I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.
Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing “Slow Medicine,” The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care. (http://ow.ly/3jnBU)
McCullough describes slow medicine as “care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.” Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine. (http://ow.ly/3jnBU)
UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, “If you come into this hospital, we’re not going to let you die.” (http://ow.ly/2Ys4n) This is a statement that puzzles me as an old time anatomic pathologist.
Slow medicine vs. UCLA on Sunday night football. Sports metaphors do not capture the complexity of modern American health care. Let me hasten to say at the start that there are times (serious acute illness correctly diagnosed where there is an evidence-based treatment that has a good chance of success) when I hope I am treated in UCLA’s ICU or operating room by UCLA specialists. However, there are also times as I get older that I hope I end up living in the Kendal-at-Hanover retirement community cared for by a wise and experienced geriatrician like Dennis McCullough and the community’s nurse practitioner; I want my providers to take things slowly and listen to what I want out of life.
This tension between slow and fast is not new, and it is not limited to American health care. The monastic culture of the Latin West in the fifth century was epitomized by the Benedictine monasteries which had “a distinctive approach to texts, one that might be called ‘slow writing and reading’ – and that contrasts as sharply with contemporary practices in reading and writing as Slow Food does with McDonald’s.” Benedictine monks by rule were allowed to read only one book a year; the idea was they should slowly and carefully understand and reflect on what they read. (http://ow.ly/3j9W2) As a modestly reflective physician who is on twitter every day, I think I am more comfortable with someplace in the middle of the monastery/twitter continuum of speed of thought and reflection.
I also think it is a mistake to place technology squarely on the UCLA medical team. I myself have sometimes fallen into this trap, but again I think it is complicated. In talking about pelvic prolapse with an experienced clinical professor of OB/GYN at a major Eastern academic medical center, I at first tried to contrast the low-tech pessary solution with the high-tech surgical solutions. My clinician colleague who prides herself on shared decision-making and her vast knowledge of different types of pessaries and different kinds of patients in her busy practice refused to be pigeonholed as either a slow or fast gynecologist. Some patients need and want pessaries; other patients need and want surgery.
I am also slowly starting to realize that high tech solutions can and will be part of the slow medicine tool kit. Dr. Joseph C. Kvedar’s concept of Emotional Automation involves humans easily developing trusting relationships with technology. It is hard to argue with Karen the virtual wellness coach/avatar who gets her human walkers to exercise more or the Boston hospital patients who prefer a robot discharge planner to a human one. I am still stunned that patients would rather talk to a robot than a human being, but their reasons make sense. The robot is not in a hurry; it does not talk down to the patient, and the patient can ask the robot the same question over and over again. The busy human discharge planner not so much. (http://e-patients.net/index.php?s=fox)
At first I did not believe that teens with chronic illness would allow Stanford researchers to track their moods by monitoring the songs on their iPods and the words in their text messages. By providing feedback on what saddens the teens, they were able to improve adherence to medications. Sussanah Fox taught me that the teens trust technology that is portable, and it is certainly better than being nagged by their mothers to take their pills. (http://e-patients.net/index.php?s=fox) In a USC study, people with social anxiety confessed more of their personal flaws, fears and fantasies to virtual figures programmed to be socially sensitive than to live therapists conducting video interviews. (http://www.nytimes.com/2010/11/23/science/23avatar.html)
I am now convinced that humans will increasingly embrace and trust technology to support slow medicine. People love and trust their iPhones. Smartphones and tablet computers have become personal and an extension of ourselves. “It is different now that we carry our second self with us. We think with the objects we love and we love the objects we think with.” So says MIT’s Sherry Turkle, the pioneering student of evocative subjects. (http://ow.ly/3jjCG) Mark Rolston, chief creative officer of Frog Design, observes that people grieve when they lose a personal electronic device. “You are leaving your brain behind,” he says. (http://ow.ly/3jjCG) So how many of you sleep with your cell phones or participate in online flame wars about iPhone vs. Android? How many of you love your iPod?
