We Need a Care Revolution: Victor Montori

Eric 00:11

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have with us today?

Alex 00:16

Today we are delighted and honored to welcome Victor Montori, who is an endocrinologist at the Mayo Clinic in Rochester, Minnesota. He’s an author. His book, Why We Revolt, is in its second edition. It’s been translated to many languages. Soon to be in Greek. And Victor will be in Greece for that. That opening of that book there. He’s a frequent lecturer around the world. We met at the summer lecture series in Portland, Oregon last month. His website is PatientRevolution.org. Victor, welcome to the GeriPal Podcast.

Victor 00:55

Eric and Alex, thanks for having me. Delighted to be here.

Eric 00:58

I am so excited for this podcast. I just had a chance to read your book, watch a couple of your grand rounds for our listeners. We’re going to be talking about what’s wrong with industrialized healthcare, why it corrupted our mission, and why it stopped caring, and how we can fix it through revolution. But before we do that, Victor, I think you have a song request for Alex.

Victor 01:22

Yes. The song request is Sledgehammer by Peter Gabriel. And please do not ask me why. [laughter]

Eric 01:27

I would ask you why, because most people don’t know this song is 100 about sex. There is no doubt about it. [laughter]

Victor 01:35

That’s just in your head. I really am a retired keyboardist. I was in a band. And when you are, you know, when you play an instrument like Alex does, you look around for role models and people that are bringing in new sound. And I always loved what Peter Gabriel brought in terms of music. And Sledgehammer is such a great, you know, celebration of joy, happiness, and has a great video as well.

Eric 02:04

Yeah. And Sledgehammer to health care. Right. It’s the revolution.

Alex 02:08

Okay, there you go. Take a sledgehammer.

Eric 02:10

Sledgehammer. But every lyric is really about sex.

Alex 02:16

But you didn’t know that, right, Victor? Because you said this was like your walk-on song.

Victor 02:20

Yeah, I’ll tell you. I got invited to speak at a Cleveland clinic at a patient experience. And they, for the first and only time, they asked me what I. What I want for a walkout. So I chose this. And I, you know, come out and, I mean, I’m loving it. I’m enjoying it, I’m feeling it. And then I decided to Google it and that was the end of that. You know, I guess the joke was on them. [laughter]

Eric 02:43

All right, Alex. Alex is going to sing the non-sexualized version of this.

Alex 02:48

I did not change the lyrics and I think this is the first Peter Gabriel we’ve had requested. Does that sound right, Eric?

Eric 02:54

Wow.

Alex 02:55

That would be over 350 podcasts. I can’t believe we hadn’t done Peter Gabriel. I love Peter Gabriel.

Victor 03:00

Shock the Monkey. That’s unsurprising.

Eric 03:02

Oh my God, I forgot about Shock the Monkey.

Alex 03:05

I think this was the first cassette tape. I owned the album, so. Love this, love this album. Great song. Here’s a little bit.

Alex 03:16

(singing)

Alex 04:27

Well, for those of you listening on the audio only podcast, you got my son jamming it on guitar. Apologies to those of you watching on YouTube. That is definitely not a guitar song, but that was a lot of fun. Thank you, Victor. Appreciate that.

Eric 04:40

Great song. We’re going to be talking about taking a sledgehammer to healthcare, but maybe I could start with a question for you, Victor, because again, just reading your title, why We Revolt A Patient Revolution for Careful and Kind Care. You know, I see a lot and I actually googled this last night is, you know, this, this idea that healthcare should be like other industries, in particular like airline industries. And you mentioned this in your book, like healthcare should be like airline industry. You know, it’s efficient, it’s standardized, it’s safe, it’s automatic. What’s wrong if anything with emulating industry and say airlines?

Victor 05:21

Yeah, well, the comment is on industrialized healthcare. And the idea of industrialized healthcare, of course, is that we become more interested in the processing of people concerned about access, concerned about throughput and the standardization of our response to whatever problem they have which then makes caring for and about the humans that we get to do, you know, a nice to have a secondary factor in the thing and the reflection with, with, with the airline industry is, is in relation to all of those things.

And I tell the story in the book well that my, you know, flying has been in my family since my grandfather was, was a pilot and my mother, you know, was there sort of the beginning of the commercial airline industry in. In my home country of Peru and. And saw it up close and personal because of the family connections with pilots and flying. And paradoxically, or perhaps because of that, my mom is fairly terrified of flying. And so when she is. And she’s flown a lot, and when she is on a plane, she is on a window seat looking outside, checking out the weather.

