HLOL Podcast Transcripts

Health Literacy

Consultations are Conversations: How Clinicians and Patients Can Help (HLOL #117)

Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some really remarkable people—hearing what health literacy is, why it matters and ways every one of us can help improve health understanding.

Today I’m talking with Dr. Victor Montori, who is professor of medicine at the Mayo Clinic. He not only is a practicing endocrinologist, researcher and author, but also a recognized expert in evidenced-based medicine and shared decision making.

Dr. Montori developed the concept of minimally-disruptive medicine and works to advance patient-centered care for patients with diabetes and other chronic conditions. Welcome.

Dr. Montori: Hi. How are you?

Helen: Patient-centered care almost sounds like both sides of the conversation right there, the patient part and the care part. What does everybody have to do to make that healthcare conversation work?

Dr. Montori: The first step is to recognize that no decision in healthcare can be made by the doctor alone. The doctor may know something about the science involved in the decision, but the expert about the patient’s values, preference and goals is the patient.

Both have to engage in the conversation to achieve a decision that reflects the science, as well as the context and values of the patient.

Helen: It’s science, and the context and values. Give an example of how that happens.

Dr. Montori: For instance, for a patient with diabetes, we try to reduce the chances that those patients will have a heart attack. We might use cholesterol medicine to achieve that goal.

Helen: You’re the expert on the cholesterol medicine.

Dr. Montori: Yes. We know the signs, and we know that those cholesterol medicines reduce the risk of heart attacks. Given the patient’s level of risk for the heart attack, which may not be too high for instance, the patient may say, “I don’t want to take a pill every day for the next 10 years to reduce that risk given that my risk is so low.”

Helen: You both have to come to terms with this one. Is that what the patient-centered care is?

Dr. Montori: I think it is. It is care that is not the same for everyone, but so that every patient, given their own context, circumstances, values, preferences and goals, gets the care not only that they need but also care that they want and the care that fits with that context.

Helen: That sounds ideal to me, but I hear about and you probably see every day those 10-minute appointments. There are busy patients and busy doctors. Does the ideal happen?

Dr. Montori: Yes. We’ve reviewed more than 700 video recordings of patient visits both in primary care and in specialty care. I’m happy to report that the ideal happens. It just doesn’t happen often enough.

The kinds of things that doctors do to make the ideal happen is to really give up on the dogmas and strong words that turn off the patient. The part of the patient is the ability to ask the right questions.

Often those questions are to do with, “What are my options? How likely is it that these options are going to improve the outcomes that I care about? What are those outcomes that I care about that these treatments can improve?” It is in that give and take that the ideal begins to emerge.

Helen: Let’s be more specific here because our listeners all care about health literacy and good health communication. Many of us are clinicians or in public health, public health educators or are somehow involved in communicating health information.

Take it one by one. You talked about doctors having to give up the dogmas and the words. Tell us more. What can we as health communicators do?

Dr. Montori: Often we feel pressure for time or for trying to accomplish some of those pay-per-performance targets.

Helen: That’s happening everywhere.

Dr. Montori: That’s right. Those are pressures that we have to do things. At least one-third of US clinicians feel they are made to practice a more aggressive form of medicine than they would like to practice. Recognizing those pressures, we have to prioritize the visit around not those things that are going to impact how others perceive our work, but the care of this patient in front of us.

Not everyone works in a situation where they have enough latitude over their practice to make these choices, but health professionals are professionals and they have a responsibility to guide the practice they have.

They shouldn’t just follow instructions. Most of the people have enough education to be able to stand up and say, “I’m willing to that, but I’m not willing to do this other thing.”

Helen: Can you give an example? I give a lot of workshops and meet a lot of people. I used to be in practice myself. Those external pressures on us are enormous. What would it be like for you as a physician or other people listening to this? How can we stand up and say “Wait, this is what we need to do”?

Dr. Montori: I can give an example where you can see the tension and how it should be resolved. Let me tell you a quick story.

I’m an endocrinologist. I take care of people with diabetes. One of my patients was referred to me by a family doctor who was telling me, “This patient does not want to take cholesterol medicines. Maybe you can do a better job.”

