Becoming a Conduit of a Patient Revolution

Podcast Transcript

Adrienne Boissy:  Today, we are broadcasting from the Patient Experience: Empathy and Innovation Summit, in downtown Cleveland. And very pleased to have one of our spectacular speakers here, Dr. Victor Montori, welcome to Studies in Empathy.

Victor Montori: Thank you for having me.

Adrienne Boissy:  I'm so glad you agreed to participate. So I'm looking forward to it.

Victor Montori: I don't think I had much of a choice, but I'm delighted to be here.

Adrienne Boissy:  You always have a choice, Victor.

Victor Montori: Well then I've exercised my judgment, and I'm here-

Adrienne Boissy:  There you go. You're not sure yet.

Victor Montori: Delighted to be here, I think.

Adrienne Boissy:  It's okay. Hey, I've heard that you have been called the patients doctor.

Victor Montori: By my mother probably. Yes.

Adrienne Boissy:  Well, I'm not revealing any names, but I'm curious, what does that mean to you?

Victor Montori: I suspect that whoever used that referred to the notion that in our research work, and in our advocacy work, we try to take the position of what might be the patient's goals, the patient's position in what we're trying to do.

So in the case of research, we can always ask questions from the standpoint of knowledge gaps. You know what, what is the next question from the research perspective? But it's way superior to think about what are the care gaps, where are we not able to completely or fully understand the patient's problematic situation, and understand what needs to be done about it? Or when we understand what needs to be done about it, do we really know what is the ability of what we have available to actually meet their needs?

And so it's much better for instance, with research in that way. Similarly, I think in terms of the kind of advocacy work that I do, I'm much less interested in advancing the purposes of healthcare organizations and companies, and I'm much more interested in how might we make sure that patients receive careful and kind care.

Adrienne Boissy:  Well, we're going to talk more about that today. Right?

Victor Montori: Maybe.

Adrienne Boissy:  And your book, Why We Revolt, talks about industrial healthcare. Can you share a little bit with the audience? What does industrial health care mean to you?

Victor Montori: Yeah, when patients are sick and they come for care, they might encounter organizations that are well set up to respond to people like them. And that they're able to respond to people like them, and that they're able to do so in ways that demonstrate that they can see who the patient is, understand their biology, understand their biography, respond in a comprehensive way and advance their health priorities. Hopefully in a way that does not overwhelm them, does not disrespect their precious resources like their own time, energy and attention.

When we see that, we would like to use the idea that they're getting careful care because it's safe and effective. It's evidence-based. It's based on science. And kind care because it's respectful of who this person is, and what's important to them, and what matters to them. Careful and kind care is what we should be getting.

The alternative is people are coming through with interesting throughput and access, and making sure that we have reliable industrial processes. And that we have business processes that produce great outcomes for the companies and corporations that actually are responding to these patient's concerns. And the result of that is impersonal. It's decontextualized. Something's happened. People are getting medicines, and surgeries, and other things, but to what extent this care is responding to this person's situation, or is responding to patients like this, is open to question. So when healthcare behaves in those ways, my shorthand is to refer to it as industrialized or industrial healthcare. Again, as an antonym, as the opposite of careful and kind patient care.

Adrienne Boissy:  I shortchanged you on your introduction because I consider you an icon in many fields, but particularly in talking about advocating for what we need for our patients on the broader national, global stage. Although you've been very humble, every time I try to compliment you, you deny it. But in the field you've really done spectacular work. You're a professor at Mayo. What are you most proud of in the work that you've done, whether that's research work or patient care work? What are you most proud of?

Victor Montori: Well, so, so I don't think we're... The cause of the patient is served well by icons, or by leaders, or people that are driving a response based on their charisma. I think what we need is a grassroots movement in which we all recognize that we're in this together, and that care for and about each other is a fundamental component of the DNA of well put together societies, in which the way healthcare manifest is just an expression of that society. Nothing foreign to it. It's just the way we... It's just a professionalization of what we do everyday with each other. I think to some extent, industrial healthcare is a reflection perhaps of the kinds of societies that instead we're building, which care becomes something that we only see when there's a natural disaster, or some violence, in which we all of a sudden remember that, that's in our DNA and we start caring for each other.

I think what I'm most most proud is of the opportunities that I've had to work with individuals who, because of their intellectual contributions, because of their ability to shape ideas, the ability to express those ideas in words, and stories that carry those ideas further have helped me have impact.

