The Proposal for a Patient Revolution | Dr. Victor Montori | TEDxZumbroRiver

Summary

The healthcare industry has lost its way, prioritizing profit over patient care, argues a doctor who has experienced healthcare in both Peru and the U.S. He shares stories of patients like Juan and John, overwhelmed by chronic conditions and a broken system. The talk calls for a 'patient revolution' to demand careful and kind care—focused on individual needs rather than financial metrics. By empowering patients and encouraging better conversations with clinicians, the speaker envisions a grassroots movement to reclaim the heart of healthcare and prioritize human well-being.

Takeaways

• 💊 The healthcare system has lost its focus on patient care and has become corrupted, prioritizing profits over people.
• 🌍 The speaker's experience as a doctor in Peru highlighted the challenges of poverty, violence, and a broken healthcare system, which parallels issues in the U.S. today.
• ⏳ Chronic conditions are now prevalent in middle-aged people, causing almost everyone to engage with the healthcare system earlier in life.
• 🩺 Patients like John with multiple chronic conditions face fragmented, overwhelming care, with doctors focusing on metrics rather than the patient's well-being.
• 💰 The cost of prescription drugs has skyrocketed, with prices reflecting what the market can bear, rather than the true cost of development.
• 📉 Healthcare companies prioritize financial and operational goals, often sidelining patient care, leading to dissatisfaction and burnout among doctors.
• 🧑‍⚕️ Doctors are overwhelmed by system pressures, leading to widespread burnout and a lack of empathy, further harming the doctor-patient relationship.
• 📚 There's no medical literature that captures the full burden and work of being a patient, leading to patients being overwhelmed by complex care plans.
• 💡 The speaker calls for 'careful and kind care,' which prioritizes individualized, empathetic treatment tailored to the patient's situation and needs.
• 🚀 A patient revolution is necessary to demand systemic change, starting with better conversations between patients and doctors, and collective action from the public.

Q & A

What is the main issue the speaker identifies with the healthcare system?

The speaker argues that the healthcare system has become corrupt and has stopped caring about patients, focusing instead on profit and financial goals, which leads to suboptimal care and patient suffering.

How does the speaker describe healthcare in Peru compared to the U.S.?

In Peru, the speaker highlights the systemic issues caused by poverty, violence, and hyperinflation, which created a broken healthcare system. In the U.S., while the system is technologically advanced, the focus on profit has caused the system to lose sight of the patients' needs.

Who is Juan, and what does his story illustrate?

Juan is a hypothetical patient in Peru who faces long waits and bureaucratic hurdles to receive care, only to be prescribed treatments he cannot afford. His story illustrates the inefficiencies and inaccessibility of healthcare in impoverished systems.

What does the speaker mean by 'the work of being a patient'?

The 'work of being a patient' refers to the burden patients endure managing chronic conditions, such as navigating healthcare systems, following complex treatment plans, and dealing with multiple healthcare providers. This work is often overlooked by medical professionals.

Why does the speaker believe the healthcare system overwhelms patients with chronic conditions?

The speaker believes the healthcare system overwhelms patients by focusing on metrics and treatments that do not take into account the individual circumstances of each patient, leading to a fragmented and exhausting experience for those with multiple conditions.

What role does biased evidence play in the healthcare system, according to the speaker?

Biased evidence arises when companies that market drugs or treatments conduct the research on their products, leading to exaggerated results. This causes doctors to prescribe expensive treatments based on skewed information, often prioritizing profit over patient care.

How does the speaker illustrate the rising costs of drugs in the U.S. healthcare system?

The speaker compares the rising costs of drugs to hyperinflation in Peru, explaining that drug prices no longer reflect the cost of innovation but are set according to what the market can bear, which prices many patients out of life-saving treatments.

What is the speaker’s vision of ‘careful and kind care’?

‘Careful and kind care’ means healthcare that is tailored to the patient’s specific circumstances and needs, provided with minimal harm, and delivered with empathy, treating the patient as part of one’s own family or tribe.

Why does the speaker call for a 'patient revolution'?

