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NonprofitI am Victor Montori, Mayo Clinic Doctor and founder of Patient Revolution, AMA!

Oct 18th 2017 by vmontori • 19 Questions • 1937 Points

I'm Doctor Victor Montori. In 2016, I helped to found the Patient Revolution, a non-profit that seeks to move our healthcare system away from its current industrialized, pro-revenue model to one that is careful, kind, and patient-focused.

I've recently released the "manifesto" of the Revolution, my book "Why We Revolt: A Patient Revolution for Careful and Kind Care," which details my experiences in a series of personal essays.

Ask me about anything from healthcare to growing up in Peru!

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Edit: Sorry but this is all the time I have today to answer all your questions. This was my first time doing AmA and it was a pleasure and fun to engage with you all. Feel free to connect through our website (http://patientrevolution.org) and let me know the stories that come to mind after you read Why We Revolt (http://patientrevolution.org/revolt). Together I believe we can achieve careful and kind care for all. Thank you again.

Q:

Hello Dr. Montori. I am a medical student interested in pursuing personalized medicine. What do you think about personalized medicines potential in the patient revolution?

A:

Very challenging. The narrow definition of personalized medicine is one based on careful measures of bodily function, chemicals, bugs, proteins, or genes. These are efforts to reduce uncertainty. I think we need to recognize that the most likely outcome of these efforts will be the recognition of new uncertainties. I am afraid they will distract us from practicing the “other” personalized medicine which is to see each person in high definition, see their biology and biography, their content and context.


Q:

I definitely see how personalized medicine can lead to disparities in care. For example advanced personalized medicine care in oncology can take place more easily in big academic hospitals then in rural health care settings or clinics in low income areas. But i also think it can lead to higher patient involvement because the team based medicine approach requires more informed consent . But perhaps it can also lead to further doctor disempowerment as you mentioned. Where cancer was previously the domain of the oncologist or the surgeon, the team based medicine approach now involves bioethicists (which is good for the patient), pathologists, and others on the tumor board.

Sorry for this long winded statement/question, I am just very interested in personalized medicine and believe it's a paradigm that can completely revolutionize medicine and wanted your thoughts on this.

Also my dad trained at the Mayo Clinic and I find your guys biorepository fascinating. Is it true that you have tumor samples from the 1800s?

Thanks for your time.

A:

The Mayo biobank has a long history indeed. Team based care is obviously superior in the care of patients with complex situations, particularly when the team includes patients and caregivers.


Q:

One thing I was very taken by in undergrad was Sherwin Nulands how we die where he talks about "The Riddle"

In it Dr. Nuland says that physicians have the tendency to dehumanize patients and view their disease as simply a Riddle to solve. Rather than focusing on patient needs, the doctor becomes obsessed with solving the riddle/ curing their disease because the inability to do so reflects poorly on the doctor. In their effort to do this, they lose sight of what is best for the patient by subjecting them to treatments that may not be in their best interest in order to solve this Riddle.

Do you see this in practice today still? The book was written in the 80s and I would like to think the medical practice has evolved past this mentality.

A:

To some extent. The main point to me is that to cope with volume and incentives, many encounters are rushed, and we fail to see people in high definition, and to capture a sufficient understanding of their biology and their biography to be able to care.


Q:

Hi Victor, I think your ideas are fascinating and definitely will be part of our future!

It seems like your model requires more total physicians in the country and in each community, because it seems like it would require more time spent per patient, in many cases.

Is this accurate? If so, do you propose lowering some standards of medical school entrance/completion? More PAs? Does even a slight increase in MDs per capita translate to a slight decrease in wages?

Thank you!

A:

Several layers here. Care takes time but we should think of this time not as simply the result of more “units of production” but of ways of caring that may require fewer encounter because we would work harder at improving health on one end and we would have unhurried encounters in which problems are more likely to be diagnosed more accurately and treatments make more sense to both the patient and the clinician. Those encounters should not be crowded out by business agendas, documentation and billing.

On the other hand healthcare should not be a place where people come to extract profits and greedy levels of income. This statement applies to corporate leaders, managers, and clinicians. So I would expect that salaries - yes salaries - for clinicians and others in healthcare including CEOs be moderate, return on investments reasonable not exorbitant and “breakthroughs” measured in human lives improved and saved and not in number of dollars pocketed.


