Victor Montori

Transcript

This transcript is AI generated and may contain errors.

Consequences to other economic priorities, including education, which has already been mentioned, and of course, other consequences for the planet.

So our response to unsustainability should not further the unsustainability of our work.

Nonetheless, this has been very attractive to the technology sector.

Eric Schmidt, who was CEO president of Google, said that every hospital should put sensors everywhere.

In fact, every person should be wearing sensors.

Every home should wire to have those sensors, and all this data should collected, sent to the cloud, the Google cloud of course, use that data to generate responses that will improve the efficacy and efficiency of healthcare.

Schmidt said that healthcare is becoming an information science, and so he would like to see more technology in healthcare.

Fast forward a few years and in a podcast of venture capitalists, venture capitals are essential people in defining what we do in health care, not only in the United States.

They have billions of dollars that when they put into a sector like healthcare is capable of actually changing healthcare without any input from the people that we care or from us as caregivers.

And this individual, Vijay Pandey, is one of those individuals that directs this money.

In that podcast, he said, think about what primary care physician does.

They ingest all this data and make a diagnosis and they send the patient to a specialist.

That's literally a data science problem.

That's literally not what you do, right?

But once these people define your work, they get to change it.

And so we moved from healthcare with some technology in it to health tech, a new sector in which the ethos of our profession is no longer in charge.

And that technological path forward is highly problematic.

If we are today in industrialized healthcare and we're worried about fractured care, transactional care hurried burdensome, generic, cruel healthcare in which care feels depersonalized.

The next step is to focus on data and when going to data five healthcare.

And there the obsession or a biological position shifts our attention away from the person leading to biographical indifference.

Medicine then needs more and more data to solve problems of care, which are then redefined as problems information.

And so we no longer care that this human is a person.

We no long care in fact that they're human.

we are processing data.

That's not the final step.

The final is to move to artificial health care in which the pursuit of the automatic and the perfect dominates.

It's a medicine of indicators.

We have sensors everywhere, algorithms running real time on every one of us, and then if we deviate from someone's definition of perfect health, then those algorithms actuate over us without our permission.

something that Big Tech has done with political processes.

You remember Facebook and Cambridge Analytica with the Myanmar genocide.

With all this manipulation that occurs with our youth, driving them to eating disorders and suicide, and what it's doing to our society is polarizing them and making the political process of democracy nearly impossible.

Those people were inviting into healthcare to try to make us more efficient and more effective, and care will become disembodied.

No longer the clinicians need to show up to work or patients show to care, but care would just happen in a disembodyed fashion.

Without us raising our voice, this is the future.

There is another way of thinking about this crisis of care, and that is to think about it as a crisis care in and of itself, which requires us to go a little bit into care.

And once again, I want to revisit this story about Minnesota.

This is the flag of the state of Minnesota in the United States.

I've described, thanks to the picture, what happened in this state that has been my home for 30 years now.

And I want to use this as a backdrop to what I think is a very good definition of care, which is what we do as species, as humans do, to maintain, repair, and improve our world so that we may live in it as well as possible.

So think about everything that's wrong in the world now at the planetary level, at a societal level and at an individual level.

And we will see crises of fear.

In this way, what we do in healthcare is an extension, a specialization of what humans should be doing and probably do on a day-to-day basis, ordinary people caring for others.

More formally, care is a moral disposition and a practice of noticing and responding.

Noticing requires us to be present, to pay attention, To understand the situation of the person in need in high definition in its biology but also in it's biography.

Not only in what is needed but what strengths they bring so that we can make a difference in their life.

And it's not enough to notice.

Oh, this person is suffering.

Look at all that empathy.

It's doing nothing for the person to feel all this empathy unless empathy grows hands and you start doing something about it.

So it is not just about noticing, but it also responding, not reacting.

You know, this order of test sent to CT, sent the specialist, like the technologists were thinking.

But it's actually responding to what's observed.

And that choice of responding creates the possibility that the person's situation, which is problematic, could be improved and be better.

An action then follows.

That action is caregiving, but it is not enough to care give.

We also need to pay attention to carer receive.

In care giving, we work with people We don't do things to them, we do with them.

We mobilize our compassion and our competence so that we can do more good than harm.

And we need to look at how this response works.

Is it a pertinent response?

Is adequate?

And is it desirable?

So care is a moral disposition and a practice of noticing and responding, of caregiving and care receiving.

Now, I'm going to share with you a case.

It's actually a very old case, an old patient of mine.

And I want you, as you listen to the story, to think about this process and identify perhaps where it may have gone wrong.

And this is a patient that I used to bring along with me many, many years ago.