And so you're describing my impact as if it was on my own doing. But for the most part I'm a conduit to a series of stories, ideas, language, and work, that folks that I've had the pleasure and I'm fortunate for having around are contributing to.

And then in terms of, you say you've done very well, you're a professor of medicine. Well that means I've done very well, but I think what we need to start looking at is, is what we're trying to create, is the work that we're doing, doing well in that we see increase in the prevalence of careful and kind care? And I don't know, I just don't. I think we're early days, and this is probably multigenerational work, that I feel that you and I are involved in. And I don't think that we can claim successes in the short term, even though that may be helpful for our corporate overlords.

Adrienne Boissy:  Well I think your concept of being a conduit for the work is something I feel very strongly about. Sometimes we do get wrapped up in the... You know, this summit or that summit, or leader, or title. And in truth, all of us have some power and influence, right? To create the kind of environment that you're talking about.

Victor Montori:  And some have... I mean you for instance, have an incredible opportunity because you're standing at the top of a team that's focused on patient experience, and you're standing... You're doing that in one of the iconic organizations that focus on healthcare in the world. And so you're in a position of enormous influence and power, and you're using it, for instance, with the summit and other things, to bring up ideas, not about how do we score higher on surveys, so that we can get paid more. Or how do we involve patients so that they can feel involved, but we keep doing our thing. You're fundamentally trying to direct an organization towards the patients.

And so again, and you're not doing it by yourself. I understand that there's a fundamentally a talented team that you've been able to rally behind you. But you're leading that in a very visible way. And I think people can recognize that. And I think that means that our responsibility is much higher because the language that we use, the ideas that we put forward, and the actions that we motivate are, I think what we may eventually be held accountable to, and that will be eventually our contribution, which I think the jury's still out as to whether we're making a difference or not.

Adrienne Boissy:  Yeah. Well some-

Victor Montori: You can say that I'm a glass half empty sort of guy, so you know-

Adrienne Boissy:  Well I'm a realist as well, and I have to say even in opening comments even today, we were talking about, let's be honest about over the last decade, how far we've come. But where we haven't really moved the needle, or the work that's left to do. And I actually think there's still quite a bit of work to do, and I still worry that there's not agreement, right? On what are the core things we shouldn't even be having discussions about. These are non-negotiables, including the patient as a member of their team, rounding together as a team to make sure everybody knows the plan. You know, some of these fundamentals at times still feel hard to execute when it shouldn't be hard. These are evidence-based, right? Best practices in the field much less-

Victor Montori: Yeah. I think one of the origins of this... Because it's a combination of arrogance and naivete, right? To assume that you know what patients need, and you just have to give it to them. And I think it's a residual cultural effect of infectious diseases. You know, there's nothing more certain than infectious diseases. And of course I'm sure if we had an infectious disease persons here, would say, "No, that's not the case."

But infectious diseases, what's the job? You identify the bug, then you look what bug juice is the right one for it, and you give it to them. Patient preference is, who cares? Right? I mean we're gonna treat the bug, and the patient is going to be very grateful on the other side because we're going to fix him. And we are moving so far from that reality, when we're dealing with patients that now accumulate multiple chronic conditions, we cannot fix any of those. There is no bug juice, there is no bug. Or their bug is a is in the way society is built, is what my... Some people call the social determinants of health, and there is no bug juice for that except political action.

So if you come to clinical care as a professional, thinking everything is like infectious diseases, I think you're missing most of the current picture. The current picture is of patients we certainly cannot fix, where the job is really to sometimes join them in their trajectory of illness, help them improve their situation, to the extent that we can, and recognize that the role that we play in doing that is incredibly small. And then spend a lot of our professional capital trying to change the conditions of life in which those individuals not only acquire the diseases that they have, but go back to try to get better.

So that's the other part, is as professionals, health professionals in general, physicians in particular have been very apolitical, when in fact once you recognize that these are social determinants of health, the lever to modify them is not to have your hospital move out to the community and take care of the homeless, it's to prevent poverty and homelessness. And that's something we accomplish in a political process, which we are fundamentally out of.

Adrienne Boissy:  You're reminding me of a conversation we had, again at the executive team, with Tom recently. And today we focused on his use of words, right? You referenced earlier that language matters, the language we use matters.

Victor Montori: Very much.

