Slow Medicine

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.

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.

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.” 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. 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.

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. 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.

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.  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. 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.

I first started thinking about this stuff in a June 21, 2010 blog post about whether the internet is good or bad for us. 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.’ Love is good, plain and simple.”

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research
organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at Kent Bottles Private Views.

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  2. helpful and insiteful article. nobody likes to go to hospital I dread setting foot in them which is why I try and really look after myself

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  4. Interesting perspective. I feel like the term “UCLA medicine” can be given to any hospital. Hospitals are fast paced and hurried, that is true. People come to the hospital to find answers, to be cured. “Slow medicine” seems like a term that needs to be used in a clinic setting, where there is more time to stand back and reflect.

  5. I love this article. It does show the complexity of medicine and technology, particularly in treating the aging patient. However, I am not surprised how a nursing home patient would “love” a robot-seal when a real human being is not availabe to be with or a live animal to cuddle. Being human, we are emotional beings trying to be rational. Rationally, one should be able to survive alone even with food, water, and shelter provided, but we are social animals. Whether we have social contact with a real Being or Technology, it provides our need to feel loved and to feel valued. As a society, we must decide how each individual will be allowed to make those decisons he or she believes to be a dignified life or death.

  6. I strongly feel its our society that is responsible for improving heath care and reducing costs …. not just the govt. and the physicians.

  7. http://ow.ly/3yduM Interesting and informative video by orthopaedic surgeon Dr. Howard Luks on the subject of over-testing, over-utilization, and unintended consequences. Dr. Luks, I would bet, would be a slow orthapaedist.

  8. I have found that easing into the new situation has worked best in my life!

  9. Interesting Blog, even though this was not what i was looking for (I am in search of clinics like this one> http://www.ccsviclinic.ca/ )… I certainly plan on visiting again! By the way, if anyone knows of a good clinic that does CCSVI Screenings? BTW..thanks a lot and i will bookmark your article: Slow Medicine…

  10. I am still struggling to convince myself that cybertherapy and robots can actually be part of the primary care solution so that all of us can benefit from slow, thoughtful medical care. Here is a tweet I just posted: KentBottles
    http://ow.ly/3lsUr Robot ER staff can speed triage in the ED. This article talks about the use of robots for triage in the Emergency Room. The future is now

  11. I can never agree with the statement that hospitals and doctors will be getting less money in the future. It will surly increase in future.

  12. Thanks for a great article. I will look for Dr. McCullogh’s book. I’m so happy to hear support for this philosophy – we are all “whole” people who, regardless of circumstances, have basic human needs to give as well as receive, feel of value, and have a sense of purpose and feelings of mastery. Fast medicine forgets about these needs and hyperfocuses on physical needs. I’m currently writing a book titled – The Encore Approach: Creating a culture of well-being with aging parents to help individuals (when they leave the hospital) shift their focus from managing illness to supporting well-being in all dimensions of wellness, and create a culture of care that actively supports resilience. I know your blog and resources will be a valuable asset during this process. Kind Regards, Kay

  13. Hospitals and doctors will be getting less money in the future. I am telling my hospital clients to figure out how to survive on 30% less revenue in the future.

  14. For ACOs to save money, someone has to take a financial hit. Who is it going to be: hopitals, pharma, docs? I don’t see anyone volunteering.

  15. “pcp writes that we get exactly the health care system he would expect from a fee for service payment system”
    No, the problem is not fee for service. The problem is that we allow proceduralists to set the value of medical services, and cognitive work is devalued. Pay more for that, and less for procedures, and watch what happens.

  16. MG does not like the term slow medicine and pcp writes that we get exactly the health care system he would expect from a fee for service payment system. I did not coin the term slow medicine, but I do like its emphasis on a thoughtful approach to shared decision-making so that patients can make intelligent choices about the inevitable trade-offs involved in treatment and testing decisions. I also think the slow medicine movement embraces the expansion of the definition of health to include more than just absence of disease. The federal health care reform legislation has a definite emphasis on shifting from fee for service to global payments. This trend and the development of accountable care organizations to receive and distribute the global payments will provide hospital systems and physicians with incentives to shift from acute care medicine to taking care of a population of patients in a way to will hopefully avoid many of the hospital admissions that take place today.

  17. The health care system we have is the inevitable and perfect result of the payment system we have. If you don’t like the way health care is delivered, change how and what you pay for. In health care, we’re getting exactly what we pay for.

