The Future of Medicine May Be Prescribing Less

Lisa Belisle: Hello, I'm Dr. Lisa Belisle and you are listening to or watching Radio Maine, our video podcast where we explore and celebrate creativity and the human spirit with the Maine connected people who really make our state great. We are sponsored by the Portland Art Gallery here in Portland, Maine. And today it's my pleasure to have the chief growth officer for Prescriby Health. She's also a cardiologist and a critical care physician. This is Dr. Jennifer Jen Monti. Thanks for coming in today.

Jen Monti: You bet. Thanks for having me.

Lisa Belisle: So you and I were talking before we started and it's a very weird thing to admit, but this idea of deprescribing medications and I really think it's appropriately prescribing medications for the right people at the right time in their medical journey and prescribing is trying to get people to that place by probably peeling away some layers that got added into patients. I don't know, their medical lexicons over probably years. So welcome. Thanks for coming in to talk with me today.

Jen Monti: You bet.

Lisa Belisle: So tell me about Prescriby. What is Prescriby? What does it do and why are you interested in being part of this?

Jen Monti: Yeah. Prescriby is a focus tapering program for medications that have been incorporated into somebody's care that maybe aren't helping anymore. And we focus on opiates, benzodiazepines, sleep medications, primarily knowing that there may have been an appropriate, very good reason for these medications to be on board and then there's probably an appropriate time to offboard or transition off of those medications. And this is people who are willing and ready to try to live a life that's free or separate from some of those medications that have been on board for in many cases, years. What I learned in medical training coming up in internal medicine and then cardiology is about this concept we call clinical inertia. In other words, somebody starts something and then nobody ever stops it. And in about my time taking care of patients, been a doc about 15 years now. If you'll ask, why are we still taking this? Sometimes the answer is no one ever mentions stopping it. And we know there's real benefit to being able to get people either off or at a reduced dose of medications that are on what we call the Beers criteria list, right? Medications that can lead to excessive sedation that contributes to falls, fractures, overall just additional chronic disease morbidity and mortality. We know if what can be thoughtful about getting away from those, it's good for people.

Lisa Belisle: One of the things that I love about Radio Maine is we talk about exploring and celebrating creativity. And what you're talking about is really looking at a situation creatively. I mean, Prescriby was founded by somebody who said, "Okay, there's an issue." And it happened to be here in Iceland. Now it's come to Maine, but there's an issue. How do we look at this in a way that's sort of generative? That's how do we try to help as opposed to say, "Well, this is bad. You shouldn't have gone this direction." It's just, "This is where we are and how do we move from where we are to where we need to be in order to benefit patients?" So I really like that.

Jen Monti: Yeah. It's been a really important cultural reframe on what we do. It's very clear how doctors or providers more broadly defined want to help with specific situations and then we don't see it sometimes all the way through. And then we end up, and you've lived it also, right? 10, 15, 17 medications. What are we doing here? I think we are at an inflection point where there's going to be a closer look, a thoughtful, closer, appropriate, evidence-based look at how we begin to apply evidence and reduce the medication burden in the right cases at the right time. This is basically precision medicine by another name, right? That's how we think about it.

Lisa Belisle: It is important to kind of consider culturally where we've come from. I mean, in medicine we really have seen an advance in what we have available pharmacologically and technology wise. And I think at least for the last couple, two decades or maybe three decades since I've been practicing, you see a layering on of things like, "Oh, well, you have this thing. Let me give you this pill. You have this thing. Let me try this procedure. You have this thing. Let me do this testing." And it doesn't necessarily mean that any of those things are bad, but the layering can be not what's ideal for patients. So this idea of precision medicine, do what is right for the patient that's in front of you at that moment and now maybe we know better and we know more and we're able to be more skillful in the way that we apply what we have.

Jen Monti: I think the word precision medicine is kind of run away towards tailored medications, right? Tailored to your genetics or tailored to your immune phenotype. And those things are all right and good, except most precision medicine is access to care at the right time with the right interventions and no more. That's how I think about it.

Lisa Belisle: So what is the Iceland connection and how did you get involved?