I meet with the patient and the reason she’s supposed to be on cholesterol medicine is because she has diabetes. After she was given the diagnosis of diabetes, this lady decided to do what we tell people to do.

In other words, she became very physically active, lost a lot of weight and essentially cured her diabetes. She did not have diabetes anymore. There was no evidence of any diabetes left.

She didn’t need the cholesterol medicine, and that’s exactly what I told her. I said, “Your diabetes seems to be cured at least for now. Therefore, you don’t need any cholesterol medication that I can see.” She stood up, gave me a hug and left the office.

I got a call from the family doctor telling me that it had cost her a lot of effort and time to convince this patient that she was still diabetic. I said, “Why is it that the specialist is arguing for the patient here and the family doctor is arguing for the disease? Usually we expect it to be the other way around.”

Then it became very clear that if this patient were still diabetic, it would still be counted as one that has diabetes and is well controlled rather than leave the list of people with diabetes because she no longer has the condition.

Helen: Does that have to do with those external measurements and performance standards? It sounds like the patient had one agenda, the primary care doctor had another agenda, and you had another agenda too.

Dr. Montori: It is the agenda of the patient that really matters here. The question is do we sometimes have other agendas that conflict with it, and do we make those explicit enough so that the patient can participate in the decision-making process? Clearly here there was a lot going on that had nothing to do with the patient’s best interest.

Helen: You really are acting as the patient’s advocate too. You’re the scientist, but you’re also the patient’s advocate in his or her life.

Dr. Montori: I expect all of my colleagues to primarily have that role. We should care, alleviate suffering and advocate. That should be part of our professional duty and it should never be abdicated.

Helen: What about those time pressures? I think that’s the factor that I hear about the most. “I don’t have time. I have too many patients. It’s just easier to prescribe the medicine.” What do you recommend for people who are feeling so overwhelmed in their practice?

Dr. Montori: Different environments have different reasons for that time pressure. In some cases, how people make money relates to how many patients they see. Obviously the more patients they see, the more money they make.

In that situation, they have to really explore their soul and find the point after which seeing more patients and getting more money is no longer rewarding for them. You have to recognize that it is in this group of professionals that the highest level of burnout is sometimes observed.

The second thing that people have to do is figure out in their organization who is setting up the times for appointments. Then they can identify the places where they can be modified.

When patients call in for their appointments, if the patients expect that there will be a conversation in that appointment, they should set up an appointment that is separate from the appointment where there are other agendas, like running through the preventive care or other things can sometimes hijack the visit and do not allow for these productive conversations to take place.

Helen: You just touched on where I wanted to go with this. Tell us more about what patients, families and all of us can be doing on that side of the conversation.

Dr. Montori: I always have difficulty with asking patients to do more. Patients are by definition sick. By definition, their abilities and resources to take care of themselves and business are limited or reduced by illness. I always am hesitant to ask patients to do more.

One of the things that we observe is patients who come in with an extra pair of ears to the consultations. It could be a recorder, but it could also be a family member or a friend. That is excellent because they don’t have to pay so much attention to the details. They’ll be recorded or noted.

Helen: Are you fine with audio recording?

Dr. Montori: Absolutely. I don’t see any reason why not. Then they can go after the details and pay attention to the big picture. Many of them come to the visit somewhat scared. They may not be able to pay any attention or remember much of the visit anyway.

If you don’t record either in a written or audio recorded fashion, most of the effort is going to get lost and you’ll find yourself repeating the same thing in the next consultation. Of course I’m okay with recording, but I’m also okay with the patient bringing an extra pair of ears.

The next thing that we probably need to train patients to do more effectively than we do now is to interject, ask questions and stop us. We often have little phrases and sentences that we use, some of them with jargon and some of them assuming that the patients have this problem every day.

We see it every day, but for the patient it might be the scary thing that happens only once. We need to slow down and recognize and honor that moment for them. The patient should be able to help us slow down.

Helen: Are you okay with people asking questions? I’m interrupting you right now to ask you questions. If I were seeing you as a patient, would that be disruptive?