Q:

Hey I watched your video, and unfortunately I am not able to buy your book, so I don't really know any strategies you propose. However, medical school generally costs >200k, and I was wondering if your project has any goals to lower the cost of medical schools?

I also am a bit confused on your perspective of documentation. It seems that you have noticed that more documentation is required in the medical field (at least for insurance purposes), so are you aiming to get rid of private insurance companies and presumably requiring less documentation and/or that doctors see fewer patients?

A:

I don't see healthcare as an industry and the same applies to education. We need health professional education to be affordable and salaries to be reasonable so that we have the right people in the right position for the right reason. I think that the Patient Revolution will be successful when we change the polarity of healthcare. Right now, doctors and patients produce care that payers and investors evaluate for quality and decide to pay for. So the accountability goes in the same direction, doctors and patients are accountable to the payers. This is why payers talk of noncompliant patients, and doctors find these patients a risk to their ability to meet the demands of the boss. This is wrong! The boss should be the patient, all the value in care should not go to payers but to patients and all the accountability should be to each of our patients. When that happens we will know we have arrived. This is why i don't call for reform. I call for a revolution.


Q:

Dr. Montori, having read through most of the questions and your responses, I wonder where you see the legal profession in your revolution? I have heard for years about doctors having to charge exorbitant fees so they can cover their malpractice insurance. I can see where careful and kind care could elevate some of this but would appreciate your views.

A:

Patients and clinicians who engage in meaningful conversations develop the kind of relationships on which they can fall back in case of unexpected or undesirable outcomes.

The challenge of course is when people cannot understand that undesirable consequences can come from healthcare (something healthcare contributes to by means of ads and press that highlight only the promise and wonders of care that resulted in awesome outcomes), or when crooks use white coats to do net harm on their way to personal power and fortune.

Defensive medicine, the practice of doing more or fewer tests or treatments than needed/wanted just because to avoid liability is not a practice that is careful or kind.


Q:

I recently learned about the struggles Lyme and ME/CFS patients face when seeking treatment in both socialized and privatized medical systems. (You can see a short video about how severe ME/CFS can be here: https://www.omf.ngo/2015/11/11/palo-alto-tv-news-covers-daviss-family-struggle-with-sever-mecfs/) These struggles include dismissal from doctors, disbelief, and prescribing treatments that do not help and sometimes harm. There is a huge need for more research about these diseases, better medical education, and better treatment. How can a non-profit like Patient Revolution help patients like these?

A:

This is a hard question. Some medical conditions appear to not be worth the same level of access and care than others. Conditions that remain hard to explain with medical science, mental and behavioral health conditions that are hard to treat successfully or that require multidisciplinary teams or that are poorly reimbursed by payers. Patients who suffer these conditions not only have to cope with the challenges of living with them, of adapting to its symptoms and limitations and thriving as they pursue their life's hopes and dreams but they must also work hard, fight sometimes, to get the care they need. This is neither careful nor kind. It is often downright cruel.

The Patient Revolution does not focus on advancing the situation of people living with any specific disease or condition, but rather with creating a healthcare system that can respond humanly to the situations patients bring. As science advances, clinicians may find themselves in increasingly better position to respond effectively. In the meantime, they should care. The Patient Revolution should help make it more likely than not that the way healthcare is "delivered" and funded does not interfere with the ability of clinicians to care, and of the patients to see their situation advanced by care.


Q:

Have you, your department, or any other specific Dept within the Mayo Clinic worked on or with any aspect of the new revolutionary CRISPR technology? And what is your opinion on what will be or what looks to be the first publicly available treatment / application of said technology? Thank you so much for your time and even if all you want to do is offer your personal opinion on the crispr technology it would be more than appreciated.

A:

Science is exciting. But I must stop there as this is beyond my expertise.


Q:

Do you like coffee or tea? How do you drink them, with creamer or what have you?

A:

Black coffee.


Q:

What will doctors do when all become robots and there are no humans left to treat? Will you take up hardware/software engineering?

A:

Great question. How is my bot doing in answering these questions thus far? :-) Careful and kind care requires judgment, humor, ability to say the right thing and be silent when necessary. I don't see these capabilities present in our cybernetic colleagues anytime soon. But even if we delegate some tasks to technology, we should do it in a way that preserves and expands our ability to engage as humans in the joint dance of healing.


Q:

Have any doctors that you know personally been opposed to Patient Revolution? If so, why?

