In an age when everything moves at lightening speed and health care payors reward physicians for seeing ever more patients, the idea of slowing down care may seem shocking. Yet, the concept of “slow medicine” is gaining attention and the admiration of practitioners, patients, and others.
Dennis McCullough, MD, CMD, has written about slow medicine in his book “My Mother, Your Mother: Embracing ‘Slow Medicine,’ the Compassionate Approach to Caring for Your Aging Loved Ones” (New York: HarperCollins Publishers, 2008), which he will discuss as a general session speaker at AMDA's Annual Symposium in Charlotte, N.C., next month.
Slow medicine can improve care, reduce costs, and make the relationships among patients, practitioners, family members, and caregivers stronger than ever, he said in an interview. It can help all stakeholders understand and appreciate the process of aging and what individuals go through as they grow old, experience diseases of aging, lose their independence, and ultimately face death.
Not New But …
Practicing slow medicine doesn't have to mean additional burdens on practitioners. “If we start to look at our interactions with residents in long-term care when we are doing our regular tasks, we can choose to listen and watch and make the most of our time with these individuals,” said Dr. McCullough.
Practitioners also can rethink how they spend their time in the facility. Instead of spending breaks in staff rooms, practitioners might have coffee in the resident dining room or another common area, he said.
Active listening can enable practitioners to make the most of their time with residents and better know who these people are, suggested Dr. McCullough. Draw out stories. Probe what people remember and want to talk about. Knowing residents as people can be enriching for staff, physicians, and family members. “There is some evidence that if you keep listening, you hear more. People often add new memories and details to stories they've repeated,” said Dr. McCullough.
He suggested starting by observing what is happening in a resident's room. “Ask about a photograph or what he or she is watching on TV.” By incorporating such activities into resident visits, the physician can learn more about what treatments, approaches, interventions, and recreation might be best for them.
Slow medicine is not really a new concept, said AMDA President Charles Crecelius, MD, CMD. “It just has been better articulated recently. … We all know that risks and benefits of therapy exist and that rushing into decisions fraught with much uncertainty about what is the best clinical course of action can lead to catastrophic results. Time is often our best ally. When the various potentials become clearer, decisions are made more thoughtfully; and families and professionals have more time to determine the best course for the unique individual.” Urgent decisions and quick action will always have their place, but most often, slow medicine is appropriate for elders, said Dr. Crecelius.
Dr. McCullough agreed that slow medicine isn't new. “I get many e-mails and letters from people who say they've been doing this but didn't know what to call it,” he said. “Having a name or label for it was helpful for them.” He explained, “Many familiar activities and issues fall under the category of slow medicine—hospice, palliative care, and narrative medicine, for example. They all involve understanding the depth of the patient's history, working with the family, and other dimensions of slow medicine.”
Slow Medicine Reflects Change
This concept has a natural place in culture change, said Dr. McCullough, of the department of community and family medicine at Dartmouth Medical School, Hanover, N.H. “Receptivity to any kind of change makes it easier to implement slow medicine,” he said.
Engaging families is a key. “The families present a source of unharnessed energies,” said Dr. McCullough. “We have families who visit almost every day, and you can utilize their energy and ideas. You can find ways to bring these families together to determine how you can draw on the positive energy coming into the facilities. They can organize and make suggestions about decision making. The social worker can ask them what concepts of slow medicine are relevant to them, and then the medical director can harness this information and implement their ideas.”
Getting buy-in for slow medicine at the facility level is a difficult task, he admitted. “Within any facility, you have some attendings who are more embracing of change and others who are resistant.” Nonetheless, the medical director can work with other team leaders to make slow medicine a part of the facility's culture. “Change will come about when you choose good men and women who believe change is possible and are willing to do the work to make it happen.”
Getting physicians to understand and embrace slow medicine can be challenging. “Before you think about educating them, think about where they are as adult learners,” said Dr. McCullough. “We have to realize that not every physician in long-term care is a geriatrician or has the same experience or knowledge we do working with this patient population. We have to embrace everyone who is interested in working with elder care.”
In fact, “inexperience in long-term care can be an asset,” he said. “Many practitioners come to this setting from different cultural backgrounds. They bring perspectives on family involvement and culture that are different and unique. In a sense, that kind of experience coming in from the outside is particularly valuable.” He added, “We can create self-aware subcultures within our communities that embrace slow medicine and incorporate some of its principles.”
Reform the System?
Dr. McCullough said he believes “that if you slow down to make medical decisions, costs are lower. … The Obama administration eventually will have to address the issue of costs, and if we can show that a more engaged, slowed-down way of dealing with elder care results in less jumping to expensive technology and fewer trips to the emergency room, costs will be reduced.”
However, if slow medicine becomes a health-savings winner, Dr. McCullough said he doesn't want its potential for improving care quality to be forgotten.
For now, physicians can start practicing slow medicine with small changes, he said. “Make an effort to communicate with family members on a regular basis, even if it's only through e-mails or messages through the nursing staff. They need to see you as an advocate, and you need to build a relationship of trust … so they are more willing to listen to your advice when it comes to crunch time.”
Don't assume that regulators or surveyors understand slow medicine, said Dr. McCullough. “We need to educate them about slow medicine. We need to figure out ways to broaden the dialogue between providers and regulators so it's not just a once- or twice-a-year thing. We need to press for them to become more aware of changes happening for the betterment in care of elderly, part of which involves more risk taking.”
Meanwhile, slow medicine is gaining adherents in related professions. Slow pharmacy is quickly gaining attention in the long-term care setting, said William Simonson, PharmD, CGP, of Suffolk, Va., past president of the American Society of Consultant Pharmacists. “Slow pharmacy means putting ourselves in our patient's place. It's an increasingly individualized approach to therapy, and it involves looking at individual residents and weighing risks and benefits with what is best for them and what they want. It's not rocket science, but it's good for our patients.”
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