Adrienne Boissy:  And it was very interesting, we were reviewing a enterprise safety event, and the team that was involved had come in to talk about it, and to talk about the root cause analysis. And one of them kept using the word proceduralist. "I'm just a proceduralist, I just do procedures." And Tom nearly came out of his seat and said, "What's a proceduralist? What do they do? Because I thought we were doctors or healers, or clinicians, or people who care. Where did this language come from?"

Victor Montori: Well it sounds like this person was particularly candid because many people sometimes perceive their own job as being just technically proficient, and being technicians. And as technicians, I think the main difference with professional, is that you don't have to worry about the downstream consequences of your actions. But as professionals we do.

And I think this notion for instance, of social determinants of health, forces us also to think about the upstream conditions in which we actually do our work. So a professional have to be... Have to have this situational awareness that goes beyond their noses, and begin to think about the worlds in which their patients actually live and thrive, in which the organizations actually try to make an impact. So yeah, maybe that person was just being very sincere, and they're a proceduralist. And maybe the boss was looking for somebody that was a professional.

Adrienne Boissy:  And that that might be exactly it. You've done a lot of work in the shared decision-making space. That's been a popular buzz word. I appreciated some of your realness about, again, where we are with that, and where are we aren't. Talk to me a little bit about where your head space is with your decision-making.

Victor Montori: Yeah, so shared decision-making is... In simple terms, a notion that informing care plans, patients and clinicians... Clinicians is by the way, my term for describing anybody that has the privilege of being at the bedside, the real virtual bedside of the patient. Anybody that's participating in caring for the patient, from the physician, the nurse, the nurse practitioner, the pharmacist, the therapist, the janitor, anybody that's contributing to the care of this patient, and gets the privilege of being at the bedside, hearing stories from patients, holding hands with patients, and looking them in the eye when they're suffering. Any of them is a clinician and they set enormous privilege. I'm a clinician, I'm very privileged to be one. So when I use clinicians, I don't mean any particular group, but the whole, the whole gamut.

Adrienne Boissy:  Understood.

Victor Montori:   So in shared decision-making, a clinician, a patient come together to form a care plan. So for instance, examples of shared decision-making that happen all the time are, discharge planning rounds. You know, where maybe some of the family members are participating, maybe there's a nurse, perhaps somebody has gone to the home to make an assessment. The patient let participate, the clinical team, and they're deciding on the timing, and preparation necessary for discharging the patient, and dismissing the patient home. And that to me is a shared decision-making experience. We usually don't call it that way. We don't recognize it and it's... But I think it happens in our hospitals with some frequency.

I am a diabetes doc and so it's crazy for me to make decisions with patients other than with them, because of course the minute they leave my office, I have no influence at all on how they're going to live their life, what they're going to eat, how active they're going to be, and how they're gonna manage the stress of life, which is sort of the main contributors to people getting completely out of control. And of course taking their medicines and so forth. So I can only work with the patients in forming plans with them. If I just unilaterally create a plan, and give it to them, in all likelihood my next note will have this disparaging word, nonadherence, or noncompliance written all over it, and it wouldn't be the patient's fault, it would just be a misdiagnosis I've made of their situation and their capacity to do that work.

So in shared decision-making, we try to do a number of things. If it is a simple choice situation, sometimes it's... Our job is to offer information about the pros and cons, and the alternatives. And patients might use their sense of what they want, or a sense of preferences to decide which is the right thing for them.

I gave an example where it's a problem-solving situation, a patient needs to go home, we need to sort out what are the conditions by which we can do that safely and effectively. Let's problem solve around that. There's no choice really between options. We're sort of trying to figure out how do we make this better.

And then there is a situation at the bedside of a patient at the end of their life, in which there's no real choice. You know, the patient's dying, and they're about to write the last page on the last chapter of their book, and how might we make sure that they come out, finish that book in the same way they've been writing the rest of the chapters, and how do we help their family do that? How do we help patient do that?

It's not a strict problem-solving thing and certainly not a choice thing. It's a meaning making sort of activity. It's completely different and much more transcendental. These are all forms of shared decision-making. Some people think of shared decision-making as something extra for which we need to have extra time. Maybe having incentives in place.