Dr. Montori: If my consultations were lectures, you would be a heckler, right? My consultations are conversations. In fact, for the last 10 years, our explicit goal from research on shared decision making has been to create conversations where none are taking place.

Conversations mean that we turn with each other. What I tell you gets modified for when you receive it, reflect it and come back to me. You now turn it and I have to turn with you. When you look at the roots of the word conversation, it means turning with each other. That’s what’s lovely.

We are better off by having that exchange than by just coming in, listening to what the doctors says, then going home and thinking about it and deciding what to do.

Maybe you decide not to follow my advice, and then I get concerned about the fact that you’re noncompliant. You then don’t come back to see me because you’re afraid that you have to confront the fact that you didn’t follow my advice.

That’s not what we need to do. We need to partner, work together, and have a conversation both in and outside the office.

Helen: I love that description. Thank you for putting it that way. I love that phrase that your consultations are really conversations.

Just listening to you tell these stories are reframing it for me. It’s taking away some of these pressures we have of too little time and too many external things going on and just getting to the heart of what’s going on with the person who needs more care that day.

Dr. Montori: Yes. I’m a chronic disease doctor. I’m a diabetes doctor, so I don’t deal with emergencies or urgencies, and I don’t deal as often with acute problems. The second thing is that I work at the Mayo Clinic in which all physicians are salaried. Whether we see 100 patients or 10, we will make the same money at the end of the month.

I’m in a very privileged position to observe what needs to happen and to potentially state this. When I go around the country talking about this, it’s time for empathy because other people are not as lucky in terms of working in an environment like this. They do have an ability to influence an environment. They have just learned to be helpless.

Similarly with many patients, they’ve learned that they’re not in control, so they’ve given up on changing this. That’s premature. I think there’s a role here for a patient revolution.

Helen: I want a provider revolution too. You figured out how to make this work and it sounds like it’s working well. You talk about that issue of control. For all of our listeners who might feel that this whole situation has gone out of control, what would you suggest everyone do to get back to our roots about why we entered this work?

Dr. Montori: I think that the words you’re using are proper. In terms of healthcare professionals, it is pertinent for people to recognize that it is about caring, so it is therefore about listening. Therefore it is about meeting the needs of the people that knock on our doors asking for help.

Patients have to recognize that doctors are fallible and ignorant, particularly about the patient’s conflicts and goals. They don’t know that they’re ignorant about this. It’s the patient’s job to remind them about what this patient is about, and then together make the healthcare fit the patient and not the other way around.

Helen: That was beautifully stated. Thank you for doing all you’re doing. Are there ways to learn more? I know you’re a well-published author. You’ve written zillions of articles. You’re passionate about these topics. Do you have a few highlights of how we could be getting more and getting a dose of Dr. Montori so we can stay a little more in control?

Dr. Montori: I mentioned that we’ve been doing work for about a decade now. Some of that work on shared decision making and on minimum-disruptive medicine, which of course are ways of making healthcare fit the patient, can be found on some of our blogs that we can give you URLs for.

Helen: We’ll have those on your Health Literacy Out Loud web page. You’re making me feel more like it’s a conversation that really matters. It’s all about care. Thank you so much for talking with us on Health Literacy Out Loud.

Dr. Montori: Thank you for all you do to advance health literacy for our patients and for our clinicians.

Helen: Thank you.

I learned so much from Dr. Montori about patient-centered care and how consultations are really conversations. But communicating clearly like this in health literacy isn’t always so easy.

For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free monthly enewsletter, What’s New in Health Literacy Consulting.

NewHealth Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find more information along with many important links, including the ones that Dr. Montori was talking about, at the Health Literacy Out Loud website at www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.


"As an instructional designer in the Biotech industry, I find Health Literacy Out Loud podcasts extremely valuable! With such a conversational flow, I feel involved in the conversation of each episode. My favorites are about education, education technology, and instruction design as they connect to health literacy. The other episodes, however, do not disappoint. Each presents engaging and new material, diverse perspectives, and relatable stories to the life and work of health professionals.“

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