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Richard Smith: The case for slow medicine

17 Dec, 12 | by BMJ

Richard SmithThe characteristics of health systems are complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. They are thus largely a black box and uncontrollable, said Gianfranco Domenighetti of the Università della Svizzera Italiana at a meeting in Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year.

Only 11% of 3000 health interventions have good evidence to support them, said Domenighetti. A third of the activity in the US health system produces no benefit, said a recent study in the New England Journal of Medicine. Half of all angioplasties are unnecessary. Some €153m a day is lost through corruption in health systems in the European Union. Four fifths of new drugs are copies of old drugs. Screening is creating diseases like ductal carcinoma in situ. Most doctors (80-90%) have taken “bribes” from pharmaceutical companies, although many may not see their free pens and lunches and subsidised travel as bribes (but if they are not bribes what are they?). Between 15% and 40% of articles in medical journals are ghostwritten. Half of clinical trials are not published, and there is systematic bias towards positive results, hence suggesting that treatments, usually drugs, are more effective and safer than they actually are.

Yet against this backcloth more than four fifths of people in most countries think medicine is an “exact or almost exact science.” In a study published in the Annals of Internal Medicine nearly 90% of patients undergoing percutaneous coronary intervention (PCI) thought that it would reduce their chances of having a heart attack, when it doesn’t. Asked about various scenarios almost half of cardiologists questioned would go ahead with a PCI even when they believed there was no benefit to the patient.

It is time, said Domenighetti, to open up the black box of healthcare. Encouraging “health literacy” seems to be a way to do this, but Domenighetti thought that this was “old wine in new bottles.” We need, he said, to encourage a healthy skepticism 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.

Domenghetti ended his talk by pointing people towards the Choosing Wisely campaign in the US where professional organisations are identifying interventions that offer little or no value. A similar but broader campaign of Slow Medicine is underway in Italy, and I have little doubt that slow medicine—like slow food and slow lovemaking—is the best kind of medicine for the 21st century.

We need to pull back from what Ivan Illich called the hubris of medicine.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.

Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna.

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  • Dylan Summers

    “We need, he said, to encourage a healthy skepticism about the medical
    market and to help people understand that medicine is far from being an
    exact science.”

    Is this ethical, though?

    Less implied effectiveness of treatment = less placebo effect = worse outcomes

  • http://www.facebook.com/gabriele.romani.923 Gabriele Romani

    Perhaps the slow medicine is not the solution for the medicine of this century, but I think it starts from some concepts that should be the pillars of health; fairness (not always guaranteed in our health systems) and respectfull as a medicine based on the relationship “human” between doctor and patient.

    In Italy, another notable initiative is called “no thanks I’ll pay” (http://www.nograziepagoio.it/chi_siamo.htm). It is formed by a group of health professionals who rejects all forms of gifts from the pharmaceutical industry. A value of universality and equal can be achieved with greater appropriateness. How can we do this?

    Surely starting from the teachings of Alessandro Liberati: research oriented towards the needs of patients.

    Gabriele Romani (Local Health Autority Reggio Emilia, Italy)

  • http://www.facebook.com/corran.toohill Corran Toohill

    Is the converse ethical? I would suggest not.

  • Huw Llewelyn

    The idea of ’slow medicine’ brings to mind the 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, imaginative and emotional and System 2 which is slower, more deliberative and more logical. The Oxford Handbook of Clinical Diagnosis calls these two types of thought ‘transparent’ and ‘non-transparent’ thinking and proceeds to define, explain and teach transparent clinical thinking in a way that can be explained to patients, clinical colleagues, journal editors, scientists and funding organisations, the main body of the book containing examples.
    The ability to think transparently in the clinical and research setting is essential if the current ills of unbridled ‘fast thinking’ are to be remedied. ‘Evidence based medicine’ currently only assesses the diagnostic screening process and drug efficacy e.g. with RCTs. It does assess treatment effectiveness in the context of evidence based treatment selection, evidence based diagnostic criteria and evidence based differential diagnosis as explained in the Oxford Handbook of Clinical Diagnosis. The medical profession (and not only a minority of experienced physicians as at present) must practice medicine using a transparent thought process if the current muddle caused by non-transparent ‘fast’ thinking (e.g. surrounding overdiagnosis and overtreatment) is to be sorted out.

  • Huw Llewelyn

    The idea of ’slow medicine’ brings to mind the 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. The Oxford Handbook of Clinical Diagnosis calls these two types of thought ‘non-transparent’ and ‘transparent’ and proceeds to define (mathematically too) and teach transparent clinical thinking in a way that can be explained to patients and professional colleagues, the bulk of the book giving examples.

    The ability to think transparently and to explain it in the clinical and research setting is essential if the current ills of unbridled ‘fast thinking’ are to be remedied. Failing this, evidence based medicine can only assesses the diagnostic screening process and treatment efficacy e.g. with RCTs. It cannot assess treatment effectiveness in the context of transparent evidence based treatment selection, evidence based diagnostic criteria and evidence based differential diagnosis as explained in the Oxford Handbook of Clinical Diagnosis. The entire medical profession (and not only a minority of experienced physicians as at present) must practice medicine using a transparent thought process if the current muddle caused by non-transparent ‘fast’ thinking (e.g. surrounding overdiagnosis and overtreatment) is to be sorted out.

  • http://www.facebook.com/people/Sergio-Stagnaro/1593214164 Sergio Stagnaro

    My “rejected”, no politically comment is posted on facebook http://www.facebook.com/bmjdotcom

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