The speaker calls for a patient revolution to shift the focus of healthcare from profit and metrics back to patient-centered care. He believes collective action by patients and caregivers is necessary to reform the system, as it cannot be fixed from within.

What does the speaker say about the role of doctors and nurses in this broken system?

The speaker acknowledges that doctors and nurses are also struggling within this broken system, often facing burnout and emotional exhaustion. They are caught between the demands of the system and their desire to provide compassionate care, making them potential allies in the push for reform.

Outlines

00:00

🩺 The Corruption of Healthcare: A Call for Change

The speaker reflects on how the healthcare industry has lost its way, prioritizing profits over patients, and calls for a 'patient revolution.' They recount their experience as a doctor in Peru, where poverty, violence, and hyperinflation devastated the healthcare system. The story of Juan, a man who suffers through endless lines and unaffordable medications, illustrates the broken system. After coming to the United States, the speaker notes that chronic conditions are now affecting younger people, leading to a system where almost everyone is touched by healthcare earlier in life, making its functionality crucial for all.

05:02

🏥 John’s Struggles in a Flawed Healthcare System

John, a 55-year-old man with multiple chronic conditions, exemplifies the overwhelming burden placed on patients. Despite taking medications for diabetes, high blood pressure, and other ailments, he faces side effects and is continuously prescribed more treatments. John’s personal struggles extend beyond his health, as he faces financial stress and family challenges, including his daughter’s addiction. His doctor, focused on meeting healthcare metrics, fails to consider John’s emotional and practical struggles, highlighting a healthcare system that disregards patients' holistic needs.

10:05

💊 The Influence of Profit on Medical Decisions

The speaker discusses how the healthcare system is driven by profit rather than patient care. Doctors often rely on biased, industry-funded studies when prescribing treatments, which results in more expensive and potentially unnecessary medications. The rising costs of drugs, which have doubled in the past five years, and the pressure on healthcare executives to meet financial goals, have shifted focus away from patients. The healthcare industry, which prioritizes profitability, now leaves one in four people struggling to afford essential medicines. This profit-driven approach erodes both patient care and the well-being of doctors, leading to burnout and a lack of empathy.

15:05

⚖️ The Overwhelming Work of Being a Patient

The speaker highlights the often-overlooked burden of 'the work of being a patient.' Patients like Maria Louisa, with multiple chronic conditions, face an overwhelming and unrecognized load as they navigate treatments, appointments, and medications. The healthcare system fails to account for or alleviate this burden, and instead, it expects patients and caregivers to take on more responsibilities. This lack of understanding contributes to patient and caregiver exhaustion. Despite occasional moments of exceptional medical care, the system remains fundamentally broken, requiring a shift toward more thoughtful and respectful patient care.

🌟 A Hope for Change: Careful and Kind Healthcare

The speaker argues that although exceptional moments of medical care do exist, they are rare and not indicative of a functioning system. Instead, they are glimmers of hope that show what is possible if we prioritize 'careful and kind' care. Careful care involves tailoring treatments to individual needs and avoiding harm, while kind care means treating patients with empathy and respect. The speaker shares research from their team on improving patient-clinician conversations, showing that when evidence is presented clearly, patients become more engaged, and both patients and doctors find joy in the practice of medicine.

📚 Bridging the Gap: Empowering Patients

The speaker explains the importance of preparing patients for conversations with their doctors by using tools that clarify their concerns and needs. Stories are shared of patients who faced fears or misunderstandings that could have been resolved through better communication. One man delayed heart surgery out of fear, while a woman underwent a mammogram just to boost her doctor’s performance metrics. The speaker emphasizes the need for patients to advocate for themselves by preparing for consultations and ensuring the conversation is centered on their specific situations.

👥 Grassroots Advocacy for Healthcare Reform

The speaker concludes by calling for collective action to reform the healthcare system. While policy change is unlikely due to the powerful influence of the system's lobby, patients and caregivers can push for better care through grassroots movements. The speaker believes that patients must stand up for their rights and demand careful and kind care. By working together, patients can spark a 'patient revolution' that will inspire doctors and nurses to join in changing the system from within. The revolution starts with individual advocacy and expands into a broader collective effort.