She holds onto her seat and she pays attention to who the pilot is and how. Particularly how the pilot looks. And she likes her pilot like the guy from the movie Airplane. Right? So the Leslie Nielsen. Leslie Nielsen, right. So it has to have like, you know, tall, white hair, you know, that sort of thing. That’s her ideal pilot. And the.

Eric 06:56

Shirley. You must be kidding. Yeah, don’t call me Shirley.

Victor 07:02

Neil Clinic actually has a role to play in that particular dial. But anyway, so the. So the. And so she pays attention to the pilot. For her, it matters. And I was walking out of one of these Delta flights that I usually take, and I asked the pilot, you know, you know, the pilot stands there and things, I think, so I follow the guy out. And it’s like, you said hi to like 250 people. Anybody, you know, stays in your mind, and he goes, nah, it’s all a blur. And that’s what we would like health care to be like. Healthcare to be like. It doesn’t matter who your doctor is or your nurse or your therapist, and you will not matter to the people that would.

Eric 07:41

And you only see the pilot at the very end if everything goes okay.

Victor 07:46

And, you know, I think it breaks down, right? I think the analogy breaks down because caring is all about the relationships that we get to be. It’s about, you know, not only the patient finding that. That they matter to someone who is going to notice what’s problematic about their situation and try to make it better. But it also means that for us as clinicians, that we walk in to do that, that we matter to someone and we get to be a part of someone’s personal story insofar as we help them do well and do better. And that’s, I think, where industrialization breaks apart is when we start. Stop considering the importance of people in care, which is the core purpose of health care.

Eric 08:32

What do you think the big motivators are for the industrialization of health care?

Victor 08:37

Well, I think we can just go around the room and start yelling them out, But I think that the main one is, I mean, I’m going to be nice and not cynical, but I think there’s increased Complexity of the situations that we get to see. There is an increased demand, there is limited supply of clinicians with the necessary expertise. There is a need for cost going through the roof, and there’s a need to contain those costs and still produce the outcomes that people expect. And there are a few ways in which one could do that. And of course, the most expeditious one is to basically standardize, simplify, accelerate and process people as fast and as well as you can.

Eric 09:25

So these are like the 15 minute primary care appointments. Like you are just seeing like 20 people in a morning.

Victor 09:33

Yeah. And that is, you know, a picture of the near past or maybe the present for many people. But the near future is of course, that you do not. You all be digital, digital first or digital only. And you will not necessarily be able to tell whether you’re actually talking to a person or to a bot. And you’ll be processed through perhaps, actually your data will be processed through. And that will be way more efficient and way less expensive and less likely to run into the problems of clinicians getting tired or upset or annoyed or whatever than we have now.

So, so this process of industrialization, the next stage is really the dentification of it and eventually will become completely artificial. And I think that just not just industrialization, but this whole process ignores the nature of care, ignores the nature of health care. And while it may give us the impression that we are caring for more people and we’re doing it better, it fails to understand the what actually is happening in care. It automates everything and gives you the appearance of. But it’s not it. That’s what I meant. And you said it in your opening that it really corrupts the mission. It denatures it, it cheapens it, it simplifies it to the point not of its core elements, but to the point of disassembling them.

So that you don’t recognize the fact that, that you matter, that as a patient, that you deserve someone else’s time, energy and attention. It tells you you don’t. And as a clinician, forget it. I mean, you know, we are the part that is going to be automated out. Make no mistake about it.

Alex 11:24

I want to stick with the clinician piece just for a moment. So many clinicians these days are burnt out, feel overworked, imbalanced, disenchanted, feel like I didn’t go into medicine to do this. This is not why I chose this profession. And to what extent do you think that is a result of the industrialization of healthcare versus other forces? You lay the blame primarily at the industrialization, that sort of for profit motive, the sort of turning us into almost assembly line workers.

Victor 12:02

Well, industrialization does not necessarily accompany either ownership or profit status of the organization or even the payer. Right. I mean, it’s interesting that this little book has actually been read by more than one person in places like Australia or Canada or the uk. The first translation was actually in Spain, the second one was in Italy. These are all places with for instance, single payer systems. Canada, of course, completely private delivery, public pay and the UK public delivery and public pay.

