[Music] [Music] uh it's been now mentioned in both presentations preceding me the importance of patient compliance to therapy particularly for patients with chronic disease and I want to discuss with you a particular set of new thinking and solutions that we are uh putting forward to overcome this this problem the um uh and I'm going to focus on the fact that this estimates vary but around two fifths of patients uh do not follow medical advice they do not um take medications as indicated or they do not come to appointments they do not get procedures that their
clinicians things are needed think are needed and studies also differ in this but there there's evidence of wasted and misallocated Healthcare resources because of this and a recent study has estimated $290 billion in the healthcare system at the moment being wasted uh or misused or being incurred as expenses for patients having complications that could have been prevented by being AAR to therapy poor adance poor Fidelity to therapies that work which are now becoming more common than in the past um also lead to patients that do not realize the value of the healthc care they they
they sign up to receive they may experience for instance the cost of taking medication for a little while may they may even experience the side effect of these of these medications but because they don't take it for long enough or as indicated they may actually not benefit from those medications and finally there's a subtle challenge to a poor uh philal treatments and that is the challenge to the patient physician relationship uh we have heard now about the challenge of patients with chronic conditions and the need for a partnership with their clinicians in seeking that partnership
trust Amy has now made a big point about this in her video trust is key and yet trust is undermined when Physicians suspect that the patient is not following advice and when the patient cannot actually tell the physician this because the the patient suspect that if the clinician were to know that she's not following the advice that that everything will be broken up and the relationship will uh cease to uh be meaningful and therapeutic so both parties are engaging in a less than completely open less than completely honest relationship in introduced by this problem of
non-adherence now we've heard that some of these problem is because people are not well educated they do not know the facts they do not understand the importance of some of these therapies and so or they make because of that they make faulty decisions and so some will argue that poor fil treatment is a patient's fault in ultimately and that they're basically compliant on purpose they intentionally non-compliant and that the way to overcome this is through education through better relationships through addressing their needs and concerns by better information and our research team has actually taken on
that challenge trying to help patients participate more actively in in Sharing clinical decisions and treatment decisions and we develop all sorts of interventions to do this and um some of these interventions can actually be found on our website sorry I went too fast there sorry I just went to the I'll start again there's a big problem with patients um so I was I was telling that our group has developed some tools to help people um participate in share decision- making and some of these tools are flashing up now and I I have a website I'll
leave up if you want to take a note where you can actually go and and experience these tools for yourself see videos of patients and clinicians using these tools we've measured their impact and we have had a measurable by get small impact on overall patients Fidelity to treatment by all accounts we think this probably accounts for half of the problem where is the other half to tell the story of the other half let me introduce to John now John is a madeup patient I made up John I thought so at least until um after presenting
this in a couple of other venues um John showed up in my clinic um and as you can imagine I was immediately moved by the fact that uh or maybe thinking of another Victor Victor Frankenstein but all of a sudden my creation showed up in my clinic and after presenting this to a a community here in Rochester of patients um this woman came up at the end and said hi my name is Jane say hi uh well that's not my real name she says but I'm just like John and it turns out that the case
I'm going to present is nothing but becoming very typical of the practice of a diabetes doctor you've heard of a diabetes patient I'm on the other side uh although I like to think of myself as being next to my patients with diabetes but here's John and so John is a 55y old man with type 2 diabetes and John also was put on Metformin and was put on glyde and also has hypertension and was put on hydrochoride and better blockers and when he takes this P this pills he sometimes feels a little dizzy he also has
high cholesterol and has depression and has a bad back um he also was told to have neuropathy that that neuropathy is the pain in his in his feet and so and he's also obes and his doctor told him you got to see an endocrinologist you also probably need to see a podiatrist an expert in your feet and you probably have to also see a dietician for that you may want to go to the mail Clinic well that means they had to take off work and get a ride and then of course what he's going to
hear he's going to hear he needs to avoid salts avoid fats avoid carbs he needs to exercise more he needs to check his feet how is he going to check his feet he's obese he has back pain so he needs to get his wife to actually look at his feet every night to make sure that they're okay now of course when he's doing all this he needs to also be checking his sugars as am me mentioned before before and his doctor just told me his sugars are too high his LDL cholesterol is too high his
weight is too big and and he knows he's been trying to lose that weight but he's not been able to do it he's in pain all the time and he can't sleep although he's not sure he got to discuss this with his doctor then he realizes um he was one of three accountants in his business then two and then just him he knows the deadline is always now and he got to perform and so he needs to take some work home and he knows by looking carefully that the numbers are not adding up and he's
worried he's worried that his company is going under and he's going to lose his insurance and he's going to be in debt and he's not going to be able to pay his mortgage if he loses his job so he's worried about his home but the biggest worry is in fact at home and when he's thinking about home he's thinking about the fact that his daughter has come back home and that should be a happy event except that his daughter came back home because of difficult circumstances now he brought with her two beautiful girls her daughters
John's grandkids and John is always worried about them because he knows he's their mother has suffered her mother is their mother's at home because her husband was abusing her and she's always wasted she's on drugs and alcohol John is always worried about her grandkids will he be there to constantly support them to be take care of them and as he's worried about this reflecting on this at home he opens up the mail and he gets a letter from his primary care doctor advising him that this number this high cholesterol this high blood sugar this this
weight that is not coming down is really not acceptable that this doctor is being has been subject to pay for performance measures that require that all the patients are well controlled and that despite his best efforts he doesn't believe John is doing his part of the job and that if this were to continue he'll be he'll have to find another doctor not not following patients Physicians advice has become the number three cause that patients report for being fired from Clinical practices number one being physically abusive to your doctor number two being asking for Narcotics number
