INTERVIEW
“The Patient Revolution” Victor Montori, MD Mayo Clinic One of the central themes in your book is careful and kind care. Please tell us what you mean by this.
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.
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.
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?
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OCTOBER 2020 MINNESOTA PHYSICIAN
“...”and innovation Reform are simply insufficient tools to address the problem. This is why we need a revolution. “...”
Please tell us what you mean by industrialized medicine and the problems it causes.
One of the problems you discuss in Why We Revolt is the corruption of evidencebased medicine (EBM). What are the signs of this corruption?
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
“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,
