Restoring the Best of Patient Care, with Mayo Clinic’s Dr. Victor Montori

Shared Decision Making and the “Patient Revolution”: Restoring the Best of Patient Care, with Mayo Clinic’s Dr. Victor Montori

September 29, 2021 – By Jared Mueller, Director – Mayo Clinic Innovation Exchange

In his recently reissued book, Why We Revolt: A Patient Revolution for Careful and Kind Care, Mayo Clinic’s Victor M. Montori, M.D. calls on the healthcare sector to correct several pathologies that have emerged from “industrial healthcare.” Dr. Montori is a globally prominent advocate for renewing a clinician-patient relationship grounded in shared decision-making, compassion, and unhurried care.

Dr. Montori is professor of medicine at Mayo Clinic in Rochester, Minnesota, and has a joint appointment as a consultant in both Mayo Clinic’s Division of Health Care Policy & Research and its Division of Endocrinology, Diabetes, Metabolism, and Nutrition. Dr. Montori is a proud Limeño, and earned a medical doctorate from Lima’s Universidad Peruana Cayetano Heredia, before completing his medical training at Mayo Clinic’s Graduate School of Medicine and earning a master of science in biomedical research at Mayo Clinic’s Graduate School of Biomedical Sciences.

Q: What is shared decision-making, for those who are new to the concept?

VM: Shared decision-making is characterized by a patient and a clinician working together, in partnership with each other, to identify the best course of action in the patient’s care. While the concept is simple, making it happen in reality is more difficult and requires investment by both the clinician and the patient.

The clinician needs to be curious, present, and generously available for an unhurried conversation with the patient who must be ready to share information, concerns, and their own experience and expertise. This is not a passive process for either the patient or the clinician. Rather, it involves working together to uncover what aspect of the patient’s situation demands action and what action the situation demands. It requires co-creating a response that makes sense to the patient, intellectually, emotionally, and practically.

Q: How have you and Mayo Clinic worked to expand the availability of shared decision-making practices?

VM: My colleagues and I have developed tools to make it easier for patients and clinicians to have meaningful conversations. These tools are freely available for anyone to download and use, anywhere in the world. While these tools can effectively support these conversations — we have tested them in clinical trials — they are often not needed to form plans of care that are informed by the best-available research and by the goals and priorities of each patient.

Our team is especially focused on the opportunity to support shared decision-making for patients who have chronic conditions. These patients often have years-long care journeys. Their preferences and desires are not constant and unchanging: their care should reflect how their needs and values evolve over the course of their lives. Yet, clinicians are often expected and held accountable to “delivering” care for people like this when the job is to care for this person.

Q: Another practice you have helped popularize is minimally disruptive medicine (or MDM). Can you share the key elements of the MDM Care Model?

VM: Exploring MDM is especially important for patients who live with multiple ongoing chronic conditions. The treatment burden for patients in those situations can be exceptionally taxing. It comes from healthcare delegating to patients and caregivers medical errands, and from the way care is organized.

Patients have to collect, organize, and synthesize disparate advice; get and receive feedback and interpret tests; integrate and implement treatments within daily routines; and figure out who pays and how to afford for all these treatments. This burden is on top of any pain, other symptoms, inconveniences, and anxiety that a patient may directly experience from the diseases and their complications. Being a patient, or being a caregiver, is often a full-time job.

As a care model, MDM seeks to advance the patient situation, aiming at the patient goals, while minimizing the burden of treatment. One of the goals of shared decision making is to find care that makes practical sense to the patient, that is, care that not just useful and desirable but also feasible.

Without attention to the cumulative burden of treatment, patients and caregivers become overwhelmed and may need to choose between attending to the demands of life or to the requirements of accessing and using healthcare and practicing self-care. Minimally disruptive medicine seeks to change this, to make care fit.

Q: What breakthrough innovations in healthcare delivery or technology excite you most?

VM: The most important development for humanity in the next 100 years will be care. We must learn to elevate care, draw it out of the domestic shadows and into the limelight. Care is what we do to make the world in which we live — our social and natural worlds — better. Thus, to be a caring person should be our grandest ambition and the biggest compliment.

We know how much more we have to work to make this a reality when we consider how we have treated caregivers and direct care workers — many of them essential workers (often women, immigrants, and people of color) particularly during the COVID-19 pandemic. We must be able to practically care for and about each other, to care for ourselves, to care for our planet.

These skills should be learned in school and expected of every citizen. This commitment to care should be our ideology, moving us from the illusion of freedom via autonomy and independence, to the reality of freedom through interdependence and solidarity. Care is a common resource, a renewable energy, universally available. I am most excited about innovations that will help us care better for each other.

Healthcare is where care becomes specialized and technological (and expensive), but it can only reflect how well we care in the community. Many innovations targeting people with chronic conditions today focus on surveillance and behavioral modification. These “solutions” rely on the industrial notion of managing or processing patients based on their objective data and just-in-time coaching and treatment. And yet, living with chronic conditions is a wicked problem that requires partnership, patience, curiosity, and creativity.

Resilience comes from the relationships of care that form in the process of caring. Effectiveness emerges from compassion and competence. And all of this must leave enough energy, time, and attention for patients to pursue their lives. No one dreams of growing up to be a great patient. I look forward to innovations in care. Right now, the most promising one is the unhurried conversation.

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