Saturday, November 20, 2010

Slow medicine

I don't know if you remember, but back in March our Earth started to spin faster. The devastating earthquake in Chile shifted our axis to create shorter days. Not that much shorter -- we are talking about a 1.26-microsecond reduction. Not particularly noticeable. But I have to wonder if our ever-increasing pace of life is not merely emblematic of these periodic but frequent cataclysmic accelerations of the planet.

What a cliche it is to say that we live in a speeding up 24/7 world, where, if you do no keep up, you drop off. We have fast cars, fast communications, fast food, and yes, fast medicine. This fast medicine concept ties together many of the ideas I have discussed here over the last few days and weeks.

It is most peculiar to me that, even in the Communist country of my birth, early on I learned the expression "time is money" from my father. It certainly did not resonate there; in fact, it did not begin to make sense until I was an adult in the US and beginning to understand what makes our economy tick. And indeed, time in our society can be counted off in dollars. Over the past 60 years, the American dream of a suburban house, 2 cars and 2.5 kids, a 40-hour-a-week job, and time on the weekends with the family, has mutated into an endless work day, constant accessibility and distant and loose connections. This is not all bad necessarily, but the promise of more efficient workplace resulting from the proliferation of technology has been forgotten. Instead, this technology, shiny and sexy and laden with the symbology of status, tethers us to perpetual productivity. And the expectation of these productivity increases accompanied by reduced production costs is what drives our economic growth. But at what personal and societal costs?

Aside from the rampant breakdown of communities, many other emerging phenomena are a part of the package. Take the obesity epidemic, for example. We can certainly continue the debate about the factors contributing to it, we can continue our search for the irrefutable smoking gun, but let's be honest: how can our fast food culture not be a major contributor? Of course it is. Along with the sedentary lifestyle and the culturally sanctioned pursuit of fast satisfaction, the biology is indisputable: cheap and accessible highly caloric food and drinks consumed in excess without the balance of physical expenditures -- bingo, the math adds up to this perfect storm. Evidence (and common sense, I might add) suggests that slow food cooked at home may be an antidote to the overdose of the toxic "nutrition" foisted onto the nation, especially the young people. But, in the words of my niece, "we don't have time for Minute rice!" We need to continue running on this treadmill that our lives have become, so as not to miss the opportunity for the carrot at the end of it. Or are we just hallucinating the carrot?

And all of this rushing about has naturally penetrated medicine. Since it is just another market,where productivity drives someone's bottom line, the treadmill will surely continue to speed up. Yet, here, I talked extensively about why the incredible shrinking appointment is such a bad idea: most real issues come at the end of the 15 minutes, when the patient's or the doctor's hand is beginning to turn the door handle. And fortuitously or not, this motif has been carried by other bloggers like Dr. Synonymous here, a dedicated family physician in Columbus, OH, trying to balance good medicine with staying in business. He poignantly describes his every-day struggles to fit his patients' seven to eleven problems into a four-problem widget that he is encouraged to produce. It is doctors like Dr. Synonymous that could rein in our catastrophic healthcare spending just by being given time and space to focus on the patient without the pressures of ever-increasing production. And then Kevin Pho, better known as KevinMD, healthcare blogger royalty, on his blog eloquently connects the dots between the widgetry of the medical appointments and some of our most pressing public health challenges. Here is what he says:

That’s a valid point. When it comes to their own children, it’s unlikely that trumpeting public health fears is going to significantly sway parents’ opinion, especially if they come in believing that vaccines are associated with autism.
A parallel situation is with antibiotic overuse. Again, public health arguments mostly fall upon deaf ears in the exam room, as there are many patients who believe that upper respiratory symptoms require an antibiotic.
What’s the answer?  More time to spend with patients, for one.  And second, Dr. Parikh alludes to the fact that most doctors don’t receive adequate training when it comes to vaccines: “If there is one thing Sears gets right, it is the fact that doctors need more education about vaccine science from the get-go.” [emphasis mine]
These are not assertions that require big studies or demonstration projects -- this is the knowledge we gain from living: relationships are everything, and relationships take time to build. And time is what continues to erode in the office encounter.

What is the answer? Even when I was in practice, I was a good diagnostician, but when it came to treatment, it did not have that much interest to me. So here, just as in practice, I find myself more interested in defining the problem and letting others help me find the solution. This is my long-winded way of admitting that I do not have the perfect answer. However, patient empowerment is one of those answers, where at the personal level the patients need to understand how to manage this "microwave" medical encounter to the best of their needs. At the policy level, patients and doctors need to pool forces and start naming the problem before the "but" subverts the discussion. And it may just be that the best solution is to restore medicine's social contract and to wrestle medicine out of the clutches of market forces back into the therapeutic arena.

Medicine will never return to its prior rhythm, but we must strive to get it to a better place, where both patients and clinicians have the time to address the obvious. The fast model of medicine, much like fast food, is creating a nation of illness and discontent. Just as in the food movement, let's start creating an infrastructure where our healthcare professionals can practice slow medicine, having the time to address our individual issues thoroughly and completely and in a manner that promotes health rather than perpetuate disease.      


  1. Good post, especially reference to the rhythm of life and our medical work. As the "natural" rhythms are allowed to be what they will, biology, patients and doctors work better. As we reaffirm and refresh primary care, we'll validate and honor those rhythms that allow the best health. Technology definitely has a role to help that happen, but, as you point out, it's being misused in ways that move health in the wrong direction. If we partner with patients better, we have hope for the health care future. Peace.

  2. Great blog. Yes, time allows for relationship and trust to grow between a patient and physician (or other practitioner). Trust allows for more information to be shared. The additional information may provide the nugget that best positions the patient & practitioner to get to the root-cause of a symptom and addressing the challenge at the root-cause rather than simply band-aiding the symptom.

    Our practitioners created such a model for this very reason.