So in all those places what you see is common is the underinvestment in care in the case of the United States is because everybody and their cousin has a value extraction machine that takes money home and leaving very little to the point of care. But in those other places, there’s been decades of policies of austerity that have not invested enough in healthcare. But I think laying the blame of industrialization on burnout and moral injury is legitimate. It’s appropriate. Of course, there are other factors that play a role, including for instance, creating expectations during training. You said this is not what I signed up for.

Creating expectations during training about what a career in healthcare will be. And then finding yourself in an industrial facility on a factory floor with, with patients being asked to produce something that is considered high quality or high value care that is evaluated by the payer to determine whether you should be paid for it. So there’s a, I thought it was about making the life and living of this person better, but no, it has to fit some standardization. The notion of care delivery even suggests a notion that carries an off the shelf box that you just have to.

Eric 13:56

Deliver order from Amazon.

Victor 13:58

That’s in fact how Amazon gets on the business there. He’s like, oh, delivery. We do, you know, we have a box. And I think that’s, I think there’s part of that as well. And then the last bit, Alex, of your question is what? This is not what I sign up for. Yeah, I think that’s changing and I think that’s something we need to pay attention to that. I think increasingly it is the case that people that are showing up to careers in healthcare might be looking for that career to be something other than patient care. And that should worry us tremendously because if we think there is a limit, a limit in the number of people that can care, that is likely to get worse.

Eric 14:38

Can I say, is it? So when you’re saying what is the mission of health care, Is it care?

Victor 14:44

Yeah, I think there are Two fundamentals. I mean, this is oversimplification, but there’s two fundamental missions. One is to fix what can be fixed. Right. Let’s get a problem and somebody comes in, you know, a little adjustment of.

Eric 14:59

Yeah.

Victor 14:59

You know, not. And we’re good now. I just realized that that analogy with the intro song is different.

Eric 15:06

No, no, no. But so this, that, that first part reminds me of, I think it was in your book or in your talks, you talk about cataract surgery and how like, it is something that is fixable. If I remember correctly, you didn’t spend a whole lot of time with the physician except during the procedure. Like it’s kind of in and out, Right? Was that the. What you were saying?

Victor 15:25

Yeah. And I think that you just come in, you get that done. The ophthalmologist doesn’t even have to have a relationship with you or with your eyeball for that matter. And this only changes if you develop a complication. It doesn’t go right. And now all of a sudden that relationship is central. If nothing else, to avoid liability, but of course, to be able to cope with the challenge, regroup and try again and do it better if you can. And then there’s this other chunk of stuff.

This is stuff that you guys do that many people that are listening to this do day in and day where they’re not going to fix much. But what they’re going to do is they’re going to support self management, they’re going to do problem solving, they’re going to do counseling around sequela of prior disease. They’re going to try to make sure that your treatment is not interfering with the life that the person is trying to have and trying to make sure that healthcare fits into those routines in life.

That is what I mean. I don’t mean caring in sort of just the attitudinal aspects or the emotional aspects of that, but the practical aspects of helping people, which you are not going to fix. I mean, as a diabetes doctor, I don’t get Christmas cards because next year you’re going to have diabetes, Right? I mean, this is going to be the same.

Eric 16:37

So most things that we care for are not the cataract surgery, not something we could take out one time visit. They’re gone. They’re now living with the disease for the rest of their life. And that we’re caring for that disease. And sometimes we are maybe making like this whole concept of pre diseases, pre diabetes, you know, Alzheimer’s disease, just based on a, you know, a blood test. Doctors also love to push diseases on people. But like people are living with this, they’re not cured. And I love this idea that you brought up too, that like it interferes with their life. And it kind of goes to this concept that you brought up of minimally disruptive care. Does that mean I remember that term? Right?

Victor 17:20

Correct. So minimally disruptive medicine is this idea that you want to advance the patient’s goals and priorities for life and for care, but do so in a way that healthcare has the smallest possible footprint on people’s lives.

Eric 17:34

I love that smallest possible footprint. I kept on reading that term, I highlighted that term small as possible footprint. It was the first time I ever saw it.

Alex 17:44

One of the things that you do so well in your book why We Revolt is you empathize and you step into those patients shoes and you paint the picture for us of what it’s like to live, you know, outside of the clinic walls where we don’t typically see the patients at home as they’re like, you know, doing all these tasks that we’ve assigned to them for hours and hours at a time.

Eric 18:05

It also reminded me of Ken Kavinsky during ags. He, he, we did updates talk and one of his articles was talking about the, the time spent with doctors and healthcare providers. The meantime was 21 days. 11% of older adults had more than 50 days of contact with healthcare per year. Per year? Per year. 50, 50 days. And then for 85 year olds, it was 27 days of contact with healthcare providers.