And I've decided to brings him back to my presentations.

His name is John.

John has diabetes.

He's on metformin and is on the GLP-1 receptor agonist.

Has hypertension and he's taking a couple of drugs We learned in one of our sessions today that combination therapy is what we need to be doing So he is on combination Therapy, but unfortunately when the beta blocker was added he started getting dizzy He's on he has high cholesterol.

He has depression a bad back He hasn't painting his feet from the neuropathy and his obese The primary care clinician has decided that he needs to see an endocrinologist.

Always a great idea.

He needs a podiatrist for his feet.

A dietician to try to help with his weight and blood pressure.

For all of that, he has to go to the medical center, so he takes time off work.

He needs to find somebody that will take him there.

And all he's going to hear is that he needs avoid salt, avoid fats, and avoid carbs.

He basically needs choose different flavors of cardboard for his diet.

Um, he need to exercise something that's very difficult because of his bad back and the pain in his feet.

that he needs to check his feet which is actually hard because he does have a big belly and it's really hard to look at his feets so he'll have to convince his wife to maybe help him with his feed and that's going to take a while.

He needs take pills which of course he's taking that why he got dizzy with the blood pressure medicine but people think that is not taking the pills that needs monitor his blood sugars, monitor blood pressures with a nice digital device.

His measures are all out of control in terms of cholesterol, the A1C for his diabetes, his weight is not really budging, it's not changing.

And what he wants to discuss is, not all these parameters.

He wants discuss that he can't really sleep.

The pain in his feet, he's back, perhaps his depression is affecting this, but that's coming up.

Now, the thing that is preventing him from sleep is that he works in a place where there used to be three people doing his job.

Then they brought all these agentic AI things and now there's two and then now he's doing the work of all three.

He is an accountant in that work.

The pressure of the works is always there.

Their deadline is now.

And he is realizing that the numbers are not adding up.

And he's taking the work home and worrying about these numbers and thinking this company is going to go under and he is gonna lose his job.

He's not gonna be able to pay his insurance, his debt, the mortgage on his house.

But the thing that he worries most in his home at the moment is not the money, it's the fact that his older daughter has come back to live with him.

has brought two beautiful granddaughters with her.

But the reason she's back home is because she was being abused by her husband and this has thrown her into addiction and use of alcohol and drugs and he described her daughter as wasted.

So what happened?

Got more pills.

So one way of thinking about what happened or what happens with patients like John is that he's experienced the pathologies of care of industrialized health care.

One of them is the failure to notice what's problematic about his human situation.

It was way more than an elevated A1C or an elevator cholesterol and weight, was it?

And so John became a blur to his clinician.

The clinician could not see John in high definition.

There's a failure to respond to what's keeping John up at night, literally.

instead responding to these metrics and indicators that were in our quality measure and our guidelines.

And when somebody seeks care and their response is indifference to the source of their pain, that's cruel.

There was limited opportunity perhaps for care to emerge because we do not know how hurried this visit may have been perhaps very little time.

So many things to cover so many guideline metrics to make so much documentation to achieve that perhaps there was no time to discuss the personal situation of John.

And again, the applications of the multiple pathways, guidelines, and standards may have actually led John to experience what I hope all of you were feeling as I was describing John's situation, which was the substantial burden, not only the burden of illness of all the symptoms John had, but the burdens of treatment that we added to his existence.

So industrialized healthcare brings along these pathologies of care.

And I'll put forward that we all would want to practice not in industrialize healthcare, but in a healthcare that's capable of careful and kind care, careful care which is evidence-based and responsive to each person's problematic situation and reflective of each persons goals and priorities.

And kind care, which upholds the dignity of each person, seeks their flourishing, not just the improvement in their medical situation, and respects their time, energy and attention, they'd much rather use for other things in life than to be a perfect patient.

Now what does that mean.

Well in the case of blur we would like to go to high definition and that may be that they mean that we need to be curious about the situation of the patient.

Many observers of health care want patients to become more engaged more involved more activated in health.

After watching thousands of clinical encounters as part of our research what I'm impressed by is the lack of engagement and involvement of clinicians in where the patients are coming in with these problematic situations and we just can't afford to ask the question of, how are you doing?

What's going on at home?

Because we know that the patient will become emotional, that they'll be crying, and they will be behind for the rest of the afternoon.

We don't want burden, but we want minimally disruptive care.

That means our organizations have to stop when they're encountering a problem of data collection.

Somebody in the committee meeting is going to go, oh, we should have the patient do it.

Oh, no, the family member can complete the survey at home.

They could actually measure things and send us the data.

And patients and families are having more and more work.

Some of that work will not get done.

