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)