Keywords

💡Healthcare system

The healthcare system refers to the organized network of institutions, resources, and people that deliver health services to meet the health needs of populations. In the video, the speaker argues that the healthcare system has become corrupt and profit-driven, prioritizing financial goals over patient care, leading to inefficiencies and neglect of patients like John, who struggle to manage multiple chronic conditions.

💡Chronic conditions

Chronic conditions are long-lasting diseases or health issues that require ongoing medical attention and affect a person's quality of life. The video highlights the rise of chronic conditions like diabetes, high blood pressure, and obesity, which now affect younger populations. The speaker emphasizes how these conditions overwhelm both patients and the healthcare system, making care less effective.

💡Corruption

Corruption in the context of this video refers to the healthcare system prioritizing profits over patient well-being. The speaker describes how pharmaceutical companies, healthcare executives, and medical practices focus more on financial targets than on providing compassionate, patient-centered care, exemplified by rising drug prices and treatment options being influenced by market forces rather than patient needs.

💡Patient revolution

The patient revolution is a call for action for patients to take control of their healthcare experience and demand better, more compassionate care. The speaker invites the audience to join in starting this movement, advocating for patient-centered care that is both careful and kind, which involves patients actively participating in their healthcare decisions and conversations with clinicians.

💡Burnout

Burnout refers to the emotional, mental, and physical exhaustion experienced by healthcare workers due to prolonged stress. The speaker notes that one in two doctors in the U.S. reports burnout symptoms, which reduces their ability to empathize with patients. This burnout is caused by the overwhelming demands of the healthcare system, which focuses more on financial metrics than on patient care.

💡Pharmaceutical industry

The pharmaceutical industry is a sector of healthcare focused on the development, production, and marketing of medications. In the video, the speaker criticizes the industry's role in inflating drug prices and how pharmaceutical companies often control the research on their own products, leading to biased results. This industry prioritizes profit over patients, with many life-saving drugs becoming unaffordable for those in need.

💡Careful and kind care

Careful and kind care refers to healthcare that is both attentive to the patient’s unique needs and delivered with empathy and compassion. The speaker argues that the current system has lost these qualities, becoming more mechanical and financially driven. He calls for a return to patient-centered care, where doctors and healthcare providers truly understand and respect the patient's situation.

💡Metrics

Metrics in this context refer to the standardized measurements that healthcare providers and systems use to assess the quality of care, such as blood pressure levels, cholesterol, or treatment outcomes. The speaker criticizes the overemphasis on metrics, arguing that they don't always reflect the patient's real experience, and that focusing too much on these numbers can overshadow the human aspects of care.

💡Economic disparity

Economic disparity refers to the unequal access to resources and services based on financial means. The speaker recounts experiences from Peru and the U.S., highlighting how poverty affects healthcare access. For instance, in Peru, patients like Juan cannot afford timely care or medications, while in the U.S., high drug prices force people to choose between life-saving treatments and their financial well-being.

💡Doctor-patient conversation

Doctor-patient conversation refers to the interaction between a healthcare provider and a patient, which is crucial for understanding the patient’s needs and providing appropriate care. The speaker emphasizes the need for high-quality conversations where patients are fully heard, their unique circumstances are understood, and their treatments are tailored accordingly. He advocates for tools to help patients prepare for these conversations to ensure better healthcare outcomes.

Highlights

The healthcare industry has corrupted its mission and stopped caring, which needs to change.

In Peru, people like Juan stand in long lines just to get a ticket to see a doctor, and often can't afford the prescribed treatment.

In the U.S., chronic conditions are becoming more common earlier in life, affecting the majority of middle-aged people.

John, a 55-year-old man, lives with multiple chronic conditions like diabetes, high blood pressure, high cholesterol, depression, and obesity, overwhelming both him and his doctors.

Patients like John are often prescribed medications based on biased evidence and are overwhelmed by the amount of medical care they require.

Healthcare systems prioritize financial targets over patient care, leading to burnout among doctors and poor patient outcomes.

One in two doctors in the U.S. report symptoms of burnout, which affects their ability to show empathy, impacting their personal lives more than their professional ones.

