Doctor argues for a Goldilocks standard of care

Doctor and patient
Lyle Swenson, a Maplewood cardiologist, spoke with a patient after a stress test in 2011.
MPR Photo/Elizabeth Stawicki

If you're seeing a doctor for hypertension, he might put you on antihypertensive medication and ask you to keep track of your blood pressure.

If you're seeing a doctor for hypertension and diabetes, he might put you on hypertensive medication and insulin, ask you to keep track of your blood pressure, prescribe a change in diet ask you to chart your blood sugar.

If you're seeing a doctor for hypertension, diabetes and depression, he might put you on antihypertensive medication and insulin, ask you to keep track of your blood pressure, prescribe a change in diet, tell you to chart your blood sugar and start taking antidepressants.

At some point, you might just take an aspirin and stop calling the doctor.

"The person who has both hypertension and diabetes, if they are asked to improve both diseases, and their depression and their back pain, they start accumulating a large amount of health care that they have to do," said Dr. Victor Montori on The Daily Circuit. "A number of visits and test and things. And this may overwhelm the capacity of them and their family to face that work."

"People get overwhelmed when we place too many demands on them or because their capacity to shoulder those demands decreases by, for instance, being sick," Montori said. "There are two ways in which people get overwhelmed. One is if they get sick and they lose capacity to do the work of being a patient. And the other one is when we ask them to do too much."

Montori, a Mayo physician who advocates for what he calls "minimally disruptive medicine," says he strives for what one might call "Goldilocks care. Not too much, not too little. Just right."

As people get older, Montori said, the likelihood that they will suffer from more than one chronic condition at the same time increases.

"If you look at all the patients with diabetes in the country, over the age of 65, how many of them only have diabetes? It's 5 percent," Montori said. "So 95 percent of patients with diabetes have other chronic conditions. One of the most common ones is depression. So add depression to that mix. Now ask them to do more things.

"Some of these patients are going to be diligent, they'll do all that. But they'll have to stop doing other things that they would have done with that time, to actually comply with what we're asking them to do. So we'd better have a good reason to ask them to improve their sugar control or their blood pressure control."

The best such reason, he said, is that it fits with the patient's own goals.

"What are the goals of health care for that patient?" Montori asked. "If the goals are to improve their sugar and their blood pressure, then we're doing good. But most people don't walk around life thinking, 'I've got to have good blood sugar. I've got to have good blood pressure. They want to be there for their grandkids, they want to do their jobs, they want to be there for their families, they want to feel healthy. And many of the things we're doing to control those diseases or chronic conditions do not advance the goals of the patients of feeling better or living longer."

In fact, a patient with hypertension or diabetes might have not feel sick until he or she starts taking medication. "In that particular case, hypertension and diabetes, they may have no symptoms except those caused by the treatments used to lower their blood sugar and their blood pressure," he said.

Patients with a variety of conditions, he said, "get to see all the health care. They get to see all the tests and X-rays and all these other things, with all the false positives that then lead to further evaluations. So these patients really accumulate the toxicity of the health care system, by virtue of the fact they have multiple chronic conditions."

So doctors need to have a frank conversation with their patients, he said, on a central question: "What are your goals?"

"You have a specific context, you have a specific set of values and preferences," Montori said. "What are your goals? Let's look at the list of conditions and list of potential treatments that the best available research evidence suggests will do more good than harm, and from those let's prioritize the ones that will advance your goals."

Besides identifying the patient's goals, he said, the doctor should try to find out the size of the patient's treatment burden and capacity to take on more. Knowing the patient's capacity — his resilience, resources, literacy, physical and mental health, and social capital — can help answer the question, "How much more or less should we do?"

To most physicians, he said, "That's all new stuff." Without such a conversation, he said, both doctor and patient may succumb to "a sense that we're on a train that cannot be stopped, that there is an inertia to do more and more and more."


With Chronic Care, Less Can Be More
It is health care designed to achieve the goals of patients while imposing the smallest possible footprint on their lives. Patients and clinicians can work together in deciding which treatments to take, prioritizing those most likely to help our patients achieve their goals and dreams. Then, we need to deliver these treatments in a way that is mindful of the work required and patients' capacity to get this work done. (Wall Street Journal)

Less medicine for overwhelmed patients
In fact, many patients already practice passive resistance: not filling prescriptions, or leaving their pill bottles untouched. It becomes a vicious cycle, Montori says: Patients feel overwhelmed, their condition gets worse, so the doctor orders more tests and treatments, making them even more overwhelmed. (Star Tribune)

Dr. Montori talks about minimally disruptive medicine:

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