Victor Montori - Why we revolt: A patient revolution for careful and kind care

Why We Revolt

A patient revolution for careful and kind care

Victor Montori

Published by

The Patient Revolution

Rochester, Minnesota, U.S.A.

Copyright 2017 by Victor Montori

All rights reserved.

Paperback edition October 2017

ISBN: 0999394819

ISBN-13: 978-0999394816 (Patient Revolution, The)

Advanced praise for Why We Revolt

We revolt because our health our very lives matter. Why We Revolt does not serve as a blueprint but as an inspiration for patients and clinicians who are ready to pry open the idea of healthcare and make it about actual health and care. This book is a necessary catalyst for conversations that will revolutionize patient care.

Kerri Sparling, diabetes patient advocate and creator of sixuntilme.com

This profoundly humanistic examination of what has gone wrong in medicine has the diagnosis just right. This book is for everyone who will ever be a patient, for every health professional, and for every administrator and policy-maker.

Gordon Guyatt, physician and researcher, father of evidence-based medicine

I went into medicine to interact with real, unique, emotive humans. Why We Revolt brings healthcare back to this primary love of and care for patients.

Sara Segner, medical student

Montori begins with a gut punch that stays with you throughout this powerful, sobering, eye-opening book. After expertly diagnosing the roots of industrial healthcare problems, he passionately plots a patient revolution. Policy makers, clinicians, patients, and journalists should set aside the very little time needed to absorb this gem and learn from its lessons.

Gary Schwitzer, journalist and publisher of healt h new s review.org

If someone gave you this book, they were probably hoping to advance a patient revolution.

I hope you can do the same.

Keep this copy, get another one, and give it to someone else.

To share your stories or send me a note:

on Twitter.

To review notes and links to online resources for each chapter:

patientrevolution.org/whywerevolt

To join and contribute to The Patient Revolution: patientrevolution.org

Thank you, and take care.

V

Contents

To my sons

Introduction Revolt

Orwell proposed that one must write, among other reasons, to see things as they are, to find out true facts and store them up for the use of posterity. This book arises from my need to do just that. And what I see is that healthcare has corrupted its mission, it has stopped caring, and I am not going along with it. It is time for a patient revolution to bring about careful and kind patient care for all.

This book also documents my sense of what is wrong about industrial healthcare. Industrial healthcare fails to notice patients. It standardizes practices for patients like this , rather than caring for this patient . Efficient specialization and narrow job definitions drive industrial healthcares focus toward organs, diseases, or test results. Rigid protocols and fear of deviating from them miss the person. Systems that prioritize access and volume place very little value on the length and depth of the interaction between patients and clinicians. Forcing encounters to be brief and shallow speeds patients through consultations in which clinicians cannot appreciate their patients situation clearly. Failure to notice is also the effect of encounters bloated with industrial agendas, such as documentation and billing, which draw attention away from patients and toward the computer monitor, distracting from care to document it.

How does care then take place when the patient is unnoticed, sometimes nothing more than a blur? Judging from the stories that clinicians and patients tell, care happens almost by mistake, when someone takes exception to or ignores protocols. In the absence of these accidents, of these caring mistakes, the industry is capable of harm through unintentional cruelty. As it makes care accidental and cruelty incidental, industrial healthcare marches on to produce fortune and power. By focusing on its industrial goals, healthcare forgoes caring.

The harm is not only to patients. Industrial healthcare is killing the healers soul. Enforced productivity depletes clinicians. Under efficiency pressures, clinicians cannot draw meaning from fleeting patient visits. They cannot get support from sped-up colleagues. They feel abused and without love and unable to love. Burnout, divorce, and suicide become inherent to the work of health care, the healers curse. Industrial healthcare has stopped caring for both patients and clinicians, everyone at the frontline.

Many of my patients, my family, and I have benefited greatly from the wonders of modern healthcare: expert surgical teams, clean and efficient facilities with the necessary equipment, carefully organized services that collaborate and coordinate, well-trained professionals who cordially attend to the sick and invest each one with dignity. All this is possible. It happens, just not routinely or by default. This is the should be that I have the great fortune of enjoying on good days.

On bad days, this should be lurks between tightly scheduled slots, in the furtive half-smile of another clinician rushing on to their next patient, in the sigh of the staff who had hoped to give more prompt service. It screams from the notes I get from family members or their friends asking for a second opinion or telling their stories, some of them horrific tales of perfect medicine for the wrong person or for the wrong problem. It pulls at my heart when I see what has happened to the patient in front of me: files filled with the results of tests and procedures, 12 medications, multiple specialists, and notes that reveal that no one ever stopped to notice. On many days, I am afraid I am that clinician, that cog of the machine, the one who fails to notice.

Simply noticing and acting on what is noticed makes patients more likely to receive care that makes intellectual, emotional, and practical sense to them care that responds to their needs and is consistent with their views of the world and their lives. This is care that recognizes and respects that patients may need to devote their scarce time, energy, and attention to matters that compete in priority with the administrative and self-care tasks healthcare has delegated to patients. This is care that responds with competence, science, creativity, and humanity to advance each patients situation without overwhelming patients or creating new ills.

The words in these chapters, I hope, will ignite in you the urgent need to join us in destroying the difference between what is and what should be . In abolishing accidental care and incidental cruelty. In making care the intentional end of our work, not the means to achieve industrial goals. In ensuring our best medicine reaches everyone who needs it. Clinicians, anyone honored by the possibility to care, must notice and act toward each person in need of their care. They must appreciate each persons circumstance, concerns, contexts, biology, and biography. To appreciate each patient, the clinician must throw moorings that, for a moment, partner the boats. Traversing rough waters unhurriedly, elegantly, together, patient and clinician can, with compassion and competence, co-create a trajectory for the patient that advances her particular situation. Such careful and kind care for all must be the end result of a patient revolution.

This book is organized as a series of essays. Part One discusses the ills of industrial healthcare, the targets of the revolution: cruelty, blur, burden, and greed. Part Two discusses some antidotes: elegance, solidarity, love, and integrity. The remainder concern careful and timeless care. The book concludes with images of a revolution of conversations and the cathedrals of care that it will build.