Patients with multiple chronic conditions face fragmented care, with different doctors prescribing multiple treatments, leading to patient overwhelm.

There is no medical textbook that describes or measures the 'work' of being a patient, which is often underestimated by healthcare providers.

Patients are often seen as a 'free' resource, and more work is transferred to them and their caregivers, further overwhelming them.

The rise in drug prices is likened to hyperinflation, and the cost now reflects what the market can bear, not the cost of innovation or production.

Around one in four people struggle to afford life-saving medications due to the skyrocketing prices.

Exceptional moments of medical care and connection should not be seen as evidence that the system works, but as proof of hope within a broken system.

Research shows that high-quality conversations between patients and doctors improve care, leading to better patient engagement and joy in medical practice.

A grassroots movement, starting with individual advocacy, can lead to collective action that demands careful and kind care from the healthcare system.

Transcripts

Transcriber: Tanya Cushman Reviewer: Rhonda Jacobs

The healthcare industry has corrupted its mission.

It has stopped caring.

This is unacceptable.

It must change,

and I'm here to invite you to join me in starting a patient revolution.

I started my journey as a doctor in Peru,

studying medicine at a time where my country was broken

by poverty, violence from terrorism and hyperinflation.

This tested the resilience of Peruvians

and all but destroyed our healthcare system.

Think of Juan.

He will have to wake up very early to stand in line at four in the morning.

This will be a long line already.

It will move very slowly.

If he wanted to get further, he could pay his way further,

but he couldn't afford it.

So he had to stand, wait patiently.

That was not the line to see the doctor.

That was the line to get the ticket to the line to see the doctor.

And so if he will get a ticket,

feel lucky,

go to the second line - long - and wait.

And wait.

Eventually, he'll find himself right outside a doctor's office,

will be inside three, four, five minutes,

a doctor will make a diagnosis, order a test, prescribe a treatment,

and Juan was out the door.

To another line.

This time at the pharmacy.

Only to discover he could not afford the treatment that he was prescribed.

Walk outside the hospital,

and somebody will approach him and offer him a cheaper version,

a counterfeit.

He'll take it home, not get better,

and find himself,

at four in the morning,

behind that slow line.

The system - corrupt, broken - has stopped caring.

Twenty years ago, I came to the United States

to pursue further training.

In that period of time,

there's been a significant change

in healthcare and the trends of health and disease:

it's been the predominance of chronic conditions.

These are conditions that you don't recover from,

that you live with.

And it used to be that chronic conditions will accumulate in older people,

and many of them will live with these chronic conditions.

But the trend is that now those conditions are happening earlier in life,

such that the average middle-aged person in this country

is no longer a healthy person,

but it's a person that lives with one or more chronic conditions.

That means that almost everyone in this room,

at a much earlier age than they would have wanted,

will be in contact with the healthcare system.

So, that the healthcare system works matters to all of us.

To see how it feels to have many of these chronic conditions accumulate,

let's meet John.

So John is a 55-year-old man.

He lives with type 2 diabetes, takes two medicines for this condition.

He also has high blood pressure, and he takes one pill for this condition,

except that his doctor thinks that his blood pressure should be lower

given what he has negotiated with the payer for John's care.

And so he adds a second pill,

and now every time John stands up, he gets a little dizzy.

John also has high cholesterol.

He has depression and a bad back.

He has pain in his feet because of damage from diabetes.

He also is obese.

His doctor is concerned that this is not getting better,

and so he would like John to meet a diabetes doctor;

he would like him to meet a foot doctor and see a dietitian.

For this, he will have to go to the medical center,

and for that, he will have to take some time off work,

and when he gets there, he will be told,

"You've got to cut the carbs, cut the fats, cut the salt.

You need to exercise -

I know you have a bad back, but you can do it."

He'll be told to check his feet.

John hasn't seen his feet in decades.

You know, he has a big belly.

He'll be told that he needed to take his pills,

but we know he's taking his pills

because he's getting dizzy when he stands up.

He'll be told to check his sugars and write them down

and bring them to the office.