Jen Monti: It's a remarkable story and team. There's an orthopedic surgeon there training to be an orthopedic surgeon who realized he was taking care of patients on the floor and handing out a remarkable amount of medication that he then couldn't track or understand what was happening. Iceland at the time had an opiate prescription rate about 50% higher than the other Nordic countries, which were already high to begin with. So he could see a disconnect and a problem there. So what he started to do was investigate the evidence base here and you start to look and you say, "Oh, there are actually guidelines for how you prescribe and taper these things." So he built an app basically through a hackathon and said, "Okay, let's see if anybody starts to use this. Either my peer physicians or people who are just interested." It's like a country of 400,000 people. So it's a lovely Petri dish in the North Atlantic for being able to kind of track and know what you're doing. There's also a unified medical record, right? They have one payer so you could do a lot of research. They had 10,000 downloads in a country of 400,000 very quickly. So he was able to say, "Oh, we've got something here." And over time, was able to start a brick and mortar clinic and start to see patients and divided into kind of two buckets. One is an acute patient, somebody who usually be orthopedic or trauma. They've come on to opiates in a kind of planned setting or an acute trauma setting and they've worked to rapidly be able to get people away from those medications. And then there's another group of patients, sort of chronic patients, been on long acting opiates for a long time. The tapering process there is a different process, but they've been able to take care of both types of patients in a brick and mortar clinic with extension to other areas of Iceland. So the Icelandic government began to understand this, it's begun to pay for the service. So if you have a hip or a knee or a spine done in Iceland, you're referred directly to the prescriby clinic, which is pretty remarkable. I got involved because we have a former state senator here in Maine. Her name is Lynn Bromley who was well acquainted with the Nordic ecosystem and new companies and connections to Maine. I knew her. She met Kerriton and said, "You two should meet sort of like mind and thinking about building." So that's how I started to learn about the work.

Lisa Belisle: As a cardiologist and a critical care clinician, what were you seeing when patients finally got to you? I mean, I obviously see things from the perspective of a family doctor, but you're seeing things when they get escalated.

Jen Monti: Yeah. So how I began to live this as an attending doc, I've been a cardiologist in Maine about 10 years is this problem called endocarditis, right? So we would have some chronic medication use and then in cases where you really are starting to fall into the addiction pathway or injectable drugs, we would see really difficult infections and problems and unremitting cases really from everywhere. And I started to think a whole lot about that and then started to think about what I would see in my clinic. And I knew that as a specialist, that was not my thing. I didn't have to get into that. I was going to talk about AFib, I was going to talk about coronary disease, but not this problem that was underlying a lot of the chronic illness. I'd felt that since I'd been training in residency and I mentioned I did residency in Baltimore City, which is a complex community, a lot of drug related morbidities and I knew it then that the prescribing practices were not attended to. In other words, we weren't being thoughtful about both sides of it. So from that time in training to then through seeing some really difficult end stage cases saying, "What are we doing at the top of the funnel here?" There are some cardiology medications you need a special license to dispense, yet anybody can write a prescription for benzos, sleep medications, opiates, and it kind of just goes out into the ether. So that's like a process problem, right?That requires a different response than what I was seeing in the clinic, which was mostly clinical inertia around addressing the problem.

Lisa Belisle: So one of the things that always concerned me, I mean, you're talking about things related to the heart that these medications can cause. It always concerned me that we're also impacting people's longer term neurologic health. And of course, the heart and the brain are related. The blood vessels flow throughout the body, All of these things are connected, but when I would see patients who are on benzodiazepines, let's just say, and some people know those medications like Ativan is one and there are other longer acting medications than Ativan, but dementia, I mean, we saw a lot of people that in their later years and we're seeing a lot of dementia. So it always kind of shocked me when I would have a patient who'd come in and they'd have all these medications on their list from another doctor and I'd say, "Did you know that you're increasing your risk of memory issues later in your life?" And they oftentimes were surprised that that was true. Did you hear the same sorts of things?

