William Cayley: Medicine—too fast, too slow, or just right?

bill_cayley“Slow Medicine” is getting more and more attention. The authors of several recent books have got readers thinking more and more about taking time, truly listening to the patient, focusing again on the thorough history and physical, and building relationships—among the good (and inspiring) reads on this are God’s Hotel, Out of Practice, and What Matters in Medicine. These books, and a growing body of essays, are inspirational calls to return to humanism, relationships, and caring in medicine.
I decided to do a bit more of my own investigating into the history of “slow medicine” as a concept, and came across a surprise. In an essay from the BMJ in 1985, George Dunea points out that “slow medicine does not always work:”

A young consultant recently saw a patient with a chronic illness, spent an hour examining her, and then took her into a side room for another hour to explain what the treatment would entail. It was done in the best tradition of “slow medicine,” but the patient was so frightened that she signed herself out of the hospital and went home that very night.

Sometimes our patients may need or want thorough, in-depth, comprehensive examination and care, but sometimes not. While fright of the patient mentioned above may have been due more to an excessive thoroughness on the part of an inexperienced doctor, the story still makes the point that “slow medicine” is not necessarily the answer for all patients.

In a similar vein, John Hickner asked (in a Journal of Family Practice editorial last fall), “Have family physicians abandoned acute care?”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

Of course the acutely ill patient needs appropriately thorough investigation, and a good history and physical is much better than a “shot-gun” approach of testing for everything and seeing what rises to the surface. However, the point remains, over-emphasis on slow medicine and chronic care, may over look the patients who need acute care. Medicine is about curing, caring, and healing, but medicine is also about service.

The complicated chronic care patient may need a lot of time and attention to arrive at an appropriate diagnosis and plan. The acutely sick patient, may also be complex and require a lot of time and attention to detail, but some acutely sick patients may just need a simple answer—do I have an ear infection? Do I have strep throat? Or a bladder infection? We need to be equally able to care for the complicated patients who need loads of time, and the acutely sick patients who need an answer for today, not a complete review of their health and wellbeing.

Doctoring is about caring, curing, and healing. Sometimes this is complicated and takes a long time, but sometimes this is just a matter of being accessible and available, to meet the needs of someone with an acute illness. The tricky part may be sorting out who of the acutely sick are complicated, and who are not—but that’s part of the challenge that makes medicine fun.

Goldilocks found that some porridge was too hot, some too cold, but some was just right. As doctors, we can’t serve everyone by being fast, nor can we serve everyone by being slow—the challenge is to “cook up” the medicine that is “just right” for each patient.

Competing interests: “I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.”

William E Cayley Jr practises at the Augusta Family Medicine Clinic, teaches at the Eau Claire Family Medicine Residency, and is a professor at the University of Wisconsin, Department of Family Medicine.