Our group has always put forward that shared decision-making is a component, or a way in which you care. It's intrinsic to it. It is not extra. You don't need extra time for it. Usually when you don't have time for shared decision-making, you probably don't have time for care. And the issue of tools and other support structures to help that is secondary. The main thing is the acknowledgement that we do not know what the right thing to do, or the best thing to do, or how to proceed now as professionals and we need to involve the patient to actually form a plan of care.

Then that achieve three things. It makes intellectual sense, so it's evidence-based. It makes emotional sense, so it feels like the right thing to do for all involved. And it makes practical sense, it fits in the life of the patient. It's feasible for them to implement and execute, which is the other part that we've been working on, which is the idea of minimally disruptive care, which is care that fits, that is a not going to make unreasonable demands on patient's energy, attention and time. Because if we do, particularly in chronic disease, and our demands are for time that they would rather spend with other things that life requires, like work and supporting their family, or spending time with the grandkids or whatnot. We know which one is not going to happen. That's probably going to be the healthcare bit.

Adrienne Boissy:  That's right. That's right. So I have a question for you. I was recently on a convened panel to talk about shared decision-making, and there was a move to certify all the decision aids we should be using, and then to survey patients as to whether or not a certified tool was used. And you know there's at least four to five questions of shared decision-making on patient satisfaction surveys. And I mean to me that just sort of like twisted something in my core about this is fundamental to the care that we're providing. Are we really gonna ruin it and mess it up, and codify it, and just make it one more thing people have to do?

Victor Montori: Industrial.

Adrienne Boissy:  It felt really yucky to me.

Victor Montori: It felt industrial.

Adrienne Boissy:  Oh, that's industrial to you.

Victor Montori: Because what it does, it takes something that is intrinsic to your caring approach, and then engineers it, right? It certifies it for quality and unbias. It puts a measurement on it and so forth. And so what happens, because we're very good at this, particularly high reliable organizations like the Mayo clinic where I work, or the Cleveland Clinic, is we will take those devices and we will implement it in a way that is just perfect, right? And so we're going to make sure that patients use these tools, and we're going to make sure that we measure this, and we're going to make sure those measures are through the roof, but are people getting care?

For instance, some of the tools that you're describing are tools that are just given to the patient. So the patient knows the pros and cons, and understands the same information about the options that are available, and so they can better prepare for the consultation. Well, the evidence shows that when you do that, the clinician then assumes that the patient understands the pros and cons on, and understands what the options are. And so streamlines the conversation in the office, where you say, "Did you read the pamphlet?" "Yes." "So what do you want to do?" "Oh, I want the PSA test." "Okay, I'll order that."

And so instead of the patient coming in prepared for a conversation, the conversation is foregone because it's been outsourced to the patient and the pamphlet. That is not shared decision-making, but it will tick all the boxes. And organizations like ours can easily deploy these tools through the portal, get it to the patient, and we can tick a box that we've done our job in promoting patient-centered care. But then when you go into the black box, or the clinical encounter, and look carefully what's going on, you see no evidence of patients and clinician forming a plan of care together that makes intellectual, emotional, and practical sense. There is no shared decision-making.

It's actually a really... And this will be a little bit self-promoting, but I will go for it anyway. When you look at the Cochrane Review of all the randomized trials of shared decision-making, the latest update, 151 randomized trials, there's only five of them that actually looked to see if the interventions actually caused shared decision-making.

Adrienne Boissy:  Five?

Victor Montori: And they're all from our group.

Adrienne Boissy:  Five?

Victor Montori: Right. Because we video record every visit to try to look at that.

Adrienne Boissy:  That's right.

Victor Montori: Most other groups don't have access or just haven't gone there to look at what's happening inside the box. But this is a symptom of something bigger. Policy makers change the incentives, change the rules, and then they look at the other end to see what comes out, and they look at outcomes, and the triple aim and whatnot. But what we need to do, is we need to go and look at that, what happens in the black box. We cannot just keep changing the conditions and look at the outcomes, and assume that when the conditions give us better outcomes it's because what's going on in the box is actually superior.

Without going inside the clinical encounter, you will not know what is the effect of those policies. So when things get commodified, or when they get engineered, when they become accessible to the industrial healthcare for them to implement check boxes, and get credit. I think... And when you feel that thing in your stomach, you felt, that kind of ripping of the nylon of your integrity, that something is no longer speaking the same language you are, because you're a clinician, you recognize that. I think the notion is, okay, let's go inside the clinical encounter. Let's take a look at what is actually going on, what is happening there, and I think what we will discover is the effects of industrial healthcare.

