Slow medicine: Part of the solution to the primary care crisis

The primary care crisis stems from multiple causes. Some of them are being substantively addressed by the Longitudinal Family Physician Payment Model. Solutions to others (such as administrative burden and alternatives to family doctors having to be small business owners) are actively being sought and implemented. I’m interested in addressing some of the causes that aren’t as widely acknowledged or discussed.

It is estimated that 30% of the tests, treatments, and procedures we order are unnecessary and 10% of them are harmful.[1] Current approaches designed to address this issue struggle to move the dial. The remedy will require a deeper look at the values and assumptions that drive what we do. Dr H. Gilbert Welch’s book Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care addresses some of them—more information is always better, action is better than inaction, and early diagnosis is always better.[2] Additional drivers of too much medicine include our society’s fear of death, black-and-white ideas about health and disease, and discomfort with uncertainty. Additionally, the influence of private interests on guidelines and standards of care has not been adequately addressed.

In a crisis, we need to go back to the basics: What is good health care? What is the goal of the work we do? I’ve considered this for some time and have come to this conclusion: good health care enables people to live their best lives. Good health care shows up when you need it and does as much as is necessary to restore health and balance to allow you to continue to live your life. Critically, it seeks to not do harm.

There are many movements in medicine that aim to keep that goal central by raising the questions and offering approaches to help us discern the better path. Some of them are realistic medicine, value-based health care, minimally disruptive medicine, less is more medicine, sustainable health care, and slow medicine. I like the framework slow medicine provides, because it gets to the fundamental assumptions. Its name immediately calls out one assumption to be questioned: Is fast always better?

Most of us working in the Canadian health care system have a visceral sense of our current system’s tempo. Fast, always; needs to be faster still. We could call it fast medicine. Often the quickest (and, importantly, the most lucrative) response to a patient or a result in front of you is to do something: write a prescription, order a test, make a referral, or ask the patient to book another appointment. Those may or may not be the correct actions. All of them create more demand on the system and require more physician hours. Fast medicine contributes to polypharmacy, fragmented care, overdiagnosis, overmedicalization, and the resultant inappropriate care. Not only that, every interaction with the health care system has an environmental cost: the transportation required for patients to attend multiple visits, the energy and resources required to produce medications and provide laboratory and medical imaging services, not to mention the waste.[3] Fast medicine decreases our joy in our work, and I believe it is a significant factor in the lack of family physicians willing to start or remain in a longitudinal practice.

Slow medicine originated in Italy (after the slow food movement) and is based on medicine that is measured, respectful, and equitable. Slow medicine acknowledges the powerful intervention of time and of healthy skepticism and vows to remember our potential to cause harm. The principles of slow medicine include using evidence-based medicine to discern between effective and ineffective care (demanding the benefit be more than marginal), without commercial interests at the table shaping those determinations; the concept of health as inclusive of the psychological, spiritual, social, and environmental realms alongside the biological; and health and well-being as complex and more than the sum of our bodily functions or the age we reach. The default shouldn’t be testing and treating but rather deliberate, careful, and measured actions. Slow medicine upholds a stance of curiosity and humility, resists the falsity of certainty, and requires an openness to doubt.

Although there is no formal slow medicine movement in Canada (yet), I’ve been experimenting with implementing the approach in my own practice. I’ve scheduled more time with patients, as well as time to think about my patients and review their charts. I make more time to call the consultants involved for advice, which often leads to fewer referrals and more useful investigations. I also share my expertise as a family physician, which includes the patient’s broader medical context and the whole person–centred lens (their values and life context to the best of my understanding). As a generalist, I endeavor to add value to the conversation by bringing a respectful skepticism of possible interventions. I aim to order fewer unnecessary tests and have sought to be more deliberate in deciding whether a follow-up appointment will contribute to a patient’s well-being. I listen more deeply to my patients, making space for their wisdom on how best to approach their health and acknowledging that my priorities are often not theirs. I’ve also spent more time finding and sharing information about the actual magnitude of benefit a medication or intervention might provide, and I find it is routinely less than both the patient and I believed (over-attribution of benefit). During this process, I am starting to see Western medicine more clearly—the good and the bad. I see the laudable achievements. We have many tools we can use to decrease suffering and improve our patients’ lives; I want to use those well. I also see that there is much we do that is unlikely to improve our patients’ well-being or that harms them, the health care system, and the environment.

Let’s not waste the opportunity our health care crisis is offering to look closely and critically at what we do and why we do it.
—Jill Norris, MD, CCFP
Victoria

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References

1.    Canadian Institute for Health Information. Unnecessary care in Canada. 2017. Accessed 27 March 2024. www.cihi.ca/sites/default/files/document/choosing-wisely-baseline-report-en-web.pdf.

2.    Welch HG. Less medicine, more health: 7 assumptions that drive too much medical care. Boston, MA: Beacon Press; 2015.

3.    Cascades. Sustainable primary care toolkit. Accessed 27 March 2024. https://cascadescanada.ca/resources/sustainable-primary-care-toolkit.