“…the most important innovation in healthcare today is the ‘unhurried conversation”.
A recognized expert in evidence-based medicine, shared decision making, and minimally disruptive medicine, an endocrinologist, health services researcher, and care activist.
Victor M. Montori, MD is the Robert H. and Susan M. Rewoldt Professor of Medicine at Mayo Clinic. Dr. Montori is the author of more than 750 peer-reviewed publications and is among the most cited researchers in clinical medicine and in social science. He works in Rochester, Minnesota, at Mayo Clinic’s KER Unit, to advance person-centered care for patients with diabetes and other chronic conditions. He is the author of the book Why We Revolt, and is leading a movement, a Patient Revolution, for Careful and Kind Care for all.
“So careful care is evidence based, kind care is respectful minimally disruptive care. No tension. It’s part of our goal. That’s what medicine is for me.”
The full text of this interview is also reproduced in BMJLeader
A champion of careful and kind care, an endocrinologist based at the Mayo Clinic, a major figure in international healthcare -but it wasn’t an easy journey…
Victor Montori: I finished medical school in Lima but my training coincided with a very tumultuous time in Peru with hyperinflation and terrorism which destroyed the infrastructure of the country and limited severely the ability to grow professionally. There was a lot to do and I struggled with the decision to stay or to pursue further training. I opted to pursue further training, applied to a million different places in the United States and, through the lottery system that allocates these spaces, I ended up in Rochester, Minnesota at the Mayo Clinic. For a couple of years, I was in Canada, on a scholarship working with Gordon Guyatt at McMaster University in Hamilton Ontario. For the last 21 years, I’ve been on staff at Mayo. I now spend about a third of my time seeing patients, mostly patients with diabetes as I’m an endocrinologist in outpatient care, and then the other whatever is left of the percentage, I do research on healthcare delivery and patient centred care. And, for the last eight years or so, I developed a non-profit organization focused on turning away from the industrialization of health care, which I believe is one of the reasons why all this work on patient centred care seems to bump against a hostile environment within healthcare, and developed a global movement for care – for careful and kind care for everyone- which is now the work and passion of over 150 fellows from six continents and 10 countries around the world and many more who find hope in this work.
DMacA: Let me take you back a little because for most of us, to be an endocrinologist in the Mayo Clinic, seems like the pinnacle of a career in medicine, but you see a lot of problems. You think there’s a crisis in healthcare.
VM: Yes. My personal ability to have the resources and the colleagues and the support that I need to practice medicine and diabetes care at the highest level possible, is of course an incredible privilege and an incredible blessing. I like to think that on good days, the teams that I work with and the ability that we have to offer that care, does help and support some of the patients that we see in ways that I hope they find valuable. My personal situation does not preclude me from observing what is I think a fundamental challenge. Very few people, except perhaps very young patients with type 1 diabetes, only have one disease. Most people have multiple ongoing chronic conditions and they, more than anyone else, experience all the pathologies of the health care system. They’ll come through the system, either through acute care doors or an emergency department, they will be frequent participants in Primary Care in all its different modalities, virtual, in person, triage phone lines, portals on the electronic medical record and then specialty care and, often times, multiple specialties providing care. So, they touch the elephant from every side and they find the elephant lacking.
“Most people have multiple ongoing chronic conditions and they, more than anyone else, experience all the pathologies of the health care system… “
They become overwhelmed by the task of navigating that system, implementing all the different care plans that are sometimes negotiated, often times forced on them, and being able to enact that on a day-to-day basis, while at the same time they’re trying to live lives which are often also highly complex and problematic. So, just from my own interaction with our patients, you can see that there’s something fundamentally wrong about the health care system in that the people that we are seeking to help are becoming overwhelmed and frustrated by the ways in which we interact with them.