Jen Monti: Yeah, the literature is very deep on all the risks as you add medications and those lists get longer and longer. And then I think we are just starting to appreciate, just starting to understand what the longer term risks are with some of this. I don't think we do enough to talk about that. I think there's a lot of upside medications. I think there's some very smart applications of medications, but we have got to be more accountable on the other side of that to understand that it is in pharma's interest to have these things prescribed forever indefinitely and that's what you're doing and we still hold the power of the pen so we have to be more accountable to that. I personally, doing this work has made me feel more accountable in my clinical practice and I want that for every patient. I want every patient to have access to the evidence bas that can help here. And I don't think we've done that as a culture.

Lisa Belisle: What I'm intrigued by is this idea of the smart use of, I guess it's sort of related to artificial intelligence in some ways. I mean, if you're talking about app development, I don't know if prescribing was originally based on any sort of AI or large language models, but there's been information that's been out. I mean, we used to call it Dr. Google back in the day and now people have access to even more information and they're using chatbots. They're using all kinds of different AI models to get their information. What I like is the possibility that we could do something that's more like an open evidence, which is more of a clinician app for patients and we could do something that would enable patients to actually buy into their own care.

Jen Monti: I think what you're referring to is where we need to head, which is sort of technology supported care. There's two ways it happens now, right? Tech companies will like hire a few physicians and be like, "Oh yeah, we have medical people informing us." And they kind of do. And then you'll have clinicians that are sort of trying to, and health systems trying to bolt technology onto the problems and our initial approach and why we have a clinic and we're not saying, "Oh, we're telehealth only is we think this is still intimately human work." When I met Caretoon, I said to myself, "Who would want to spend all their time on this incredibly difficult human emotional problem?" And that's what makes it thorny and hard to solve. So the approach that we have is human first supported by technology so that we are giving good information, right? I mean, we have an app patients engage with, but it's not the core piece of care. You imagine it's sort of what connecting you between bits of in- person care and we think that's going to be the way to win. There are great examples of companies that are kind of like app only and they raise a billion dollars and they're broken gone, right? They're broken gone in two years. And then there's examples where well-meaning clinical groups want to have a technology component and sometimes it works, sometimes it doesn't. I think we're still early in the days here. This is like early days for digital health. Our approach here was like, can we bring the best evidence we can to caring for these patients, which means we're going to have the best data set for deprescribing. I think we probably already have the best set in the world, which is hard to believe. I mean, Deloitte and other companies like that, they'll sell you data on this topic. It won't be yours, right? It won't be densely regional. It will be 18 months old and it will be an aggregate. We think we can build to take care of populations in a way that's hyper specific so we can really surgically take care of people and population.

Lisa Belisle: It is intriguing to hear you put actual names and labels on the problem that I've been pondering for a while. I mean, I was on the leadership team of a virtual health company and I really enjoyed it. We were doing a lot of virtual care in primary care and in acute care, but you're absolutely right. There was an interface issue. There was, please take this very specific work and also interface it with the current work being done by health systems and the mesh isn't really there yet and then go one step further and do work with AI and there's no great interface there either. So how do we get clinicians who are working in the space that you're describing, clinicians that are working in standard health systems, that are working in the community where we think that we're all talking the same language, but we're really not. People are speaking their own specific language around their own healthcare experience. How do we get people talking and understanding what the issue is and how to solve it together?

Jen Monti: Yeah. I think what's really interesting is that consumers will drive it, right where eventually health systems and in many places, there's one health system, right? It's a classic innovator's dilemma, right? A health system might have a whole bunch of a particular market, they might not see the reason to do it. And as a cardiologist, this reminded me of the Apple Watch, right? People used to bring in their Apple watch and be like, "Doc, I have sinus tachycardia." And I'm like, "Don't bring that to me. You are fine." But over time, then they've innovated around AFib indication and now most clinics have a way to accept that data in and look at it. I can't bill for an Apple watch today, but the data is incredibly useful. We found ways to incorporate it. Now there's going to be hypertension notification coming off of wearables. It's not perfect, but it's a very good public population level screening tool where I've seen consumer companies therefore patients bring it into the office where then we have to, as clinicians, adapt to that. So I have my cardiology experiences of it. I also have my companies, I love because they've done a good job in helping me be a better doc. A company called iRhythm, which is like the Ziopatch company, right? If I want to monitor a heart rhythm, that's who I want because I like the interface and I like how they help me take care of patients. Those are the ones that are going to eventually get well integrated, but right now it's the Wild West, right? I mean, there's almost unlimited platform options and who's going to own it and what is the distribution is super interesting. Oftentimes I see companies that maybe it's AI related or they're taking on a particular function and in the back of your head you're just like, the winner is whoever owns distribution, which is epic, right? Not only epic, but you have to think about it that way. In the constellation of all these innovators, how are they going to land in that existing kind of workflow and technology investment that people have already made?

