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Welcome to slow medicine

Dr Muiris Houston looks at a new concept for Irish medicine

Medicine is nothing if not fast-moving. It continually embraces new concepts such as evidence-based medicine and narrative medicine. The latest idea to emerge from its chrysalis is that of Slow Medicine.

In a blog earlier this year the former editor of the British Medical Journal, Richard Smith, described the proceedings of a Slow Medicine meeting in Bologna titled La Sanità tra Ragione e Passione (Health through Reason and Passion).

Slow Medicine is an initiative based on the successful Slow Food movement. Founded in Piedmont, Italy in 1989, Slow Food aims to counter the rise of fast food and fast life and the disappearance of local food traditions. Slow Food wants to reverse what it sees as people’s dwindling interest in the food they eat, where it comes from and how it tastes. Rather than dieting per se, Slow Food steers the person away from last-minute consumption of highly processed food and towards a more thoughtful and planned diet.

It is time, said Domenighetti, to open up the black box of healthcare. We need to encourage a healthy scepticism about the medical market

The Bologna Slow Medicine meeting heard that the characteristics of health systems are “complexity, uncertainty, opacity, poor measurement, variability in decision-making, asymmetry of information, conflict of interest, and corruption”.

Gianfranco Domenighetti of the Università della Svizzera Italiana said only 11% of some 3,000 health interventions have good evidence to support them. It is time, said Domenighetti, to open up the black box of healthcare. We need to encourage a healthy scepticism about the medical market and to help people understand that medicine is far from being an exact science.

Data should be published exposing variations in practice, corruption, and conflicts of interest. We should explain that health depends mostly on exogenous factors, not the healthcare system. And people should be given practical tools to promote their autonomy – tools like access to evidence-based information.

A US proponent of Slow Medicine is Dr Dennis McCullough, a community geriatrician and author of My Mother your Mother – Embracing Slow Medicine, The Compassionate Approach to Caring for Your Aging Loved Ones.

“The practice of Slow Medicine has taught me that it is wise to slow down and moderate the urgent pressures of decision-making that are often pushed prematurely on elders by society, the medical profession, worried friends and family,” Dr McCullough says.

He is especially critical of our tendency towards polypharmacy in older people. Excessive drug use by the frail elderly may be the result of overdiagnosis. In a “fast medicine” culture patients are more inclined to allow their future be dictated by test results. When these results suggest both curative and preventive medicines, then multiple-item prescriptions are the result.

Talking helps an older person understand and accept where they are in life and grasp the consequences of their choices

So how does Slow Medicine work for older people? “First, it requires more listening on everyone’s part,” Dr McCullough says. “Talking helps an older person understand and accept where they are in life and grasp the consequences of their choices. This is especially important when making decisions about living locations and medical treatments.

“Second, it means allowing enough time to make those decisions. True emergencies are rare in medical care. Allowing elders and their families days, weeks, or even months to weigh the pros and cons of their choices is very important.

“Third, older people benefit from the involvement of family and friends in their decision-making process. When it comes to ageing, the best decisions are made after lengthy consultation with the people someone trusts the most.”

Back in Europe, the Slow Medicine movement offers remedies based on the principles of being measured, respectful and equitable.

On the topic of measured care it says the dissemination and use of new treatments and new diagnostic procedures is not always accompanied by greater benefits for patients.

“Economic interests, as well as cultural and social pressures, encourage both an excessive use of health services and an expansion of people’s expectations beyond what is realistic, what the health system is able to deliver... A measured medicine involves the ability to act with moderation, gradually, and essentially, and uses the resources available appropriately and without waste...Slow Medicine recognises that doing more does not mean doing better.

“A respectful medicine is able to acknowledge and take into consideration the values, preferences and orientations of a person in every moment of life… Slow Medicine recognises that people’s values, expectations and desires are different and inviolable.”

The manifesto says equitable medicine promotes appropriate care, which is appropriate to the person, and proven to be effective and acceptable for both patients and health professionals: “An equitable medicine opposes inequality and facilitates access to health and social services. It overcomes the fragmentation of care, and encourages the exchange of information and knowledge among professionals. Slow Medicine promotes appropriate and good quality care for all.”

Although too new a discipline to have completed much in the way of research, intuitively [Slow Medicine] would seem to reduce the likelihood of litigation

The idea of Slow Medicine is echoed in Nobel prize-winner Daniel Kahneman’s book Thinking, Fast and Slow. Its central thesis is the dichotomy between two modes of thought: System 1, which is fast, instinctive and emotional, and System 2 which is slower, more deliberative and more logical. And Carl Honore, author of Slow Fix, says that applied to medicine a slow fix means taking time to work out the root cause of any ailment; learning what we can from the patient; taking a holistic approach to traditional forms of medicine; marrying medical treatment with wider changes in lifestyle; and treating the mind and body together.

What are the medicolegal implications of practising Slow Medicine? Although too new a discipline to have completed much in the way of research, intuitively it would seem to reduce the likelihood of litigation. It is hard to imagine how additional time spent listening to the patient and a greater attention to detail, as advocated by Slow Medicine, could produce a negative outcome.

There is evidence to show that effective communication after an adverse outcome reduces or stabilises rates of patient action against doctors. And poor doctor–patient interactions increase the likelihood of a patient initiating legal action over their care.

However, by discouraging or delaying certain treatment options, Slow Medicine may conversely trigger litigation if a person subsequently feels they have been “talked out” of a management plan that included the latest developments in the field. It is possible that, after the event, patients and families may sue over what was not done.

It is possible that, after the event, patients and families may sue over what was not done

The British Medical Association has backed a “Too Much Medicine” campaign, which shares some of the themes promoted by the Slow Medicine movement. It aims to tackle the threat to health and the waste of money caused by unnecessary care. The initiative hopes to dovetail with the Choosing Wisely campaign in the US, which has created evidence-based lists of medical interventions that may be unnecessary.

Ray Moynihan, Senior Research Fellow at Bond University in Australia, says: “Whether these different streams seamlessly coalesce is unclear, but the prospect of a radically new social contract between medicine and the wider society may not be far off, based on a clear commitment to stop harming so many of the healthy.”

A common emerging theme seems to be for the medical profession to practise medicine in a more transparent manner if current levels of overdiagnosis and overtreatment are to change.

Slow Medicine may become part of a wider movement, ultimately driven by the age-old maxim: Primum non nocere.

Dr Muiris Houston is a GP and medical journalist

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