Victor 18:37

You have to appreciate the impact that that has on reducing loneliness.

Eric 18:41

Yeah, yeah, yeah, they love us. They want to see us all the time.

Victor 18:48

I think the fact that we don’t coordinate and organize our services so that we don’t impose that sort of burden on folks is important. The other thing is how many times in committee meetings, at hospitals and other groups, people are scratching their heads, how are we going to get this done? And of course the creative idea is let’s give it to the family, let’s give it to the patients. They can do it for us.

Eric 19:09

We’re going to empower them.

Victor 19:11

Yeah, we were just giving them a bunch of errands and we need to think of people as completely overwhelmed. And I think at that point we start realizing that in fact what we need to be doing is constantly trying to simplify, make healthcare elegant. The simplest possible thing that will get us to the solution. Not efficiency. Efficiency is easy. It’s elegance that we should be aiming for.

Alex 19:33

Right. It’s like check your way, get your meds, check your finger. Sticks. Record your finger sticks. Use this app to record your finger sticks. You know, come in, get your labs drawn, order your meds, wait in line for your meds, come to see your doctor, wait in the waiting room to see your doctor. So many the burdens we impose upon people who have complex lives and often have multiple chronic conditions and they’re trying to manage sometimes, you know, their jobs are the end of their careers or family members, disability, whatever. There’s so much more going on. The footprint that healthcare imposes upon people. I think this is one of the huge points that was just eye opening to me about your book and about your talk is just that enormous footprint. It’s the opposite of minimally disruptive medicine that we are imposing.

Victor 20:23

It’s reasonable. Right. I think at some point it is reasonable to expect patients to do A, B and C. Of course, they just don’t have that one disease. They just don’t get that one instruction. And these instructions pile on each other. Turns out there’s another group that actually experiences the same thing, which are primary care clinicians. Right. As every guideline and quality metric comes up, it’s the exact same situation. Let’s do this one more thing. And you have these 27 plus hours that primary care clinicians have to do per day if they want to do everything that is in the guidelines and the fact that guidelines never consider the time needed to treat of the recommendations that they put in, they just look at the number needed to treat on a good day and they make that recommendation.

Eric 21:04

Yeah.

Alex 21:05

I think that was Cynthia Boyd’s terrific article. She added up, like, you know, all the hours it would take to do all the guideline recommendations of primary care. It was like 27 hours. It was ridiculous.

Victor 21:16

But.

Alex 21:16

And what we don’t. And you know, primary care clinicians get that. And what I think your book also opens our eyes to is the amount that we impose upon patients.

Victor 21:24

Yeah. And you’ve done programs where you actually shown, for instance, how distasteful some of the things that you ask all the hospital. Right. And it’s the same thing is when you say, oh, just crush the tablet. Oh, just push it with a syringe or just do it with it. You’ve never actually done it yourself. And you have no idea how pretty difficult some of these tasks that you give to people are.

You, you used to give them your, your, maybe your predecessors used to give those tests to the nurses. You remember, all the work of being a patient was to lie in bed. Bed. While the healthcare professionals in the hospital did things to you to get you back on health. Now these are things that you do to yourself. And so what we need to do is work with you, because you will be doing all that implementation within the workflows of your life, your work, your family, your community.

Eric 22:14

So let me ask you this, is that. So that there’s this. When we’re thinking about the footprints that we’re leaving, a lot of it comes from this idea of standardization. And like, if I’m going to take your field, endocrinology, like diabetes, there is a lot of quality metrics about hemoglobin disease. There’s a lot of tasks that we ask patients to do. There’s a lot of tasks that we ask primary care providers do in this, this goal of standardization to get blood sugars down to prevent future disease. Is there a role for standardization versus, like, what are the potential risks? When. When we think about it, yeah, I.

Victor 22:52

Think there is a role for standardization and for maybe bringing technology to help with some of these things as well. The problem is the lack of prioritization that often takes place as we pile these things on. And just like polypharmacy, the lack of recognition that there are things that no longer matter that perhaps we can set aside. I mean, how many patients do I see who have had type 2 diabetes, say, for a decade? And I asked them, oh, you checked your sugars? And they say yes. And what are you on? Well, I’m on metformin.