My own colleagues have to be completely unaware of reality to fail to recognize that we have a huge crisis, not only in attracting the best and the brightest into what I think is the most wonderful calling and career, which is to care for your fellow human. We have difficulty attracting young people into it, keeping them in this profession, and some of the most experienced and caring people are leaving the profession, exiting earlier than they planned because they can’t take it anymore. They are tired, they are frustrated. They’re frustrated because they know what the right thing is and they can’t make it happen, or they can make it happen but at an incredible cost in the administrative burdens that they need to overcome, and silly policies that indicate to them clearly that nobody trusts them, trusts their judgment or trusts their honesty.
At the same time, we have massive problems of financial sustainability plus environmental sustainability, given that healthcare has a significant carbon footprint on the planet. It’s a massive crisis of care at the human level, at the economic level, and at the planetary level so, yes I am very worried, even if I’m working in medical Disneyland.
DMacA: You spoke about the right kind of care. Bearing in mind that you came from the evidence-based centre of the world at McMaster, and you’re also very interested and promote the whole concept of kindness, how do we navigate the tension between those two. How do we differentiate between being a nice doctor and a good doctor?
VM: First, I need to sort out the language. I like to think I’m nice and I like to think I’m kind, but when I talk about careful and kind care, when I am using the adjective kind, I’m using it less to indicate being nice and mostly to indicate my commitment to my kin in that I have to be respectful of my patients’ goals and priorities in life. These rarely, of course it’s never but I’m going to be generous and say rarely, include being a great patient. As a healthcare professional, and as an agent of a healthcare system, I have to be very careful with the limited time energy and attention that the patient and their family have for healthcare. I find it is often the case that, in our own arrogance, we think that if the patient is sick- what else is there for them to worry about, and to think they should prioritize this thing that I’m telling them to do. We often have people come in for appointments and we expect that they can wait hours to see us or that they can go back and forth to different parts of our system which are not well connected and not well integrated and not co-located, and they can go one place or the other and move around because… what else is there to do. Yes, they can self-manage and measure everything and write it down or send it to us. But, all of these things reveal a lack of fundamental respect for the fact that these people are trying to make a ‘living’ in the broadest sense of that word and, not only is disease and illness interfering with that, but also our care. And so, my use of the word ‘kind’ reflects this desire to be fundamentally respectful of the fact that people have other reasons for living and this illness is an interruption. What we need to try to do is to provide care and create care plans that fit in a minimally disruptive way. To that extent, there is no disconnect or tension with evidence-based practice. The job of the clinician is to co-create a plan of care that draws from the evidence for people like this, to create a plan of care for this person and that is where careful care comes in.
So careful care is evidence based, kind care is respectful minimally disruptive care. No tension. It’s part of our goal. That’s what medicine is for me.
“….there’s something fundamentally wrong about the health care system in that the people that we are seeking to help are becoming overwhelmed and frustrated by the ways in which we interact with them.”
DMacA: When I hear you talk about careful care and kind care, it strikes me that you sound like a rather unusual revolutionary. Tell me about the Patient Revolution.
VM: This is about fundamentally and radically changing the conditions in which we care and in which people receive care. This revolution is sincere in that we need to fundamentally change healthcare but it’s also nonviolent. And it’s revolutionary in intent to change the fundamentals. But its mechanism of success is more about eroding the dominant approach of today and creating and fostering and building an alternative that will eventually overcome in frequency, and in prevalence, and impact, the dominant structure today. It’s a more of an erosion of the existing, and a replacement with something better rather than the destruction of the existing without construction of an alternative. If we don’t construct an alternative, we would leave people without the care that they need which would not be the most caring thing we could do. This is why a revolution for care has to be a caring revolution as well.
And, it’s one that is hopeful because, if you look at healthcare today, we have the coexistence of some of the worst ways in which we can care for people and some of the best ways. The problem is that some of the worst ways are the ones that are dominating and so, if we could just change that balance and make the better ways, the more careful and kind ways, the dominant approach, those most likely to be experienced by patients coming to see us, we will be successful.
DMacA: What are the steps that we can do as individuals and organizations to make this happen?
