Why we revolt: a patient revolution for careful and kind care by Victor Montori

Abstract

In 1997, Cynthia Mulrow, a clinician researcher, coauthored an article in Annals of Internal Medicine describing the rise of the systematic review as a source of evidence to help inform good clinical decision-making. The article also heralded the then recent formation of the Cochrane Collaboration, an international organisation aiming to disseminate good evidence through systematic reviews. The article was noteworthy for a figure which captured perfectly in a Venn diagram the elements that contribute to clinical decision-making. These include evidence (of course!), patient and physician factors (including values, beliefs and prior experiences) and constraints (including factors such as time, reimbursement policies and laws). The Mulrow Venn diagram has been part of my teaching and presentation portfolio for over two decades. In the style of Desert Island Discs, if I were asked to choose one slide from the innumerable slides in my Powerpoint collection, I would have little doubt which one to bring with me. As a clinician interested in understanding why certain things happen in clinical practice, the Venn diagram has always served as a good place to begin the thought process. At about the same time that Mulrow was publishing her Venn diagram, a young Peruvian medical graduate was beginning his postgraduate training in Medicine at the Mayo Clinic. Victor Montori would go on to do subspecialty training in Endocrinology and spend 2 years of postgraduate training at McMaster University where he was exposed to people like Gordon Guyatt who inspired him to pursue a career in Evidence-Based Medicine. Together with Guyatt and many other collaborators around the world, Montori has explored in depth the challenges and opportunities presented by EBM including its potential for doing good and harm. A major part of his work has focused on how best to incorporate the patient’s values and beliefs into the consultation to generate a shared-decision making output. He has helped shape a lot of the thinking in this area through research that has emphasised the primacy of the patient–clinician interaction during the consultation. Although it is a key element of what we do as clinicians, very little research has been undertaken on the consultation, certainly not in a biomedically-oriented specialty like Endocrinology. Why we revolt: A patient revolution for careful and kind care represents an impressive coming together of a lot of Montori’s work to date and his vision for the future of clinical medicine. The book amounts to a call to arms for patients and clinicians to regain the ground that has been lost to (what he terms) the industrialisation of healthcare. In the first section of the book, Montori describes how medicine has lost its way and has sold its soul to the corporate world of healthcare provision where profit and greed are more important than good patient outcomes. He describes very well how outside forces such as reimbursement policies, requirements for documentation and * Sean F. Dinneen [email protected]