objectives could as effectively be achieved with factory
-sealed bottles or containers with tamper-proof caps. The re-introduction
of such containers – and the bulking up of all pills to at least (say)
7.5mm in diameter - could significantly improve patients’ adherence to
agreed treatment regimens.
Competing interests:
None declared
Competing interests: No competing interests
I agree absolutely. There is a saying "if you let the patient talk,
they will tell you the diagnosis".
It is very rare for my working diagnosis to be changed by the examination,
rarer still by investigation.
Yet we still insist on treating test results not what the patient is
complaining of. Why? Because we interrupt, assume and confabulate,
thinking we know best. We don't.
Then we wonder why the patient doesn't accept, take or respond to out
treatment. Talking might not win any Nobel prizes, but it will save
unneccesary investigations, admissions and possibly lives.
Competing interests:
None declared
Competing interests: No competing interests
More and more patients are burdened with complex, time consuming,
sometimes expensive and all too often counterproductive management and
treatment regimes. If we doctors establish relationships with our patients
which give them confidence and time to talk, we can find out what they
feel. Only then can we hope to simplify these routines to something that
is safe, therapeutic and allows them some time off from being a patient.
Competing interests:
None declared
Competing interests: No competing interests
May et al make some excellent points. I believe that medical care has
advanced to the point that it is essentially too complex and sophisticated
for
patients to manage; certainly many doctors and health care systems cannot
manage it well, so why on earth should we expect patients to be able to
accomplish this feat? In my practice, anecdotal observation suggests that
most doctors seeing any given patient, whether in the hospital or as an
outpatient, do not know what medications the patient is normally taking -
and clearly patients do not either.
Here in the US, the financial barriers to filling prescriptions
(often at different
pharmacies for different drugs, either for cost reasons or because of
insurance policies), the cost of treatment, the difficulty of getting to
various
appointments where there is little or no public transport, the
incomprehensibility of medical bills and insurance policies, and the
prevalent
"rationing by inconvenience" by third-party payors, all add to the
problem.
Medical payment systems and the medicolegal context encourage excessive
complexity, with over-testing, over-imaging, over-visiting of doctors, and
when I try to save a patient a burdensome visit to me by emailing their
response to a new medication I am voluntarily cutting my income and that
of
my employer. Only when the system incentivises rational care will we move
towards improving the problem - as usual, anyone can make things
complicated, but it takes genius to simplify things
Competing interests:
None declared
Competing interests: No competing interests
I was inspired by this article in this week's BMJ. I am a jobbing,
nobody and hick GP in Chingford, North East London, an area where I am
seeing the fallout of the Credit Crunch in the Consulting Room day in and
day out. In addition, I have a sub-interest in rehabilitating people with
chronic conditions back to work or sustaining them in the workplace.
Recently, there has been a sustained effort by the Department of Work and
Pensions in the UK to encourage those on long term disability back to the
workplace. This is very welcome and I concur that work is good for health.
This trend has been supported by an initiative from the Royal College of
General Practitioners.
Yet, hitherto, there has been virtually nothing on how difficult it is to
manage a chronic condition and the fact that this represents almost a
second career in itself requiring massive organisational skills on the
part of the individual and frequently unbelievable logistical efforts by
health services that frequently do not repay the patient's commitment or
engagement.
Interestingly, whilst there has been a lot of discussion of the role of
Primary Care and its accesibility through, in the UK, the Darzi report,
Secondary Care remains in patient contact for non Acute problems and
especially Chronic Disease Management the same 9 to 5 Monday to Friday
phenomenon that it always has been.
I think this article strongly supports the view that every time we write a
referral to a new service, request that they undertake a new
investiigation (even as simple as a blood test) or ask them to attend
another outpatients appointment, we need to think hard about the effort
and resources that will entail our patients with chronic conditions have
to go through.
As a GP the Patient Experience element of my pay is increasing. As this
trend, which is altogether fair I think, spreads, can we really afford not
to take this aspect of delivering healthcare seriously?
Dr Shahid Dadabhoy
GP
The Microfaculty,
107/109 Chingford Mount Road,
Chingford,
London E4 8LT
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Lothian has a high incidence of COPD and as Associate Medical
Director for NHS Lothian, I was heartened to read Professors May, Montori,
and Mair’s article, ‘We need minimally disruptive medicine’, and would
like to highlight telehealth as a practical way of enabling minimally
disruptive medicine. I very much agree with their observation that patient
involvement must play a central part in disentangling individual and
collective treatment burdens. NHS Lothian is rolling out one of the
largest telehealth programmes in the UK, working with Intel Corporation
and Tunstall Healthcare Group. The project includes 400 patients with
chronic conditions including COPD and heart failure.
We have found telehealth helps improve patient awareness of their
condition and self management, empowers our patients to take more control
and to move to the centre of the treatment process. It has been adopted
enthusiastically by patients and their carers and they report greater
feelings of confidence and independence. Importantly it enables the
healthcare team to cut through the over complex care environment that most
of these patients exist within, allowing earlier treatment intervention to
anticipate and manage exacerbations and thereby prevent the condition from
worsening. This in turn can help to reduce the number of unplanned
hospital admissions.