Well, we need to investigate when we see noncompliance, nonadherence, or low fidelity.

Why is that happening when there is a no-show?

And we need to simplify care particularly when your patients go to secondary care and the hospitals become incredibly confusing and difficult places to navigate or the electronic versions of that are apps for access to health care data are too complex for people to follow.

We want unhurried conversations instead of hurried visits, which basically means we must limit interruptions and distractions or pop-ups and alerts.

We need to make sure that our schedules are responsive to the fact that every time I meet with Mrs.

Jones, it's going to be a 32-minute visit.

And you go, oh, why would you keep scheduling her for 15-minutes visits when we know it is going take longer?

Well, this will be good use of that AI thing.

We need to reinvent continuity of care.

I know there are some workshops and activities in this conference about this, but continuity care in many places is now considered a luxury.

Health care people begin to imagine that you are all interchangeable.

You're a GP, you're GP.

I'm a patient with diabetes, I need to see a G.P.." I would see whoever is available.

And as long as they're being seen in the same organization, there's continuity.

There's the medical record, right?

So we have continuity of information.

No, but we want continuity relationship.

Well, the So we need to reinvent that.

And also, we must limit all these must-do recommendations that crowd out the agenda of the visit, creating massive opportunity costs that Mina Johansson keeps highlighting that prevents us from caring and responding to the real problematic situation of a patient.

We need eliminate wrong doors and make navigation easy.

I'm sure in this room there will be a thousand more ideas about how to approach and get careful and kind care for everybody.

But fundamentally, We need to move on from a system that thinks that what's cool is our ability to know so there's no more and our Ability to do we have the technology why not use it to actually be able to care What needs to be protected and fostered is the ability?

To care we need To move from this notion of people either as biomedical source or Of raw data or as target for intervention check our language when we talk about people we often refer to people in this way and Realize that what our material the material with which we work is the life of people That that is precious Material with, which, we, work when,we are at the bedside when We are with people it's not their data And we need to move from this obsession with full knowledge, the elimination of uncertainty, that pursuit of precision, prediction, and perfection, to what I know I'm speaking to the choir when

I say to realize that if it's life, it is an adventure.

And what makes life an adventurer is the fact that we do not know how it will play.

We sort of know the ending, but we don't know we're going to get there.

Right?

And that is, that ambiguity and that uncertainty is the adventure of life, and is so precious about the work that we get to do.

Gregorio Marañón, an internist from Spain at the beginning of last century, was asked, what's the most important tool of the clinician?

He said it's a chair.

Because when you sit down, time changes.

It slows down and becomes a place, not a resource, a space in which you get to understand what's going on in this life and what do we need to do to make a difference.

And so instead of industrialized healthcare, I propose to you that we start talking with pride about artisanal healthcare.

and of us as artisans of care.

Not artists, because artists are inspired and who knows, you know, I'm gonna put your nose over here.

It's gonna look like a Picasso.

That would be a bad thing, right?

So it's not about artistry, it is not inspiration.

I am gonna be inspired to give you bed of lockers perioperatively, even though the poistral showed that it was no effect, but we're gonna use it because I feel inspired.

So that would an artist of here, and I don't care much about artistry in healthcare, speaks of loving the work, paying attention to the detail, passing your hand over the finished wood and realizing it's smooth and it reflects what you were hoping to achieve.

You craft care with, you learn with the masters and you do it with people.

And you start by saying, I don't know.

There's a humility to that craft.

That I think is important and it moves us from the generic universal truths of guidelines and performance To this person in this moment here Which is the space in which we do our work And so I've been asked what's the most important innovation in healthcare today and I believe it is The Unhurried Conversation If you can have an organization, a system that is able to foster unhurried conversations between clinicians so that they can learn from each other, so they support emotionally each we're talking about an organization that is at the top of innovation, in my opinion, because it is in the inherent conversation

in that space that we go from an undesirable situation in its joint appreciation, shared appreciation in high definition, to the co-production, co creation between patient and clinician of care that fits that life, not asking the patient to change their life to fit our treatment, but actually form care that fits the life of the patient so that their situation can be improved.

All of us, I mean, we heard about I did not sign up to this or I signed up care.

What we signed to do was to make a difference in people's lives.

The difference we sign to is this difference, the difference between an undesirable situation and an improved one.

So we come to the visit and we appreciate the challenging life situation of a patient, disorganized, the patient lost in it, challenging, difficult, unclear where to start.

And then we begin to work with our patient, finding sense in something that doesn't make sense.

You know and I know that there's this little satisfaction that we get when we sort of figure something out.

We find order in the disorder.

and we find a way forward in this patient's life.