You know, this is where our group found that we are interrupting patients within 11 seconds. You know, these sorts of things, where you go, "Well why are you doing that?" Or a clinic, if half of our clinicians are burned out. You know, why are we doing that? Or 75% of our patients are overwhelmed. So how are you getting to that? Well, if you look at that black box, and you see that interaction, there will be no mystery to you. You will see exactly how we are actually creating those problems.

Adrienne Boissy:  You know, I unlike the person that went into infectious disease, went into something that I can't cure, right? I'm a neurologist taking care of multiple sclerosis patients-

Victor Montori: I wanted to be a neurologist.

Adrienne Boissy:  That's the first time I've ever met somebody who wanted to be a neurologist.

Victor Montori: Yeah, because of the time. Right? I mean, the decade of the brain was in the '90s. I got into medical school in 1986, so all these times... You know, the decade of the brain was coming, and the... I read the life of Ramon y Cajal. I looked at all his slides, with all that silver-staining, and look at the beautiful brain. The notion of the brain, thinking about the brain was completely fascinating to me.

Adrienne Boissy:  I knew you were a good person.

Victor Montori: Yeah. And then I went into endocrinology, and then the world became clear to me.

Adrienne Boissy:  Well thanks for that. But my point is more around the idea that I went into something, I can't... You know, I can't fix MS, and I really... Part of what was important to me about being a physician was having the opportunity to heal when I could, heal the spaces that I might be able to touch, and to walk with people even on their journey. Like I can't... Sometimes I have nothing else to offer other than I'm not going to leave you. I'm going to stay right with you through, through to the end. And so it's interesting as we talk about choices, right? And how you define a professional.

Victor Montori: Where else? In what other walk of life do you get to be with people at their most desperate? In the room, perhaps holding hands, expressing a form of love that is, it's an unusual form of love because there is no other interest, and the interest of the loved one at that very moment, where you're gaining a deep understanding of not only the challenges and difficulties caused by illness, but also the incredible strength of the human spirit to even overcome that. And you are there.

I mean, that's why I use the word privilege to describe that. And it's an incredible luck that we have to be in those desperate moments with people, not because we're going to enjoy them. I mean, we're not going to enjoy their suffering. And it's not because we're going to suffer with them, and get burned out in the process, but it's the fact that that is such a special calling.

And then to have business and engineering processes that are there to make us safe. They are there to make us good stewards of precious resources and nothing else, be at the forefront of that, and invade it, and then take it over, and then make it into a black box. My God, you know this.

So this is why... When we're talking about a patient revolution, we're really not talking about, "Oh, maybe we should just put a new coat of paint on the building." No, no. We're talking about changing the fundamentals so that we really move away from industrial healthcare because it really affects those precious moments, and to give room for your neurologist and you, to actually just be with the patient for the time that is necessary, so you can help them cope, and heal if possible.

Adrienne Boissy:  Yeah. And you're walking on the edge of something that always resonates with clinicians, who I think believe in healing, is this idea that those moments that bearing witness with another, cannot just restore and potentially heal and touch the patient, but it leaves a mark on us. And sometimes when people are saying, "Does empathy matter for the clinicians?" You know, I think about those moments, that these can be just as restorative of our humanity, of our compassion, of our capacity to care.

Victor Montori: Well, I think compassion is incredibly strong. I think religion has understood that for a long time, and they've made it core to almost every religion, is a notion of solidarity and compassion. And then people kind of stick to those things for an incredibly long time, even going to war for those sorts of things. So it's obviously critical to our society, to our community that we have compassion, and we... And as professionals we have to exercise that as a matter of our job.

But you know, this is our chow, this is our food, this is our nourishment. Because every time you talk to your colleague, and you ask him, "Where are you going on vacation?" They'll say, "Oh, I'm going to Central America." "What are you doing in Central America?" "Oh, I'm taking care of people." "But that's your job. What kind of vacation is this where you do the same thing as your job?" "No, but there, I get to take care of people." And they usually make that distinction, and you have to ask yourself so what kind of environments have we created, in which people who would choose that for their vacation, cannot find it as a matter of their job?

And so I think there's a lot of opportunity to completely redesign and redefine what comes across today as healthcare. It's really not about care. I think to some extent with corrupted our mission. We've made it about our institutions. We've made it about our business processes. We've made it about our metrics. We have to turn it around, and make it about careful and kind care.