What do you do with the numbers? Oh, I write them down. Why do you write them down? Because my doctor told me to. Does your doctor look at the numbers? Oh, just kind of, you know, looks at them and gets a breeze, you know, when they’re going through the notebook. And what do you do with this? Does he change your treatment? Do you change? No. And you’ve been doing this for a decade? Yes. And that’s crazy, right? And so.

Eric 23:51

So Victor throws him on a continuous glucose monitor.

Victor 23:55

Really? But we did a study where we’ve actually looked at patients with diabetes and look at the burden of treatment for them. And you know, on average, people are spending about two. You know, people with diabetes are spending about two hours a day dealing with healthcare.

Eric 24:09

So it’s like a part time, two hours a day.

Victor 24:11

Yeah. And when we’ve looked at the burden of treatment, in particular, one of the things that we’ve noticed is that some patients with diabetes experience a significant burden of treatment that comes from digital tools. And so you mentioned the continuous glucose monitor. And there are other things. And when these Things work for people that for instance, monitor four to seven times a day and use that information to change insulin doses. The continuous glucose monitor is, is incredible for people that can make it work in terms of the ease of use and support for people that cannot make it work for whom it is difficult for, or maybe they are not using the numbers for it.

It’s a complete waste of time, energy and attention. I mean, just think about remembering the passwords that you will use to get into the different apps to get the information. And you have now two factor confirmation. Have a separate device, forget it. And that’s even, that’s if you don’t, if you remember to keep things charged and all. For many people this is now a new source, not a facility and ease, but actually a burden. So digital burden is now a new component of the burden of treatment.

Alex 25:19

Yeah, this is really interesting. I was looking at your CV and I sorted it by year because if I sorted it by like most cited, they’re like many with like over 3,000 citations. It was amazing. So I looked by year and the most recent, like you’re developing scales about the digital burden of healthcare and it’s something, you know, I hadn’t really thought about previously, but I have a lot of collaborators and colleagues who are doing, you know, clinician researchers or researchers who are developing apps. Like everybody’s trying to develop an app.

Victor 25:56

There’s a paper exam from colleagues in France who looked, basically simulated a typical, you know, one of your patients, you know, typical multimorbidity person living with multimorbidity and that, you know, that average person was looking at 13 different apps and seven different devices that were FDA approved and that clinicians could prescribe because they have been associated with a large enough beneficial effects that they would, would find them desirable. Imagine having to go through 13 different apps and say nobody would do it. Right? So it’s a new form of non compliance that you’re not using your bloody app. Right. So we’ve lost the plot. We’ve lost the plot. And I think the plot can be. Any conversation with a patient will remind us of what is the plot. And the plot is to care for and about them.

Eric 26:44

So the question is how, how do we revolt against that? So there’s all these pressures that continue to push for greater and greater industrialization of health care, greater efficiencies and when I say efficiencies, it’s really not efficient. It’s just about throughput, getting more people onto the plane and off the plane safely. That is the, that Is that seems to be the growing focus. How do you revolt against that?

Victor 27:15

Very hard. The most movement. So first of all, I want to say that we are not using the word revolution because it’s cute. It is not right. People die in revolutions. There’s a lot of destruction and none of that is consistent with our mission of caring. But revolution also means turning away. And revolution also points at changing the fundamentals. So that word was carefully chosen. I know it was not a popular choice, but it was carefully chosen because it tells you about the magnitude of the changes necessary and the fact that the direction of travel. So improvement to be better at industrializing health care is not the solution.

Eric 27:53

This is not just incremental improvement that we need because incremental improvement continues to push us further and further towards industrialization?

Victor 28:01

I think so. And it gives you the impression that you’re doing something right and where you’re just going in the same direction. Now I’m not a practical person, so. So it’s like, you know, oh, how do I help myself tomorrow when I go to, you know, that is not the point. The point is that you don’t have to be advocating for yourself every time you go because the place is designed to advance your goals. And so how do we get to that point? And I think it’s a multi, you know, it’s a complex set of parts that we need to move. There are some macro parts that are a little bit on the side but are necessary probably as conditions for our success.

Those include making sure we have very robust and evidence based and effective and large scale efforts at public health. If we continue to have societies that make people sick, we will never have a large enough, efficient enough, industrialized enough healthcare system that can pick them up right and take care. It’s just not going to happen. So we need to create societies that make people healthy, not sick, that help them flourish. These are not societies with policies of cruelty. And so we, in that respect, we are also going in the wrong direction. I think as people get desperate, they engage in all sorts of behaviors and that state of desperation has all sorts of epigenetic effects that actually contribute to disease at every stage of life and reduce people’s healthy life expectancy by years, which no healthcare technology is is able to match.