And we are satisfied by this, and the patient is satisfied with this.

This is the craft of care.

So my colleague Marlene Kuhneman and others put together this manifesto that describes this work.

Patients and clinicians collaborate in designing care plans that maximally respond to each patient's unique situation and priorities while minimally disrupting their lives and loves.

The definition of artisanship.

Now, I want to bring up this picture again, because I would suggest that the reason we have that notion of perfection in a conveyor belt is because when we get to fix people, this sort of is a good thing.

I had cataract surgery in my left eye, not because I'm old, but because i had an injury when I was 15 years old.

My point is that I am not that old to have catarract surgeries.

And I remember I sat down at the chair And I got an IV line put in.

People talked to me.

I don't know what they said.

All of a sudden, I had to pull back.

And then somebody started moving, playing with my eyes.

Then all of the sudden it was done.

and I was sitting up.

Somebody took my IV out, and then I walked away.

The whole thing took 15 minutes.

It was perfectly the first time.

Now we put forward that perhaps that's ideal.

That's an ideal experience.

This sort of conveyor belt sort work when we can cure.

But our health care has to be ambidextrous.

We should be able to do this and have all these right diagnoses, right time, the first time with the right team and the technology with perfect safety.

But we need to know the difference between when that is called for and when this is call for.

When we to manage symptoms, mitigate harms, cope with disappointment, prevent complications, rehabilitate sequela, support self-management and problem solving.

That's about perfection.

That about fit.

And we need to be able to actually be to do both.

Now, to care is fundamentally human.

Everyone that's here is here because someone at a critical time decided to for about and with you.

The mission is infinite and the capacity to face that mission Which brings us back to this notion that, well, let's give up on this human thing and let bring AI to help us out.

And I want to offer just a few reflections before we finish.

Do we understand what care is and what it does to the mattering of people?

I know I matter when I show up to see my patient and I'm able to make a small difference in their life.

I walk away from that encounter feeling good about what I do and about myself.

But my patient that came in and got my attention and my skill and me to work on their problem also felt that their life mattered.

What happens when the best that you can get is the response of a bot?

Who is worthy of human care will become so rare that it will only be for the privileged?

And here, it's helpful to think about Paul Farmer and the idea that some lives matter less is the root of all that is wrong with the world.

And the problem of solutionism.

The idea is that every complex human problem has a technological solution, and that's the right answer.

And this is paraphrasing, but if you think technology can solve your problems of care, you don't understand technology, and you do understand your problem of here.

So the real question, like with every tool that is offered to us, is can AI help humans get better?

And this is data from a semiglue and Johnson, a semi-glue worldly Nobel Prize for economics, which people think is fake.

But anyway, he got it.

And in his book, Looking at 1,000 Years of Progress, Progress and Power is the book.

Power and Progress concluded, there is nothing automatic about new technologies bringing prosperity.

Whether they do or not, it's a choice.

It's an economic, social, and political choice, And we, all of us in this room, need to stand up and make sure that the choice when it comes to AI is the choose of being used to cultivate care, to make care healthcare's only purpose.

And, we need make room for care by making sure we stop transferring all sorts of human problems to professional healthcare.

I come from a country that has basically given up on public health.

I cannot afford that.

We need to make sure that most of prevention happens at the community and at structural levels where the social determinants of health exist.

And we need promote common care.

Make sure we learn how to take care of each other.

If somebody drops dead, we can bring that person back from the dead.

There's a defibrillator on the left side of the theater.

We've been told multiple times.

Um, and if somebody's hungry, We can cook them a meal.

Between cooking them a meal and resuscitating them from the dead, there's a whole range of skills that we should all have.

And they should be so popular and we should so proud of doing those skills as we do with our cooking.

And just that we have cooking shows and cooking books and chefs and other people, we shouldn't have the same for all their forms of care.

So advancing public health and common care will then make professional health care smaller and perhaps more humanly sustainable.

Clinicians working in it can be well and can look after their competence.

appropriate conditions for care, that when we bring new technologies, we not only do a financial impact analysis, but we do care impact analyses, how it will affect our care and it'll be minimally disruptive.

That requires us to reimagine healthcare.

But it's difficult because of so, so much interest there is in keeping things the way they are, even though they're fully broken.

The exercise of imagination is dangerous to those who profit from the way things are because it has the power to show that the ways things is not permanent, not universal, and not necessary.

So let's advocate for care.

Let's remember what we learned during the pandemic.

That care, when it's not exploited, can renew that caregiver, and it can be a renewable force.

That care is fundamentally human.

And care, when it's done well, can't be beautiful.

Let's work together for careful and kind care for all.

Thank you very much for your attention.