Direct Primary care and “Slow Medicine”
“The art of medicine consists in amusing the patient while nature cures the disease.” – Voltaire 1694-1778
In her recent book, Slow Medicine (Riverhead Books, 2017), Dr. Victoria Sweet describes a subtle, but growing, movement in medicine. Dr. Sweet writes about a type of medicine she has been exploring and trying to understand for over twenty years—an exploration she initially referenced in her book God’s Hotel (Riverhead Books, 2012). It is a type of medicine I have been grasping around the edges of since my residency, starting over ten years ago.
I noticed, in my early days in the emergency department, that while we did many things to patients, most of it was unnecessary, some of it made patients worse, and the experience—as a whole—was negative for our patients. They came in, they were poked, prodded, scanned, pushed and ultimately—normally—discharged in more or less the condition they came in. Rarely did I have the time to explain why I had ordered all those tests, or what they told me, or even what I had ultimately discovered—at least not in a way the patient could understand.
On the intensive care ward, we would give medications, feedings, fluids and people would gradually improve, or not. The nurses would make minute little adjustments to this dial or that, and breathing might come easier, or not, and gradually patients would improve, or not. As things worsened I might put in a breathing tube, or change ventilator settings, or put in a large line in their neck to give medications. And gradually, patients would improve, or not.
In short, it was a constant fiddling. At no point would we just stop, and ask ourselves, “what, of any of this, is actually necessary?” All antibiotics were broad spectrum and labs were done daily. Changes were made, every single day, without fail. Were they necessary? Who knows. We thought so. Otherwise, what was our point?
This type of medicine, the standard western practice of doing something, even if it will make no difference, do nothing at all, or worse, is what Sweet calls “Fast Medicine”. Fast medicine has its place. Antibiotics, ICU’s, labs, CT’s, MRI’s, surgeries—they all save lives. They can also harm, even kill. Usually, under the usual circumstances, overall they do more good than harm, but they can do plenty of harm even while doing good. Patients who get antibiotics for pneumonia can get C. difficile colitis and end up hospitalized. Patients who get an unnecessary CT scan of the head can have a finding which looks like a mass, even if it’s nothing at all, which can result in a biopsy. That biopsy can get infected, and they can end up paralyzed or unable to speak from subsequent treatment and procedures. A medication added to treat the side-effect of a first medication—which treats symptoms rather than disease—can itself cause a life-threatening reaction.
What, then, is slow medicine?
Slow medicine is something else, entirely. Our Great-Great-Grandparents would have recognized it, though. Before we had so many effective(ish) treatments, we had slow medicine. It was explanation. It was watching. It was gentle; elixirs, poultices, fresh air and rest.
As modern medicine came around, though, things started to change. There were X-rays that allowed, for the first time, a peering inside the body. There were labs which could tell doctors about anemia, and infection, and the effectiveness of treatments. Then, medical research started to grow in importance. Doctors started to realize that some people got better whether you gave them “real” medicine or a “placebo”. The important thing was that the patients had to believe that the treatment worked.
So they performed experiments where a “real” medicine was compared with a “pretend” medicine, and neither the patient, nor the doctor, knew which was which. The strange thing was, for almost any disease, no matter whether the patient got the “real” medicine or the “fake” medicine, some percentage of patients got better. In one trial, 30% of patients on a waiting list for the trial reported improvement![i] When both groups were compared to no treatment at all, the people getting the “fake” medicine still get better more often than the people getting no treatment at all.
What that means is that for most diseases—though by no means all of them—some people are going to get better, whether we treat them or not. For a large number of the normal, day to day, things we are plagued with, the vast majority of us are going to get better without any treatment at all. For most medicines, the “number needed to treat” or “NNT” is more than 10 to 1. This means that for every patient who could benefit from a medication, 9 other people will be taking it. The problem is, neither doctors, nor patients, have any way of knowing which patients are likely to benefit, and which aren’t.
There’s a counterpoint to “NNT”, it’s called “number needed to harm” or “NNH”. This is how many patients need to take a medication (on average) for 1 to experience harm. Some medications have numbers as low as 10 for the NNH. Most are higher, on the order of 100 or 300. “Harm” can mean anything from a moderate reaction like nausea and vomiting to a major reaction like death.
Slow medicine is a recognition of these aspects of medicine. That first, most people get better without our interventions. Second, sometimes the best intervention is an explanation of the disease process, and what to expect. Third, when we intervene, we have the potential to harm.
Slow medicine is also a recognition that healing is more than just doing things to people. Healing lies in removing the obstacles to health and healing. Those obstacles can be economic, like poverty or hunger. They can be interpersonal, like loneliness or abusive relationships. They can be spiritual, like a loss of faith or feeling inadequate or disconnected from the universe or God. They can be physical, like an inability to walk or move due to an unhealed fracture. They can be medical, like being on too many medications with too many interactions to have any of them work effectively.
Slow medicine is a recognition that time does heal, and that, with time, both doctor and patient can work out a path to healing, a path to health and a path to living—instead of just existing.
Direct Primary Care allows for the practice of slow-medicine. It allows for a knowing between doctor and patient. It gives the most precious gift of all, time. Time to care. Time to nurture. Time to heal. Direct Primary Care also allows for the practice of fast medicine, when needed, in a more efficient, more careful, way.
Fast within slow, and slow within fast. Direct Primary Care is true Primary Care, the fundamentals of medicine, thorough and complete, in a relaxed atmosphere at a relaxed pace. It’s the best of slow and the best of fast, using all of modern medicine and all of the ancient wisdom of healing to allow modern practitioners to be true healers.
A healer. It’s what I’ve always wanted to be, but couldn’t under the current system of Big-Box Clinics and Assembly-line medicine.
But, now, with slow-medicine, I am that healer, and I love it.