three is not following physician advice so what is the problem with non compliance for John and I would put forward the problem is that the program that he's on is overwhelming it does not fit in the context of John's life but what happens when a patient like this shows up to a practice like the one he goes to The Physician recognizes that John is not achieving the goals of each of those conditions not getting the sugar down not getting the cholesterol down not getting the blood pressure down not losing weight and so what do we
do with patients that show up in the circumstance we actually collaborate to co-create a program that fits better no what we do is we intensify the program the patient needs more treatment which does not help why are doctors so evil of course doctors are not evil what they're trying to do is they're trying to practice the best possible care they can and and the way that that care is being designed these days is through evidence-based guidelines they tend to be produced in a disease specific fashion so you have a guideline for diabetes a guideline for
blood pressure a guideline for cholesterol and each of those guidelines have the Seas specific goals that the physician and the patient should achieve and they push the clinician to to organize and the treatment according to these guidelines and to refer a patient to specialist that may actually help with each with each of these guidelines now there may not be somebody like that Primary Care Clin to organize the different advice that each of these specialist will provide the patient or to coordinate those visits I mean if imagine if you if for one procedure you have to
go to a particular place that specializes in that procedure and only does that and then for another procedure for visiting a dition you only go to the dietician clinic and you only and that's where they do that and you have to do this how many times do you have to take off work and organize you know take care of the kids the pets the house and the the the the the the transportation so nobody necessarily is organizing this in an in in an in integrated fashion around the patient and so poor coordination becomes a problem
these treatments become increasingly complex in terms of the treatments and their monitoring there's decreased health care support and there's a at the same time we're shifting towards self-management with all these devices Amy has shown us so we're taking the complexity and pushing it to the patient this increases the treatment burden and there's therefore some patients who will fail to cope at the end they'll be poor Fidelity to the treatment program now some of this happens because clinicians think that effective therapy means they just have to do it and they may not have the ability to
make it fit into the program this is data from the Mayo Clinic you can see that when a patient has a heart attack at the Mayo Clinic 100% of those patients leave the hospital with all the necessary care but immediately these these patients who have adequate education and have adequate resources to pay for these medications taking them so we don't realize all all the Care that we can because we just do it we don't make sure that it fits we use the same treatment goals despite of the context that was John that you met before
but maybe John doesn't have the problems of home that we describe for John maybe uh there's another John that actually has the same problems of home but not the same problems of work yet for all three we use the same treatment goals and if John were 10 years younger we'll have actually the same treatment goals and if he was 10 years older at much higher risk of complications we will still use the same treatment goals we do not tailor to context and because we don't tailor to context the programs may not fit and when the
programs don't fit patients go to the experts on fitting programs to different context other patients and here's an example from one of these websites in which a patient is trying to make sure that their habit of drinking beer fits with their new medication for diabetes and he's asking for help why we would a patient go to a community of people that are complet complet strangers rather than trust their doctor it may be that these complete strangers are in fact experts on fitting and their doctor is not Jorge Berner Shaw coined this this this wonderful phrase
because Physicians sometimes feel that that patients are being disobedient but because they're being lazy they don't do the work when in fact maybe patients are trying to do what Gandhi was trying to do with the English which is to make them see from his point that it was in the best interest of Britain to actually let India be independent not fight them it's just have them see it from their point of view maybe patients by declining our treatments are trying to let us know that there's something a miss and they want us to see it
their way and what we are proposing in our research is to actually come up at the end of the day with a healthc care delivery designed to reduce the burden of treatment by focusing and pursuing the patient goals and we're calling this minely disruptive medicine now what would be the elements of this our group is trying right now to focus on how to measure treatment burden we have no way of knowing how burdened the patient is with all the treatments that we're throwing at them as well as all the navigation of the Health Care system
through medical home and other initiatives we're trying to see how better ways of coordinating and organizing care can minimize or decrease the disruption on Care by focusing on changing the way guidelines are put together so that we can realize the value of take paying attention to comorbidity we are trying to make what we're holding clinicians accountable to be more consistent with these goals minimally disruptive medicine and then we need to learn to prioritize from the patient's perspective in diabetes we've we've glorified controlling the blood sugars we make all the visits all the quality of care
all the concerns about the patient about this when a patient shows up the first thing ask what is my sugar and that's okay except that the visit becomes a visit to the principal who's now now going through a report card rather than a visit about how how things are going and every decision takes this technical nature rather than focus on how to make things fit right we like patients and clinicians to focus on the goals that matter can I live longer at least prevent premature death can I feel better can I live and hindered by
complications with both of these e I'm by the treatment can I make the program fit and I'm going to um leave you with this uh video This is actually a video that I'm going to play in the background is from the word inyou Hand Project from two diabetes.com Mani Hernandez which actually was shown in in Amy's video it manages this and it highlights the the experience of patients with chronic conditions trying to make things fit and as you see these hands I will invite you to a reflection are these hands rejecting medical care when they're
being non-compliant as we say or are these hands tell asking for help and I will put forward that these hands are doing both they're asking for a transformation in health care that will make Health Care fit to the lives of the patients and they're asking for our compassion they're they're asking for a companionship they're asking for our partnership they're asking for care and I think this is this is the the the the the road we'll have to travel now towards minimally disruptive medicine thank you for your attention [Music] [Music]