The difference between the top decile and the bottom decile. And healthy life expectancies is in developed countries in the order of seven to 15 years. There’s no technologies that we have that give seven or 15 years more of life. So that’s I think part one, and we’re far there. Part two is we need to promote common care skills and practices. So an example of common care is cooking. I think a lot of people are very proud of their cooking, and they have cooking books and they look at cooking shows and they invite people over and they do something. And that’s one way of caring for other people, is to prepare food for them. But there are other ways of caring for people where we just don’t have the investments in tools, techniques, promotion, elevation, recognition.

For instance, feeding people that cannot be fed by themselves or helping them bathe or dress or move, give them basic emotional support when they’re struggling emotionally and so forth. And we’ve de skilled people. I mean, when a young mother calls in the middle of the night to her mother, to grandma, because the kid won’t stop screaming, grandmas used to say, put some brandy on the kid’s gums and you’ll be all right. You call grandma now and grandma says, oh, you must go to the emergency room. You know, this could be an inborn error of metabolism or something. And so we, we certainly. We’ve deskilled grandma, right? And so we need to. We need to revert that, and we need to get people to be skilled.

So that takes care, I think, for this, you know, the social and politically modifiable determinants of health. It takes care of the fact that we’ve been deskilled, and we need to democratize a lot more health care, care and medicine information that we, I think we have kept close to the chest because that’s what gives us value. But it’s time to give it away and make sure that people can use it on their own responsibly. And that frees us, in clinicians of every kind and every level to actually have the time to deal with situations that exceed those fundamental basic skills and activities that would require us as a society that will recognize care as something valuable, which, which something we learned during the pandemic, but we quickly forgot.

Eric 31:44

So I got a question because this came up during our national meeting. I was talking with. We had a session on AI and the use of AI and AI for dictation, AI for writing notes. And somebody said, oh, my God, how amazing would it be? Like, I don’t have to do this thing that takes me 10, 15 minutes. I can spend time with my patients instead. And this idea that, oh, yeah, the healthcare system is totally going to have you do that instead of shortening your time because now they’re paying for AI to write the note for you so you can see more patients.

Victor 32:19

I think that would be the natural response from industrialized healthcare. Right. It’s actually very interesting. I think this is the note writing. I think I need to make a little story about it. But think about it. You see a patient, I’m going to write a note. Why? To remind myself to communicate with the other clinicians. Put two lines and then somebody says, oh, but those. That note can be used to figure out if you’re liable for maybe a mishap. Oh, I’m going to write now a paragraph so I can document a little better. Okay, that’s good. Oh, you know, we can use that note for billing. Oh, I’m going to write now a page so we make sure that we get adequate levels.

Eric 32:53

These are all the things you have to put in the note for billing.

Victor 32:55

Yeah. Okay, so now we’re going to bring in the electronic record. Okay. So we, we can. You now dictate and it will show up. Type. Okay, great, great, I’ll dictate. Well, you know, dictation is expensive. We have now voice recognition. You just talk to it and it will come up. Yeah, but you have to edit it because it’s not perfect. Okay, I’ll do. You know what? Just type it yourself. And now you go, oh, my God. You’re spending all this time typing notes. We need an AI solution for this. I mean, like, what are we doing, right? It’s, it’s. We are solving a problem that was created. Created by levels of the industrialization that have nothing to do with caring for this patient.

Eric 33:34

And the fascinating thing, because I remember this in one of your talks, is that in the future, it’s going to be AI is going to be writing our notes from billing purposes. The insurance company is going to have AI to review our notes, and then probably the insurance company is going to have an AI supervisor to make sure that AI person that’s reviewing the notes. So it’s this whole new ecosystem, an artificial intelligence that’s talking to each other. And like we’re just.

Victor 33:59

Well, and all the middlemen that are producing those bots are actually cashing in and leaving less resources for the point of care.

Eric 34:05

So this. What do you call it, this value.

Alex 34:08

Extraction. Extraction.

Eric 34:10

It’s like mineral extraction.

Victor 34:11

What will happen is patients are not no longer going to have to go in because we will have complete access to all their data and all their information, everything. And there will be no reason for us to go in because there will be bots that can scan all that data, identify what’s wrong and use all the means of behavioral actuation that Amazon has to make us buy stuff or Google has to make us buy stuff when they sell our search information for advertisers and so forth to actually change people’s behavior. So a lot of care will, in fact, be completely disembodied. No clinician or patient will have to ever meet again.