A:

The patient revolution requires turning away from industrial healthcare and toward careful and kind care. Most of my colleagues respond favorably, but feel disempowered, as if they had not control over their professional activities anymore. For patients this is surprising as they see many clinicians as powerful entities. Some are, and some are entrepreneurial profiting from the status quo, but many more are just trying to do what they love in very unfavorable contexts. This explains, in part, why 1 in 2 or 1 in 3 clinicians are reporting feelings of depersonalization and burnout including unable to feel empathy for their patients. This is the ultimate challenge: industrial healthcare is capable of hurting patients and the clinicians that are there to help patients.


Q:

Hi Victor -- two questions:

  1. As someone outside of the sphere of healthcare, I agree that the industrialization is a problem (I'm in favor of having hospitals as a government service instead of private corporations). What are some things that myself and others could do to influence? Or do you think change is more on the clinician side of things?

  2. Thoughts on changes to Single Payer and how that might impact things re: industrialization?

A:

Excellent questions. I call this a Patient Revolution because I think patients (citizens really) will have to lead the change. Those who depend on the system as is will likely join later, when it feels a little safer to challenge it. So for not, i think citizens (patients, caregivers) and also students of the helping professions who still remember why they chose this route (to help others) will have to lead.

Things to do? We are still working it out. We think promoting conversations is very powerful. There are conversations that must take place at least at three levels. The first level is between clinicians and patients. There patients and caregivers can do more to make sure those conversations are more likely than not to be careful. The Patient Revolution organization website (patientrevolution.org) has some tools that you can use tomorrow, and some others that can be used to prepare for visits. We have done several training sessions in public libraries around the country where people have felt ready to ask difficult questions in their upcoming consultations. Similarly, we can promote deliberative democracy conversations between towns and their clinics and hospitals, and at the national level to advocate for models of care that are careful and kind. This would involve aspects of healthcare driven by greed such as the price of meds and access to affordable and careful and kind care for all.

In terms of models of care - the right answer depends on the country and the culture that each nation has. The key ingredient to the solution in my mind is solidarity. After that, the system needs to work out how to come up with an approach that advances access to all, is sustainable and is innovative. We should not trade these off against each other but optimize all three. Calling all innovators, but asking them to engage not on the basis of greed but of its antithesis: solidarity.


Q:

For 8 years now I've had a persistent feeling of tightness and pressure in my chest that exists 100% of the time. Like I can always feel my heart beating, or like my chest is going to explode. It's frustrating and annoying and sometimes downright scary. Every doctor and specialist I've been too though says it's nothing because they can't seem to find anything wrong with me, even after countless stress tests, blood tests, enzyme tests, echo cardiograms, X-rays, and god knows what else.......

What the hell should I do? What's the next step?

A:

I don't know. Sounds like a tough situation. Perhaps someone with a broad perspective (like an internist) should take a fresh look at your problem. Coping with persistent symptoms is really hard, adapting to them and thriving despite them a tough trick.


A:

Hold the Mayo!!!


Q:

What do you think of "alternative medicine", in particular Chiropractic?

A:

I find that many practices that are not supported by science can be easily ignored by traditional medicine. But there is one aspect that is often better practiced “there”: noticing the person. I would like to see a practice of care that is BOTH strongly grounded in science and that attends to the care of THIS patient, seen in high definition.


Q:

In your professional opinion, and with you being at the Forefront of medical advancement that is the Mayo Clinic, how many years would you estimate it will be until we see the pancreatic cancer cure rate exceed the 20% mark?

A:

I don’t know. Only to say that science does not only move smoothly but also in jumps, in paradigm shifts. So any predictions will probably be wrong.


Q:

Have you seen Gordon Hayward's injury?

What is your opinion on the severity of it?

A:

Yes, but I am not qualified to make a comment beyond what any fan who saw could make. I am always amazed at the resilient spirit and capacity to recover of athletes. Let's wish him the fastest and most complete recovery possible. It is a reminder that any of us can become injured or fall ill at any time, and that we should all, at all times feel that when that happens our community can cushion our fall and support our coping and recovery, regardless of our ability to pay. That is in part what I mean by Careful and Kind Care for all.


Q:

Are you attempting to sort out a union, as well?

A:

Not sure I follow


Q:

A doctor's labour union. For example https://www.hcsa.com/

A:

I am much more interested in a patient-led movement, in advocating for careful and kind care.