Fast UCLA medicine is the status quo, but slow medicine with its shared decision-making, community involvement, and new technologies is slowly gaining ground. We have to embrace slow medicine, when appropriate, because it is the only way we can decrease per-capita cost and increase quality. I agree with Orszag and Obama that we have to teach the patients and doctors in Newark, New Jersey how to practice Portland, Oregon and Salt Lake City medicine in the last two years of life. According to Jack Wennberg’s book Tracking Medicine, patients in Newark spend 35 days in the hospital during their last two years, and people in Portland and Salt Lake City spend 12 days. (http://ow.ly/3jnGq) I would like UCLA to emulate Mayo Clinic in their end of life care so that we can save $700 billion a year and improve the American economy for us all. (http://ow.ly/2YrRu)
I first started thinking about this stuff in a June 21, 2010 blog post about whether the internet is good or bad for us (http://ow.ly/3jme5). I can still remember the ambivalent feelings I had then about paro, but I ended that blog with the following:
“So where does that leave me with Paro, the cute little seal robot that seems to comfort some old people in nursing homes with dementia? I don’t like Paro because it is not alive and is not a genuine harp seal puppy. I would prefer that all old people with dementia have a caring human being to be there for them. If a human is not available for whatever reason, I would prefer that a live puppy be there to cuddle. (Full disclosure, I love bichons, two in particular). If people and puppies are not available, I see no reason not to use Paro.
Holding her seal robot, Lois Simmeth, 73, who lives in a Pittsburgh nursing home says, ‘I love animals. I know you’re not real but somehow, I don’t know, I love you.’ (http://ow.ly/21cj7) Love is good, plain and simple.”
Well stated Kent. My own experience shows that the slow medicine model can work well in a *busy* orthopedic practice. By embracing EBM, when applicable, and by understanding that many orthopedic issues (meniscus tears, rotator cuff tears,etc) are attritional and can be managed non-operatively... It validates that a slow approach can be successful by minimizing unnecessary studies and unnecessary surgery---- spending a few extra few minutes with patients so they understand the natural history of the issues they face and thus understand why surgery, MRIs etc are not always necessary goes a very long way to ensuring success of a *slow* technique in orthopedic practice.
ReplyDeleteKent, we are so sympatico on this! We really need to bring back the slow approach, of course in the modern context. Looking forward to collaborating with you on some of these ideas.
ReplyDeleteThis blog is a new discovery for me (via Maggie Mahar's HealthBeat). It provides a thoughtful approach to the role of technology in not only health and medicine, but also its role as emotional mediator in contemporary life.
ReplyDeleteDoesn't say much about the Boston hospital that people would rather deal with a robot than their staff.
ReplyDeleteThis is my first exposure to the term "Slow Medicine", but after reading the description I realize that I have been practicing it for 30 years as a family physician. Had I not seen the term "Slow Medicine", I would have called it "thoughtful medicine". And I find it closely related to and very compatible with Evidence Based Medicine.
ReplyDeleteThe origin of my style of "Slow" came from the influence of Duke Family Medicine pioneer, Terry Kane in the mid 1970s. He trained us to consider all potential effects (costs, potential adverse outcomes, effects of potential false positive results, and most importantly the possibility that a result may have no effect on course of treatment elected) before ordering a test. Similar lines of thinking were encouraged for initiating treatments.
Is Dr. McCullough really a pioneer of the style or is he coining a term to describe the style?
It does seem to me that the contrasting style, ?"Fast" medicine has been increasingly the standard through the 30 years of my practice. Add to that increasing fragmentation of care, decreasing communication among providers and reliance on protocols of care that are potentially inappropriate for some patients, especially the elderly.
It is very nice to see "Slow Medicine", or whatever name is applied advocated by physicians of stature and discussed as a respectable issue.
Evan Ballard, MD
Family Physician
Jonesville, NC
My parents moved to Kendal at Hanover when this Continuing Care Retirement Community (CCRC) first opened in 1991. My father died almost eight years ago, but my mother is still alive. Since she now has dementia, we are engaging in slow medicine--which is in accordance with her wishes made while of sound mind. Both my parents, as well as so many other residents I have known throughout the years, have always thought so highly of Dr. McCullough as well as of the wonderful nurse practitioner to whom you also referred—and who is still there, by the way. That all said, I can not say enough good things about Kendal at Hanover. Furthermore, after visiting there for twenty years now, let me say that I have heard nothing but praise from residents as well as family members. You would like it there for more reasons than their practice of slow medicine! However, knowing what my mother's wishes have always been for her final years, I am certainly grateful that my parents chose this CCRC. It has certainly made it much easier for me as the daughter than it easily could have been.
ReplyDeleteAuthor, "The Post-Traumatic Stress Disorder Relationship"