october 2020, Volume XXXIV, Number 7
Victor Montori, MD
One of the central themes in your book is careful and kind care. Please tell us what you mean by this.
Health care should be careful in that the care plan should respond well to the patient’s situation, the response should be based on the best available research evidence, and it should be safely implemented. Health care should also be kind in that it must respect the patient’s precious and limited time, energy, and attention, avoid delegating unnecessary medical errands to patients and caregivers, and must form care plans that can be made to fit well within each patient’s daily routine. This often requires collaboration between clinicians and patients.
Please tell us what you mean by industrialized medicine and the problems it causes.
At the core of industrial health care is the notion that what happens at the point of care is the “delivery of care” by a provider (a person or an institution) and patient. Patients are expected to be engaged and activated to do their part in this care delivery. Payers judge the care delivered in terms of its quality and cost. Patients are not the reason for health care’s actions but are uncompensated employees. In this way, industrial health care has corrupted its mission. Typically, industrial health care focuses on care for “people like this” (not for this person), disregards continuity of care, promotes transactional interactions, focuses on documentation of care rather than on the care itself, and seeks to optimize financial outcomes rather than human ones. It is cruel to patients and clinicians alike. In industrial health care, whatever “value” is accrued flows away from the clinical encounter and to management and funders. Accountability is also inverted. Clinicians and patients are held accountable by the administration, rather than managers asking themselves, how might I enable care to be easier, better, safer, more equitable, and more effective today for patients and their clinicians?
Reform and innovation are simply insufficient tools to address the problem. This is why we need a revolution.
You speak widely about the burden of treatment on patients. How do physicians respond to that idea?
Clinicians respond with sympathy as they find themselves overwhelmed by industrial health care. They spend half the time with patients clicking on fields in the medical record, a task that must often continue at home. They experience workloads that exceed their capacity and sometimes key actions must be skipped to get through the day. This produces moral injury and burnout, with clinicians leaving the practice or cutting down on their patient care times. This burden is repeated with patients, particularly people living with multiple chronic conditions, who have to accommodate not only the demands of living but also the demands health care makes. When these demands exceed a patient’s capacity, they may not complete all the tasks and will be labeled, cruelly, as noncompliant. About 40% of patients living with chronic conditions reported being overwhelmed. Clinicians interested in co-crafting programs of care that makes sense to patients must face not just time pressures but also the need to meet practice standards and performance metrics that are often in conflict with the notion of minimally disruptive medicine. Clinicians bear witness to this churning, how it limits access to care, how it overwhelms patients, how it often fails to improve their patients’ situation, and how it leaves them dissatisfied.
One of the problems you discuss in Why We Revolt is the corruption of evidence-based medicine (EBM). What are the signs of this corruption?
“Evidence-based” was added as an adjective to better describe a form of medicine in which we carefully and judiciously draw from the best available research to figure out with our patients how to respond to their problematic human situation. The main advance of EBM has been to note that not all observations and certainly not all research evidence are equally credible, and no matter how credible, no piece of evidence ever tells us how to care. Care is formed in response to this patient, not to patients like this. Research evidence alone is not enough. It must also include what we can glean from experience and expertise of the clinician and the patient. When research evidence is motivated by a purpose different from supporting patient care (i.e., to gain FDA approval or increase market share) the questions asked and the findings published are tainted by a desire to further industrial goals. In this way, the evidence base becomes corrupted because of biased methods, results, and publication. Clinicians and patients are left to make decisions based in part on the wrong information, making care less safe and effective, i.e., less careful.
Another theme is “timelessness in care” and the problems time constraints create. Please share some of your thoughts on this.
Care is a fundamentally human activity. Humans process complex information through thoughtful contemplation: space to talk, observe, reflect, and be silent. These actions take time and give care its natural tempo. This is why it is silly to demand for care to be efficient. We should not waste resources, time key among these. But we should also not accelerate the tempo of care arbitrarily. Like a ballerina, there is no wasted move, but also no haste in the movement. There is a certain length of care that enables time to become dense and deep. Sometimes this requires visits to be longer, but not excessively so. Sometimes what is necessary is the continuity of relationship—not with the institution, as industrial health care would have it—but with a caring clinician so that the time for care that matters spans across multiple moments. Careful and kind care takes time. This does not refer to length only, but also to depth. It does not refer to duration only, but also to rhythm.
What is the biggest challenge you are facing in building a movement?
The biggest challenge is how well industrial health care fits with the rest of the world in which we are asked to flourish. In this world, we live distracted lives, pressed for time, and expected to achieve more, faster, and with less. Demands for high efficiency reach education, mentorship, family care, friendships, craftmanship. This industrialization of human activities includes health care, and when it reaches those other ones, it often produces “value” while betraying and abandoning its essence, its purpose. Despite this corruption of its mission, whole economies—from clinician income to retirement funds—depend on the economic success of industrial health care, of having it remaining as it is. As we have seen during COVID-19, health care can collapse while health care payers celebrate unprecedented profits. It can celebrate the creation of value and yet fail to offer protective equipment to its clinicians and cruelly let patients die alone because their loved ones cannot be allowed at their bedside. This is why reform and innovation are simply insufficient tools to address the problem. This is why we need a revolution.
How can physicians get involved?
The central requirement of a revolution is to visualize a better alternative and a path towards it. The Patient Revolution’s vision of careful and kind care for all puts care at the center. In this future, the ability to care becomes the guiding force by which resources are managed, strategies planned, and executions judged. It expects citizens to take the lead and clinicians to soon join an effort to upend what is there in exchange for something better. We are working to develop some larger initiatives in pursuit of this goal. In the meantime, our website (https://patientrevolution.org) offers some tools for patients and clinicians, not to compensate for the lack of care in industrial health care, but to offer glimpses of this future, and to let clinicians and patients experience together the possibility of a better alternative.
© Minnesota Physician Publishing · All Rights Reserved. 2019
Victor Montori, MD, is professor of medicine at Mayo Clinic. He is a practicing endocrinologist, researcher, and author and a recognized expert in evidence-based medicine and shared decision-making. Dr. Montori co-developed the concept of minimally disruptive medicine and works to advance person-centered care for patients with diabetes and other chronic conditions. He is the author of the book Why We Revolt: A Patient Revolution for Careful and Kind Care.