Q&A: 'Slow medicine' promotes shared decision-making, listening to patients

Adopting “slow medicine” over “fast medicine” confers “real and tangible” improvements in health, according to an opinion piece published in the Journal of the American Board of Family Medicine.

Elena Hill, MD, MPH, a family medicine attending physician at Bronxcare Health Systems, suggests that primary care physicians in particular are well-suited to practice a slower, more patient-focused style of care, whereby empathy, listening and spending additional time with each patient can serve as an effective intervention without any additional spending.

There is pressure among physicians to order tests, write prescriptions and refer patients to specialists, which can lead to overordering and overdiagnosing, according to Hill. As an attending resident, she makes it a point to ask residents which labs they are ordering and why. Training new doctors to avoid overordering invasive tests and overdiagnosing patients is the first step toward teaching the concept of slow medicine, Hill noted.

Healio Primary Care spoke with Hill to learn more about how slow medicine improves the health of patients and represents the value of primary care.

Healio Primary Care: Can you briefly describe the dichotomy between slow medicine and fast medicine?

Hill: I describe the dichotomy between “fast medicine” (which involves high medical use and spending and a lot of “doing”) and what I and many others in the field are calling “slow medicine,” the provision of services that are truly in the patient's best interest and in keeping with their goals of care.

Healio Primary Care: Besides spending a longer duration of time with each patient, what else is involved in slow medicine?

Hill: Slow medicine is a lot more than just having more time with each patient. It is an overall philosophy on care. It believes that patients themselves know best what their body needs and what they need to make themselves healthy. It promotes shared decision-making between providers and patients. Let me give an example. The evidence is pretty clear that metformin is a medication that is helpful in treating and preventing progression of diabetes. However, the evidence for patients who are what we call prediabetic (some elevated sugars, but not high enough to meet criteria for diabetes) is less clear. This comes up all the time in medicine. There are actually very few treatments that we are sure or have very strong evidence are helpful. A lot of the medications and treatments we give routinely have very weak evidence for their efficacy. Therefore, when I have a patient with prediabetes, I don't ever say, “Metformin will make you better. I am going to prescribe it for you.” What I always say instead is, “Based on what myself and other doctors know, we aren't really sure if metformin is helpful in preventing you from developing diabetes; some doctors think it might be, while others don't. So, I will let you decide. Would you prefer to work on eating healthy, losing weight and trying other lifestyle changes before starting a medicine for pre-diabetes, or would you prefer to take medication in the hopes that it might prevent your disease from getting worse? Either decision would be reasonable, from my perspective. What do you think?” This is very much in keeping with the philosophy of slow medicine: acknowledging both what we know, and what we don't know, and working with patients to decide together what decisions they want to make for their health.

Healio Primary Care: How does slow medicine align with better patient health?

Hill: While there is certainly value in “fast medicine” (some of the things my surgical or other specialist colleagues can do to cure disease is absolutely amazing and I have so much respect for them), slow medicine does acknowledge that simply “doing a lot of stuff” — prescribing lots of medications, ordering lots of repeat tests that don't end up changing what we do to treat patients, etc. — does not actually improve outcomes. In fact, there are ample studies showing that doing “too much” — polypharmacy and the over prescription of medications, for example — lands many patients in the hospital because of medication errors and can be harmful to patients overall.

Slow medicine begs us to ask the question, for each and every decision that we make, “Is this really going to make the patient better? Is it going to improve their day-to-day quality of life? If not, lets decide not to do it.” I love the expression “Don't just do something; sit there!” When a patient comes with a concern, we don't have to immediately solve it in one office visit. Alas, many problems in medicine are unsolvable. Helping a patient to bear a disease or a discomfort, helping them to adapt in spite of the presence of disease, might make a bigger difference in improving their health than sending them for an endless series of specialist visits or tests when the evidence that those things will be curative is very weak. I truly feel that my patients are the most satisfied when they are simply listened to and allowed to voice their thoughts and opinions about their care. Some of my patients have been going to various doctors for years for the same health issue, often issues that are not fixable. I don't think they really expect me to fix them. However, when I simply listen to them, and give them the space to grieve their feelings or their frustrations, they often leave the office truly feeling better, even though their condition remains the same. Much of disease is not about curing it, but bearing it, and if we can do that, we can honestly and truly make patients feel better.

Healio Primary Care: How does this practice contribute to preventive medicine?

Hill: Primary care physicians are in a unique position to be the providers of slow medicine. Much of our role involves arbitrating the opinions and recommendations of various specialists and synthesizing them into a plan that actually makes sense for a patient. For example, I was recently working in the hospital and had a patient who is 85 with advanced dementia who has a lung mass and there is a concern for developing cancer. I consulted my oncology colleagues who immediately recommended a biopsy with the eventual plan for a surgery. And, according to the protocols for how we would manage cancer, they were absolutely correct that these would be the next steps. However, when I looked at this patient as his primary doctor, I thought the idea of putting this man, who is 85 years old with advanced dementia, through a biopsy and maybe even an operation when he won't understand what is going on or why we are doing what we are doing will probably terrify him and will be unlikely to prolong his life in a meaningful way. When I discussed this the next day with his wife, she was also in agreement. In the end, we decided to send him home with support services so that he can live out his remaining time in a safe and familiar environment surrounded by the faces of people he loves. Primary care providers are and should be trained to think in this way: not being driven by protocols but seeing the whole picture about a patient’s care and what is truly best for them.

Healio Primary Care: Why are PCPs in the best position to practice and disseminate slow medicine?

Hill: I think that part of advocating for slow medicine is changing the way we train new doctors. I’ll give another example. Working in the hospital in residency, every morning, I would order routine blood work for my patients in the hospital because I knew that if I didn't, my attending doctor supervising me would ask me why I hadn't, even though the results were otherwise normal every day and weren't going to change one thing we were doing for the patient. To me, it was just a click of a button in the computer, but for the patient, it meant getting woken up yet again at 5 a.m. when they are trying to get sleep and heal themselves, just so we could have some blood data that we probably weren't even going to use. However, as a trainee I was too intimidated to not do things the way “they were supposed to be done.” I think a lot of trainees feel disempowered in this way. Now, when I work with residents, I ask them to tell me why they are getting every test they are getting. Sometimes they stare at me blankly and say, “Because I thought we had to get those labs every morning.” And then I say (gently, and with love, I hope!), “Dr. X, you don't have to do anything in medicine. Every time we do something, it should be for the benefit of the patient. And if you don't think something truly is beneficial, I give you permission not to do it. In fact, I want you to argue with me if I am doing something that you think is unnecessary or not truly helping patient care.” This trains them to stop “doing” things perfunctorily. I believe changing the way we train new doctors to think will help to change the culture of fast medicine in this country.

Reference:

Hill E. J Am Board Fam Med. 2021;doi:10.3122/jabfm.2021.04.200477.