Yours sincerely,
Brian Montgomery
Competing interests:
None declared
Competing interests: No competing interests
It might be helpful to recast how chronic illness is viewed, both for
patients
and healthcare providers. May et al note that "chronic disease is the
great
epidemic of our times" reflecting the "epidemiological shift from acute
disease, where the emphasis was on cure."
In fact, one might say that the emphasis shifted from dying of
untreatable
diseases to curing those, and living to a greater age with incurable but
manageable disease. A primary reason for an "epidemic" of chronic disease
is
not because so many more are occurring, but because so many more are
living with them rather than dying from something else.
Thus, the "epidemic" is largely a lot of people who would, according
to old
expectations and treatments, be dead. Suppose that many of the women who
formerly died in childbirth now often lived, but with some sort of ongoing
problem? Would we note the success of preventing their deaths, or bemoan
the fact that there were so many women with birth-related problems?
I think it would help both patients and healthcare providers to
start seeing
chronic disease as the other side of not dying early. It is, in fact, the
"price" of
a longer life for many. Some may choose to "throw in the towel" once the
burden becomes too great--not be treated, at least for some things, with
the
recognition that this might hasten their deaths. Others might be more than
willing to do whatever is necessary to prolong life.
But both require a dialogue between physician and patient about
exactly what
they are getting for the price of ongoing disease management and adherence
to treatment.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
We have read with interest the recent paper by May and colleagues [1]
on the challenges that multiple co-occurring chronic diseases present for
consumers, carers and health professionals.
We agree with the authors’ argument that the co-occurrence of
multiple conditions, or multimorbidity [2], creates a heavy burden. In
such situations it may be difficult to manage medicines effectively and
medicines-related adverse events can flourish.
Ideally, interventions to promote safer, more effective medicines use
could help to diminish many of these problems. We argue that while such
interventions might focus in part on promoting treatment adherence they
must also take a wider perspective on consumers’ medicines use. This could
take many forms, such as interventions to promote understanding of
medicines; to support people to take medicines safely and effectively; to
improve self-care skills; or to minimise harms [3].
In reality, the state of the evidence on consumers’ use of medicines
appears far from ideal. As part of a larger research project4, we selected
systematic reviews of interventions directed to consumers and aiming to
improve the use of medicines, and assessed the extent to which these
reviews and their included studies considered multimorbidity. The dataset
comprised relevant reviews published on the Cochrane Database of
Systematic Reviews and the Database of Abstracts of Reviews of Effects
from inception to September 2008 [4].
Of the 53 reviews, 45 (85%) did not explicitly consider
multimorbidity, either at the review or included study level. In the
remaining eight reviews, people with multimorbidity were not explicitly
excluded, but were typically found in only a minority of the included
studies. Furthermore, while inclusion of these people might imply interest
in multimorbidity, there was little discussion of the impact of
multimorbidity on medicines use in this smaller subset of reviews. There
was one exception: polypharmacy in the elderly was addressed in some
detail by a few reviews. However, there is almost no evidence to guide
action on the issue of polypharmacy in other populations, despite rising
chronic disease and multimorbidity rates across all age groups [5].
This gap has serious implications for decision making and self-care
by people with multimorbidity. As May and colleagues point out, the
evidence underpinning interventions to promote safe and effective
medicines use does not apply to patients typically seen in clinical
practice. Furthermore, the evidence fails to consider the interactions
between diseases and the way this affects people’s lives. This creates a
significant burden of decision making for consumers, their carers and
health professionals. Given that multimorbidity is common [5] and is
associated with conspicuously poor outcomes [2,6], this decisional burden
has profound implications for evidence-based healthcare. Explicitly
recognising the impact of multimorbidity and its effects on medicines use
and other aspects of self-care will be essential if we are to improve
outcomes in people with chronic illnesses.
Yours sincerely
Rebecca Ryan, Sophie Hill
References
1 May C, Montori V, Mair FS. We need minimally disruptive medicine.
BMJ 2009; 339:b2803.
2 Fortin M, Soubhi H, Hudon C et al. Multimorbidity's many
challenges. BMJ 2007; 19;334(7602):1016-7.
3 Ryan R, Santesso N, Hill S et al. Consumer-oriented interventions
for evidence-based prescribing and medicine use: an overview of Cochrane
reviews (Protocol). Cochrane Database of Systematic Reviews 2009, Issue 2.
Art. No.: CD007768. DOI: 10.1002/14651858.CD007768
4 See ‘Consumer’ under Rx for Change database, available at:
http://www.cadth.ca/index.php/en/compus/optimal-ther-
resources/interventions
5 Fortin M, Bravo G, Hudon C, et al. Prevalence of multimorbidity
among adults seen in family practice. Annals of Family Medicine. 2005;
3(3):223-8.
6 Smith SM, Soubhi H, Fortin M, et al. Interventions to improve
outcomes in patients with multimorbidity in primary care and community
settings. (Protocol). Cochrane Database of Systematic Reviews 2007, Issue
2. Art. No.: CD006560:DOI: 10.1002/14651858.CD006560.
Competing interests:
None declared
Competing interests: No competing interests
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Competing interests: No competing interests