Lisa Belisle: I do love the idea that we ... I mean, we've always been consumer driven, whether we've realized it or not within medicine. I mean, ultimately it's the patient who comes to us because they have something that they want to have solved for them in their lives or they want something optimized, let's just say. Let's not assume it's a problem. But I mean, this paternalistic way that we've ... And I guess since I'm a woman and I've been in medicine a long time, maybe it's also maternalistic, this parental way of approaching medicine where it's not patient driven. I have the information, I have the power of the pen, you're the patient, you do what I tell you to do. And I think this kind of flipping of the script that you're describing, we need to really recognize this and we need to stop. I think there are still some clinicians who resent patients who come in who have a certain amount of knowledge about their own situation, their own numbers, their own Apple Watch information. So how do we shift that mindset within the clinician community that still is kind of irritated

Jen Monti: By patients? It can be overwhelming, right?

Lisa Belisle: Yes. And there are good reasons, right? If you're seeing a patient every 15 minutes and they want to come in with their Oura Ring readings and they're like, "Let me show you by 12 months worth of data." And you're like, "I would love to be able to sit here with you and I Just do not have the time." So there's good reasons for sort of that conflict on both sides. How do we impact that?

Jen Monti: Yeah. I think we also have to be humble that the reason people are doing that is because we are not actually meeting the need. As you mentioned, they come with some specific need and it's across a different range, right? People have real ranges of problems, but the reason AI and health chatbots are getting ... They're meeting a need, right? It's not that people ... There's no access, right? So people are looking for some help with these different areas. I want to challenge myself as a clinician to say, what are the most difficult, thorny problems of health that my expertise can really unlock in a way that consumer tools probably are not going to do in the short term? I mean, they're coming for all of it and I welcome the disruption, but what as a really skilled clinician where the judgment is an enormous part of what's happening here, what problems do we need to unlock on to really help in a unique way? And I actually think this is one because use of medications that are potentially addictive is a loaded topic. It's an emotional topic. It takes a certain approach that I don't think consumer health AI companies are coming for right now. If that makes sense It's an expertise there and it's sort of a third rail of American medicine in some ways, right? We're coming out of this disastrous epidemic out. I mean, we're in it, we're still living it problem and we're saying, okay, we need to build the prevention layer, right? That's what I think prescriby health is. It's the prevention layer for addiction. If you look at the governor's plan for how we're going to address the problem and I've looked at it closely and there's all sorts of, it's very sharp and it says the right things and it's doing a lot of right things down at the bottom of the funnel, right addiction treatment, taking care of children who are impacted in homes that have been impacted by addiction. And then there are bullet points about prevention, but I've not seen at scale a solution to prevention that I think can help at scale and that's what we're trying to go for. I don't want access to prevention type care to be zip code dependent.

Lisa Belisle: I mean, I'm encouraged and I think what you're doing and prescribing is really great and also, I mean, so I have three board certifications. I know that you have multiple board certifications and one of them is actually in preventive medicine and public health. And I get frustrated when I hear about prevention. I mean, I love deprescribing. I love the idea that we should make sure patients are on the right medication for them and not just continue things through clinical inertia, but primary prevention is where we don't start in the first place. So for me, the sort of downstream effect just continues to be such a puzzle. How do we even put programs in place way before we get to the place where we have to deprescribe? So do you have thoughts on that?