  18. Craig “Quack” Vickstrom, MD comments that it is society’s job to decrease per-capita cost and increase the quality of health care. I agree with him that the public has a large role to play by understanding that more is not always better in health care. However, physicians who make up about 20% of the health care budget control much more than that percentage by the tests they order, the patients they hospitalize, and the consults they request. Jack Wennberg’s book Tracking Medicine and Atul Gawande’s famous June 1, 2009 McAllen, Texas New Yorker article document the role doctors play in the quest for more efficient, higher quality health care. Determined MD concentrates on the need for all us to accept that all humans die, and I agree with most of his analysis. Chuck Davis correctly points out that America has much to learn from other countries. I agree and suggest TR Reid’s book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care as an excellent starting point for anyone who wants to learn from the global experience. Reid also points out that each country has to take into account its history and culture in developing the best way to transform their health care system.

  19. “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.”
    Perhaps you could try learning from the many countries that do so much better than the USA.

  20. This is an excellent and thoughtful post. I had not seen this perspective of linking technology bonding or emotional automation with healthcare improvement.
    thank you for the insight

  21. Don’t care for the term at all (‘slow medicine’ has too many negative possible connections associated with it) and I am not exactly sure what this term is trying to specifically address. Is it issues mainly associated end-of-life care? Lack of followup/coordination in the current medical system?

  22. The government’s hypocrisy is exposed. The government’s fee controls is the root cause. Hpspitals get a fixed fee based on dx. This is at UCLA, Boston, Pittsburgh, Baltimore. They run patients on the fast moving conveyor belt to get everything done as quickly and mindlessly as possible to shorten the los. Then, on day 4 or 5, the patient gets a peg and a trache, and it is off to the final marshalling yard before deaths, aka LTAC

  23. I once had seen some sci fi show where they would wage cyber war and the data results would tell the opposing governments how many people should be euthanized. Not a shot fired and these people would lay down their lives.
    We are not the stepford wives or zombies being controlled by a super being. People have a determination to stave off the Grim Reaper. Get use to it!!

  24. I’m not afraid to address the elephant in the room, and that is we die, and we as this culture now do not want to accept that basic fact. We live too long overall, we drain precious resources to stay alive even if just a few days more, and we pass on this pathetic notion that future generations can change the facts, the truth.
    Think about this one point, if you increase the average life span of humans past what is biologically realistic, and think that age is about 70-75 years old as an AVERAGE, more people will experience watching their children die before they, as parents, die. Because the older people live, they put more demands on their offspring, be it wars, economic needs for the parent, having to travel more to maintain contacts, and put up with the eventual aggravations of answering to parents for decades longer than intended. All experiences that shorten the life span of the recipients of demanding elderly. This is truth, again, per the elephant standing behind you.
    So, quality of life is the pursuit. Ask any realistic, grounded septagenarian how they feel as they watch their circle around them contract, both people and the erosion of cultural beliefs that nurished them in their upbringing, and more often than not, they accept the coming of the end. I am not encouraging euthanasia, nor suicide, nor just abandonment, just the natural process of living, and dying.
    It is like I wrote at another thread yesterday, promoting a drug to allow someone to live four or so months longer with terminially ill prostate cancer is not an advancement, is not a right, but just a delay.
    Hey boomers, you are all going to die, as I am in that group too, and I will not stand for your selfish and limited insights to try to change the rules for our generation. And this legislation per Washington politicians is their way of reminding you of this. Wow, what a thank you for voting for them!
    Not that I personally did.

  25. About Intermountain: Eliz Warren on a now famous video describes Intermountain as being responsible for bankrupting more patients than any program in the country. Some one said: “As Dr. James at Intermountain states – the providers hold the key to improving health care and reducing costs, not the legislators.”
    They may be slow to take care of patients, but fast to bill.

  26. Our society holds the key to improving health care and reducing cost, not physicians.

  27. I hear what you are saying and I think it is an important message. We select students and then train them to be tech proficient. I am not sure that we have enough people with the basic personality type to do what you describe to make a big change towards slow medicine. Patients, some anyway, want physicians with the warmth of Marcus Welby, but the genius and energy of the TV super docs. I just dont think that you get that total package very often.

  28. Agree with Kathy, nicely done Dr. Bottles. As Dr. James at Intermountain states – the providers hold the key to improving health care and reducing costs, not the legislators.