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.