Eric 34:45

Is that a good thing, thing or bad thing?

Victor 34:47

Sorry?

Eric 34:48

Is that a good thing or a bad thing?

Victor 34:50

Horrendous, right? Because people say, oh, I hate to go to the doctor. Yeah. And I. Many of us, I think, hate sometimes our jobs, you know, going and talk to patients. But actually, I will put forward that it’s not because we profoundly dislike being with each other, but I do think that those who design these solutions really dislike being with other people, and they just assume that we do as well. And I think that’s a critical mistake.

Eric 35:11

It’s that corruption of our mission.

Alex 35:13

Yeah, I want to get back to that because I worry that I wonder if people in geriatrics and palliative care feel like they. That doesn’t apply to them. But before we get there, I want to stick with the revolution for a moment. Your website is called Patient Revolution. And so I have two parts to question. Why must the revolution start with the patients rather than the clinicians? And then the second part is, what is the clinician’s role?

Victor 35:43

Yeah. So we made a mistake. I think we should have called it the care revolution. And I think if we were to think about now, what is the activist, the perfect activist for this revolution, I would say, is the caregiver. I think people say, oh, all of us are patients, but we are all caregivers. We have to take. Somebody took care of us. That’s why we’re here. And we will take care of other people. I think that’s what we have in common. And I think it’s becoming increasingly difficult to be a caregiver, to be a parent, to be a clinician or a nurse, a physician, to be a therapist, I think is increasingly difficult. So this is actually a caregiver revolution.

The reason we went with patient revolution is because the logical people who should determine how we care for people are those who do it routinely, those who do it every day. That’s not the patient, that’s a clinician. And we’ve had, you know, hundreds of years to get this right. In fact, arguably, we. We got it terribly wrong, then in some places got it phenomenally right. And then we decided to, you know, forget it. And now we all have it back. Terribly wrong, in my opinion. But where’s the revolt? Do you see it? Do you see the. Our professional organization standing up and going like we’re not going to. You see what you see, even our newest organizations, our physician unions, they’re really advocating for better pay. And of that nature, nobody’s advocating for better care conditions seriously.

Right. And so I think clinicians and patients, and I think this is quite unique about this organization, the patient revolution is that patients and clinicians are not set up in opposite sides. I think they’re set up on the same side. Both of them victimized by the industrialization of care, both of them in solidarity, trying to fight it back. And so I think it’s a patient and clinician revolution. I think it’s a caregiver revolution. I think it’s a care revolution. But when I wrote about patient revolution, I basically said, we cannot expect professionals who personally make a living out of this system to be in a position to actually fight it back. It’s actually worse.

I think there’s significant amount of learned helplessness by healthcare professionals that prevents us from really acting up in a way that will fundamentally change healthcare. I don’t think we can expect it of patients who are sick and need our help, but I think when we go get together as participants in care, as caregivers and receivers, I think we may have a shot to fundamentally change healthcare.

Eric 38:23

Go ahead. Go ahead, Alex.

Alex 38:24

So the other question is just coming back to this, to the geriatrics and palliative care folks have it better? You know, somehow have we traded away specialties, you know, the opportunity to make a lot of money, you know, to have prestige for professions where we get to spend more time with patients, where we’re focused on goals of care. What matters most? Or are we deluding ourselves? Are we deluding ourselves? I don’t know. I think that’s an open question. I’m interested in your thoughts, Victor.

Victor 39:00

When I talk about minimally disruptive medicine, I often say, you know what that’s like? Geriatrics for the young. And that is like palliative. Palliative care for those who are not dying. Which, of course, is not a good way of saying it, because palliative care is true for everybody. But I think it’s right. I think the practice of geriatrics, the practice of palliative care. Some practices in psychiatry get this right, where they honor the time spent. They lower the lights, they make sure they’re incandescent and not fluorescent, they sit down, they pull down Chair, you know, those.

Those habits, those rituals, those symbols, they are, I think, teaching the rest of health care what is at stake. When we are talking about care, I think. I think that is right. The. You see the tendency stores industrialization creeping all the time. The replacement of the thoughtful conversation for the form. The idea that the purpose of the form is to document and then put it in the chart and then the job is done. That is the industrialization creeping in and corrupting what is fundamentally, I think one of the places where it could easily be that it is from geriatrics, from palliative care, from some form of pediatrics, from psychiatry, that we may actually have those sort of pockets where the revolution may actually come that should spread.