But his doctor will look away from it into the computer

to those laboratory measures

like the A1C measure or cholesterol measure

that the doctor is being held accountable to.

And John's weight will be the thing that the doctors will discuss,

not the fact that John lives with pain and can't sleep.

Now, the reason John can't sleep

is that he used to be in a company

where there were three accountants, then two and then one.

He needs to perform - the deadline's always now -

and he's noticing that the numbers of this company are not adding up,

that this company's going under, and with that, potentially his job

and his ability to deal with his financial obligations

including his mortgage.

But the thing about home that worries him the most

is not the mortgage,

it's the fact that his oldest daughter has come back to live with him

with two beautiful granddaughters,

and she's coming away from an abusive relationship,

and she is addicted to pain killers.

And as John is opening the mail,

he gets a letter from his primary care doctor

that explains

that because he's not meeting the parameters of care set for quality,

he needs to get another primary care doctor.

Now, that's not very caring.

This system cannot care about John or for John.

In Peru, I understood it: poverty, violence, hyperinflation.

Here, what's going on?

Well, first let's find out

how is it that doctors know what to prescribe patients.

Mostly it's, if they're good, by reviewing the medical literature, the science.

Now, if you are careful, you'll notice

that the majority of new drugs and majority of new treatments and tests

are evaluated by those who market, by those who sell, those same tests.

[This] shouldn't be a shocking statistic,

but when industry evaluates its own products,

they're twice as likely to [inaudible] favor the product

compared to an independent assessment.

And if the test is true, is positive,

this result is four times more likely to get published

and to be published quickly.

So by the time the independent, more moderate assessments

become available,

most of the doctors have developed already a level of enthusiasm

for those treatments, for those tests.

And so they will prescribe them, enthusiastically.

The treatments that they will prescribe have become increasingly more expensive.

It was revealed recently that the price of the top drugs in this country

has doubled in the last five years.

Reminds me of hyperinflation in Peru.

And the problem with this

is that it used to be that we were told

that the price of the drugs reflected the cost of developing these drugs,

the cost of innovation and manufacturing and distribution and marketing.

Now we are told the prices of those drugs reflects what the market can bear.

In other words, what is it that people can pay?

The end result

of caring fundamentally about the profit of the investors and stockholders

is about one in four people now struggle to afford some of these drugs.

Some of them are life saving,

and we're pricing people out of what could save their lives.

Healthcare companies,

you know, what we used to call hospitals and clinics,

have gotten into the game.

Their executives, many of them,

are held accountable to short-term targets and goals,

which, by necessity, will have to be operational and financial.

Money will then displace the patient as what matters most.

In the consultation, it means that if you have a certain amount of time,

doctors will have to pay close attention to documentation

and to get adequate billing for that visit,

and that may crowd out the agenda of the patient:

the patient will no longer be first.

This soul-crushing reality is affecting our frontline healers.

One in every two doctors in the United States

are now reporting symptoms of burnout,

among them the inability to feel empathy for whoever is suffering.

For some reason, patients have been spared the result of this lack of empathy,

but not those doctors' families,

with doctors exhibiting higher rates of divorce and suicide.

When people live with multiple chronic conditions, like John,

and doctors are held accountable

to metrics that don't reflect the situation of each patient,

a patient with multiple chronic conditions

will have multiple doctors, multiple treatments,

and they will accumulate.

The result is in this picture.

Look at Maria Louisa.

Look at her desk - plenty of healthcare.

But now, look at her eyes, look at her face.

Is this the face of health, of thriving, of adapting and growing?

No - she's overwhelmed.

We overwhelm patients with multiple chronic conditions

because we just don't know what is the work of being a patient.

There is not a single medical textbook

that describes the work of being a patient,

what it is, how much it is, how it accumulates,

how to alleviate it.

We don't measure the work of being a patient in our practice.

We just don't know it.

Furthermore, we assume it's not a big deal.

How do I know?

Because many people think that the patients and caregivers

are the least utilized resource in healthcare.

In other words, we should transfer more work to them - they're free.

And yet we're overwhelming patients, we're overwhelming caregivers.