Jen Monti: It's interesting. In this case for deep prescription, the initial index use may very well have been appropriate, which is interesting, right? I think that we should treat medications like the temporary things they were before there became a big play to keep people on medications chronically. So every time we prescribe, it comes with an intention to deprescribe That is a massive cultural shift and I am not naive about that in terms of what we are going to be asking, but this is how we should be applying these risky chemicals to humans on a daily basis and we're going to have to ... I don't think we're alone in trying to make that culture shift. I think even at the HHS level, we're starting to hear discussions about things like deprescribing. Do I agree with all of it? Of course not. There's a range of political opinions around this, but I do think there is alignment that we ought to look at this. And there have been CDC guidelines for over a decade for how to do responsible deprescribing. And we see this all the time, right? What is a guideline? What is a society issued guideline or a government level guideline? It is like a 47 page PDF. You might print out once, right? It sits on your desk and collects them desks. Prescriby health is just operationalizing guidelines in a way that's effective and useful for clinicians and patients. And when we stick on that evidence base, it's a very powerful way to get at the culture question. Is this the right thing to do? I don't know. There's been evidence for a decade and we know that when you reduce doses or move away from medications, people tend to do better. And if they don't, then they don't and that's a clinical judgment. And my team with our medical director and our team who's ready today to take care of people are there to make that judgment. I think the terrible thing that happens is people get put on medications like this. They'd like to try to get away from them and they try to do it themselves and then they're unsuccessful.That's why we have a tapering process to help people navigate this. It's a hard thing to do.

Lisa Belisle: So I want to make sure that we talk about how locally here in the Portland area and in Maine, people can utilize the services that prescriby. So I definitely want to make sure we get to that. But before we get there, it always intrigues me as to how different clinicians choose their path. And I know you grew up in a more rural part of Connecticut. Most people in Maine we think rural Connecticut. What is that? Because we've got really rural. But certainly you grew up in a town that is probably more like Maine, I would guess, than many parts of Connecticut. Why did you choose to go into medicine? Why cardiology? Why Maine?

Jen Monti: Yeah. That's good questions. Maybe I'll start at the beginning of all that and then end in Maine. I grew up in a town of about probably about 6,000 people when I lived there and five kids in my family, so big family, went to public school in this town called Ellington, Connecticut, worked on a blueberry farm, high bush, but very similar I think to the type of experience you might have in a small town in Maine. And my sister died suddenly when I was 16. She went into the hospital for ... No, she had an ear infection. She got an antibiotic she was allergic to. She went into the hospital, got an undetected pneumonia and died the week before Thanksgiving when I was a junior in high school. So whoa, right? So that is like the full crumb of my life and going through college and thinking about medical school. I said, "If you could prevent something like that one time, that would be worth doing." Because you see how that type of trauma becomes really sort of intergenerational. I'm sure my children are deeply affected by how that affected me. So for me, it called me, right? I think if that hadn't happened, I'd be designing bridges or a civil engineer of some type. So that's how I came to medicine. I remember clearly sitting in undergraduate science class and learning how aspirin worked and learning that it came from bark. And I was like, whoa. It was like a little bit of a eureka moment for me to look around and be like, how do more people not die? In other words, most people make it a good these days, almost 80 years. So I was also sort of like amazed by how it all works in an engineering way. And then as you go up the chain into training, I went to medical school in Cleveland, Ohio and you're sitting in this amazing medical institution in some of the sickest neighborhoods in America, which has to turn your mind towards a public health frame, right? So I did a master's in public health when I was at Case Western also. So that was my frame. And at the same time, you had all these little startup technology companies starting to anchor on Euclid Avenue between Cleveland Clinic and Case Western. I'd taken a few years off before I went to medical school. I worked in the Bay Area. I learned to do things like value early stage companies. So when I was coming up in medicine, I was like, oh, this is what you do. You check out the startups across the street, you go find some engineers to work on a particular problem. So that's just sort of what made sense to me. Case Western is ultimately an engineering school. So I feel very grateful to have done my medical training in a place with engineers and they're like Midwestern and humble and interesting and willing to work together. So I took that same model. We'd make these medical journeys, did my residency at Hopkins and then my fellowship at Penn and as I got more expertise, I just started to work on problems within that niche but always with like a cross-functional team. So I think anyone who thinks medicine is we're doing great. We're really kicking butt taking care of people is not looking around to be like, we are the sickest country with some of the most remarkable medical assets. So I love to hit a medical home run. I love to send someone to get their heart valve fixed, identify a genetic abnormality in a family and like use new injectable medicines for cholesterol. That's awesome. That's not solving the biggest problems of our time. And I think that prescriby, that way of thinking about building is going to get us closer.