My practice in diabetes care, I suspect, is very similar to many of the geriatrics practice or palliative care practice where, you know, I may not be saying, tell me what your goals of care are, but we are actually bringing those up as we are figuring out what is the problematic nature of your situation that demands action. And we are working together to figure out what is the action that that situation. Situation demands.

Alex 40:53

Right.

Victor 40:54

Do it iteratively. And we go over time. And so continuity of care, the kinds of things that used to characterize primary care, you know, comprehensiveness, this becomes the mark of the kind of shared decision.

Alex 41:06

Making as you’ve written about. Yeah, I think it was very similar to what we do in, you know, geriatrics, palliative care. We may have different terms for our goals of care discussions, you know, what matters most, but fundamentally that the concept’s the same.

Victor 41:20

Eric.

Eric 41:21

Yeah, I guess my last question, because we’re running out of time, man, I could talk for another hour here. Is this idea, like. I feel like sometimes the word quality is another term that industrialization loves. Like, even in, like, the work that we do in geriatric palliative care, there are these metrics. There’s these quality metrics. And the only way to get quality metrics is you actually have to capture the data. So now you have to put in all these big notes, like, is this other thing. It’s not RVUs. It’s just about documenting that we’ve done this thing for the sake of documentation, for the sake of these quality metrics, which is important.

Then we can show, hey, palliative care is doing this great thing, or geriatrics is doing this great thing as far as fall preventions or pain or goals of care conversations. But then you’re learning for the test, like you’re trying to do this thing. For the quality metric, the throughput how many patients that we’re seeing and not necessarily the care that we’re delivering. And I think that is potentially a source of burnout in our fields.

Victor 42:19

Yeah, I have to say, a healthcare system that is unreliable, that is dangerous, that is unsafe, where there’s a bunch of artists coming up with things off the top of their head to do with their patients is actually a very undesirable development as well. So what we’re looking for here is that we as professionals maybe partnering with our patients, we’ll do our best. I am an evidence based medicine believer and evangelist. I think ways of doing it, what I’m very careful is in noticing that there are very, very few and there should be even fewer strong recommendations in the guidelines.

In other words, must dos that if you don’t do then you’re a bad quality clinician and your patient is getting bad quality. There are very few of those because everything is so context sensitive. And in the past we used to think, well, there’s no way of assessing that context sensitivity, so everything should be the same for everybody. And that will be our first go. Okay, as a first go, that was all right.

But we got stuck there. And perhaps this is a potential role for technology and AI to come and help us. Maybe we can have sensors that will tell us what the quality of care is not just on the measures on the labs, but also on the way we interact with each other. And that might be feedback that will make us better, not just technically better on the responding to the biology, but also more human and able to respond to the biographical elements of our patients.

Eric 43:40

I love that this is idea of nuance too and the term elegance when we’re applying it to healthcare. Victor, last question for you. If you had a magic wand, what would you want our listeners to do?

Victor 43:55

I mean, this is terrible because now you’re going to have sledgehammer and magic wand.

Eric 43:58

Yeah, that’s coming up next. It’s coming up next.

Victor 44:00

You know, it’s not good. No, I don’t think it’s a magic one. I think it’s going to be hard, hard work and moral commitment, moral commitment from all of us in the profession of care that we actually make care the main thing, the top thing, the most important thing. And then that we join with other people in the community to say, you know, we want societies in which we care for each other and we have a revolution for care. That’s what I think is the world needs now large, but I think it also needs it in our profession and in our activities.

Eric 44:31

And I love that. I love just thinking also, like, there’s a lot of talk on wellness for physicians and other healthcare providers, and I think a lot of it stems from how we feel sometimes, like the system doesn’t help us care for patients. And I think instead of looking at wellness from within is thinking about this bigger picture that you’re describing, Victor. So thank you for bringing that up. And we’ll take a sledgehammer to the healthcare system.

Alex 44:56

There it is.

Alex 45:02

(singing)

Eric 46:13

Victor, big thank you for being on this podcast. Great song and great video. I agree, one of the best videos out there for music videos. Thank you, Victor.

Victor 46:22

Thanks both for having me. Delighted to be here.

Eric 46:25

I encourage all of our readers to read the book. We’ll have it on our show notes. It was really fantastic. And lastly, thank you to all of our listeners for your continued support.

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