Now, at this point,

I think it's completely reasonable for you to go, "Wait a minute, Victor.

We've all heard of moments of incredible medical prowess,

scientific miracles that lift people from the dead,

that give people a second chance.

We have the best medicine in the world here.

And I know that.

I know that because of my parents.

They have benefited from that.

I know that because my kids benefit from that."

And then you might say,

"But, Victor, I have wonderful encounters

with my clinicians, with my doctor, with my nurses.

They are incredible moments of human connection

that I can tell you stories."

And that is the thing.

These exceptional situations

should not be evidence that the system is all right.

They are evidence of hope:

we can give that even though the system is broken.

This is as unacceptable as it is modifiable.

We have a healthcare industry that has corrupted its mission

and has stopped caring.

And what we need, what we want, is careful and kind care.

Careful - that is for us, for our situation, in our circumstance,

for who we are and for what we want to do,

and you need to understand it,

and the doctors and nurses and healthcare systems

need to understand it,

and that happens when we have a conversation.

And it's careful because it doesn't harm,

to the extent that it's possible.

It was revealed recently that health care is the third cause of death

after heart attacks and cancer.

And kind, which comes from the root "kin,"

seeing the other as if the other was a member of our tribe, of our family -

just like us.

And so treating them with respect,

particularly respecting those resources -

energy, attention, time -

that are so precious when you're sick.

How might we get there?

For the last 10 years or so, with a great group of colleagues,

we've been doing research to try to answer this question:

How do we get care that is best for this patient,

that is best for their family?

And we've looked at the conversations between patients and clinicians,

and we've brought in tools that set the record straight

so the clinicians will not have to use

the biased evidence, the biased science, that was available to them -

correct the record

and then create those conversations.

But magic happened.

Not only was evidence translated in a way that was meaningful to people,

but people would become engaged

and other important things that support the patient through suffering

and support the healer who is struggling

is that there was joy emerging in the practice.

We took our magic - because we were excited about it -

and went around the country, public libraries and living rooms,

and started engaging patients,

saying, "How can you, then, bring similar tools -

like those that support the clinician and patient interaction -

how can you bring similar tools into the conversation

so you can have high quality conversations?

And we heard incredible stories,

like a man who delayed open-heart surgery because of fear,

because in his imagination,

his doctor will open his chest and will hold his heart in his hand,

and this patient was really concerned that the doctor will drop the heart

and the heart will go around the operating room.

(Laughter)

He thought it would be silly to ask,

and so he didn't, and so he delayed surgery.

Or the woman who asked for genetic testing.

The doctor said, "Eh, you don't need that,"

but never inquired why she was asking.

She never met her father; she was curious about her future.

Or the woman at age 40, opens the mail:

"Happy Birthday. You're 40. You need a mammogram."

And she did her homework, and she thought, "Eh, I'll get it later.

I'll get it at some other time, when I get older,"

and told her doctor.

And her doctor said, "Well, wait a minute.

My performance measures include

proportion of women at 40 that get their first mammogram.

Please do it for me."

And she got a mammogram to make his numbers better.

We needed to improve that,

and one of the ways we found to improve it

is to prepare people to ask for those conversations,

to make sure that those conversations bring their situation, in high definition,

so that the treatments and tests recommended

will be the right ones for them.

And so in your packet, there's cards that are available,

and these cards allow you to prepare for those moments -

understanding why it matters what you're asking

and what you're nervous about.

Preparing ahead of the consultation

with these cards

could potentially bridge that gap and open those consultations,

make sure that they're about you.

Improving the conversations one at a time

is not going to change the system that we have.

But it is a start of a grassroots movement.

It is the start of individual advocacy,

where we stand up, as patients,

and we make sure that we get careful and kind care.

And then we get collective action,

and in that collective action,

we find ourselves changing this unacceptable system.

We can't wait for policymakers to do it;

the system is too powerful, as well as its lobby.

Doctors, nurses,

their livelihood depends on this system as it is.

But they will join because they're struggling too.

So while we're healthy,

while we have our voice,

while we have our energy,

let's work together.

Let's start the patient revolution.

Thank you.

(Applause)