VM: There are several things. One that has already come up in this conversation is one that is close to my heart. It’s the notion of language. We rarely speak, when we talk about healthcare, about cruelty, and yet when you go seeking health care, what you experience instead may be indifference, that’s fundamentally cruel. When you’re looking for care and somebody slaps a label on you as a non-compliant patient, and that prevents you from getting a fresh look from another clinician to try to help you, that’s fundamentally cruel. Cruelty should be considered a ‘never’ event in healthcare- similar to amputating the wrong leg. This is to illustrate the power of language.
I think we need a language of reform, of revolution, that calls out the pathologies of care, the kinds of distortions of care that industrialized healthcare does. And so we speak, for instance, of seeing patients as a blur – when your clinician may have the impression that they know you because they’ve looked at your medical record but has no time to ask about who you are.
“Every one of our Patient Revolution Fellows has a sphere of influence. That sphere of influence could be quite limited, could be limited to where they work, in behind the desk or in an office, or in the hospital, or in an administrative position, or perhaps on a leadership, perhaps they’re board members, perhaps they’re policy makers.”
We talk about the burden of treatment and we’ve discussed a little bit about the unkindness of the overwhelmed patients. Seventy percent of our patients have multiple chronic conditions , 40% are overwhelmed to the point where they’re about to stop doing something potentially life-saving as a result of how much work they have. We talk about burden, we talk about hurry and, while everybody’s celebrating AI as perhaps the most significant innovation in healthcare in our time, I keep insisting that the most important innovation in healthcare today is the ‘unhurried conversation’. That space is a sandbox in which patients and clinicians can come together to fully understand the situation of the patient not as blurry but in high definition. And then to co-create a plan of care that is not overwhelming but rather fits well with the patient priorities and the patient situation. The language I’m using is an initial step. We want people to begin to start calling out these pathologies of care and identify ways forward that are going to de-industrialize the healthcare system. That’s one step.
The second step is to decide to act. Every one of our Patient Revolution Fellows has a sphere of influence. That sphere of influence could be quite limited, could be limited to where they work, behind the desk, or in an office, or in the hospital, or in an administrative position, or perhaps in leadership, perhaps they’re board members, perhaps they’re policy makers. They have different spheres of influence and we talk about micro revolutions- what could you do within your sphere of influence to bring about a change that you think may have a chance of addressing one of these pathologies of care?
To give you an example, you’re are a lowly medical student and you choose to start by describing the patient’s personal and social situation rather than by describing their age and the disease with which they present. You don’t need permission for that, you just need to do it, and somebody to notice and then to catch on, and now you have a small revolution that you’re doing within your spheres of influence.
If you’re an administrator and you’re in a committee meeting and somebody says, ” I know! We should just ask the families and the patients to do this because we don’t have the resources to do it” you should be the person in that room that says “hold on! We need to assume that our patients and families are overwhelmed and this transfer of work to them might be good for us, might make us more efficient and higher value, but it’s actually landing on people who are going to be quite tired and overwhelmed, and this will not be the most caring thing we could do, how about…”
These mini revolutions are the next step. If this was a pond we would be bringing invasive species in to try to overwhelm the existing species of industrialized fish. The goal, I think, is to keep doing this. As an organization, what Patient Revolution does is three things: One is that we have a school so we help people understand and use this language, understand and use these concepts, and understand change and how they might conduct these revolutions. We have a greenhouse where we try to develop new ideas and tools to help people at the front lines undertake this, and then we create a community that gives people courage to continue to act in these ways, and elevate and communicate what they’ve learned, when things haven’t worked out, and the massive successes that they’re having when they act here and now. And, with that we hope that we can continue to promote a movement for care of global reach.
DMacA: Victor thank you very much for that wonderful, optimistic, and enthusiastic message. I took one phrase that for me is the action that everybody can take, and that’s the action, for the patient, of the ‘unhurried conversation’ Victor it’s been an absolute pleasure talking to you.