Lisa Belisle: Well, I know I asked you a multi-part question and the final one was, how did you get to Maine?

Jen Monti: So I finished my fellowship at the University of Pennsylvania in Philadelphia and I started to look around and say, "Huh, where do I want to live that aligns with my values?" Part of the reason you do the medical hop around is you have a lot of flexibility in that. So I started to look at just regions and ecosystems I thought would be a place I want to raise a couple kids and someone said, "You should look at the Maine medical center in Portland." It's cool city, it's now 10 years ago, cool, getting cooler and also there's tons of need. So I realized I could do some things I really wanted to do right away, which was start a cardio genetics clinic. So I'd see a lot of families. Good genetics is ultimately family medicine with high tech tools. I came up, interviewed, walked around the West End, met Doug Sawyer was our chief at the time, this guy named Mark Godiaz was the service line chief. You started to meet people, look around, you're like, "Yeah, I'm good." I interviewed at a couple of other places, but I realized there were the public health problems and the access problems where I could do some good there and that turned out to be true. You don't really learn to be a doctor until you're an attending, right? Once you're ultimately the decider, you behave differently. So I think I came a doctor at Maine Health and then grateful to that group, probably, I don't know, 40 or 50 cardiologists, that's who teaches you your first few years as an attending.

Lisa Belisle: I want to double down on that because I also, I went to Maine Medical Center for my training and went away did a fellowship, came back and I still some of my earliest teachers and some of them were cardiologists. They were the people that really taught me to be the doctor that I am today in addition to my father who was also a doctor.

Jen Monti: Yeah. No, there's a couple of guys. There's one I want to mention specifically his name. Dr. John Walde passed away in the past couple of years, relatively young, but he was firm and if he said something to me, I might not like it, but he was right. And he really taught you to really accept the mantle of what it means to be responsible for people.

Lisa Belisle: Well, Jen, I'm really glad you came in today. I know you have a lot going on. You're very busy and I think the work that you're doing with Prescriby is fantastic. It's been great to learn about it. How can clinicians and patients, how can they actually access prescriby?

Jen Monti: Yep. Our website's prescribyhealth.com so you can start to learn a little bit there. There's nothing to prevent a patient calling today to come in and be taken care of. And we are working one by one to educate our local health systems to make sure that we have that referral pathway that's essential. So direct contact, talk to a primary care doctor and we'll get you into the office. Office is in South Portland. It's right behind Intermed.

Lisa Belisle: Okay. Very good. Thank you. I've been speaking today with Dr. Jennifer Jen Monti. She is the chief growth officer of prescriby health. She's also a practicing cardiologist, critical care clinician. I know that if you've been listening to or watching this podcast, you know how strongly I feel about the appropriate medications for the appropriate patient at the appropriate time. If you are somebody who has a family member or yourself and you're thinking, "Gosh, I think this list of medications is too long." I really do encourage you to speak to your own clinician, but then really look into prescriby health. And those of you who watch or listen to Radio Maine a lot, you know I don't usually do this sort of call to action on the medical level so I do feel strongly about this and it's an important topic for us all to consider. I'm Dr. Lisa Belisle. You've been listening to or watching Radio Maine, our video podcast where we explore and celebrate creativity and the human spirit sponsored by the Portland Art Gallery in Portland, Maine. We hope that you will join us at one of our first Thursday art openings. Find us at radiomaine.com. Jen, I hope we can convince you to come join us at one of our first Thursday art openings and introduce you to the rest of our creative community, but it'll be great and it's been great to meet you today. Thank you.

Jen Monti: Thank you.