Adrienne Boissy:  One last question for you.

Victor Montori: I can't believe it.

Adrienne Boissy:  You ready?

Victor Montori: I'm not.

Adrienne Boissy:  You can't believe it because you want to keep talking? Or you're hoping we're done?

Victor Montori: I'm sure there's more. I'm sure there's going to be more, yeah. You know? And no, I'm not ready, but go ahead.

Adrienne Boissy:  Where does this fire in your belly come from? I mean-

Victor Montori:  I just had a chorizo arepas, I think for lunch. Is that what you're asking? Is this heartburn?

Adrienne Boissy:  It's not a literal thing.

Victor Montori: Oh, I'm sorry. I'm a very concrete sort of person.

Adrienne Boissy:  Where does this passion and drive, and-

Victor Montori: I don't know.

Adrienne Boissy:  Oh, come on.

Victor Montori: I don't know. The the worst experience of my life, when it comes to presenting this sort of work, happened in Rochester, Minnesota, where I live. When they were coaching me to present at a TEDx Talk, worst experience of my life. I give 70 talks a year. And that was... They put these two coaches, and they worked with me to try to get out of me at TED Talk, okay? And I thought it would be easy. It turns out it was not. And the thing that they struggled the most is I didn't have a superhero origin story. You know, so I was not raised by wolves. I was raised mostly by my mom and my sisters. So maybe I was raised by wolves.

Anyway, I was not bit by a spider. I have no bats, and there are no superpowers to account for. So there is an origin story. I was trained in Peru, at the time of hyperinflation and terrorism, suffering was the common denominator. I saw people grieve for the murder of a policemen, and a coroner early in the 1980s, and then get completely used to that and have... And I can see the story go to the back of the newspapers and so forth, within just a year or two. I saw the whole society in Peru disintegrate. So does that contribute? I was there during the only epidemic of cholera in my country, and see how unprepared we were. And then the idea that some people just... I mean, I was well off, I had access to care, and I had asthma when I was a kid, so I got a lot of care.

But these... Some people just would not get any. Does that create a sensibility for social justice? Probably. But there's a lot of people that have been there with me, and they have a different set of values, and a different set of fights, and different things that drive them. So I don't... I mean I'm sure I can make a compelling story for your listeners, but I don't have one. I just...

Adrienne Boissy:  Yeah, I would prefer you not make it up.

Victor Montori: Yeah, no. I sincerely think that, that's... This has been the next step in what I started as a clinician, became a researcher, start publishing. The work I did was on evidence-based medicine. The second principle of it said, you need to involve patients. Okay, we're not doing that. Let's do that. So that's shared decision-making. Let's come up with something that works in people's lives. Well that's minimally disruptive medicine.

And then you start doing this, and you write the papers, and you publish the results, and you present it in a compelling way, and then nothing happens on the field. And you start asking questions, why is nothing happening? And you realize that you have systems in place that codify what should happen. And what should happen is to make it look like care's happening, but not real care. Well maybe that gives you a little of that fire in the belly, because maybe some of the work that you've done is being wasted. And more importantly, patients are coming in and out and they're getting healthcare, but they're not getting care.

You know, I have three boys. You know they're going to be sick at some point. Do I want them to get the same healthcare that I am capable or able to give people right now? I want it to be better. I think you do the same. I think a lot of people want you there to be better. But the question is do we want it to be better and from an industrial and business perspective? Should more people make more money? Healthcare, is that what we want to do? Should more companies? Or do we want healthcare to move towards the direction of being more humane, and more in touch with what makes us people. I like that a lot more.

Adrienne Boissy:  I do too.

Victor Montori: Maybe we should be working together.

Adrienne Boissy:  Well, I'm happy to join your revolution. Just consider us signed up.

Victor Montori: All right. So, PatientRevolution.org. Click on, donate.

Adrienne Boissy:  Let's talk about that after.

Victor Montori: Yes. Well it would be lovely to do so.

Adrienne Boissy:  All right. Thank you so much, Victor, for your time.

Victor Montori: Delighted, Adrienne. Thank you for having me.

Adrienne Boissy:  This concludes Studies in Empathy podcast. You can find additional podcast episodes on our website, My.ClevelandClinic.org/podcasts. Subscribe to Studies in Empathy podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcasts. Thank you for listening. Please join us again soon.