By Alberto Dolara
Originally published in Italian Heart Journal: Supplement. Official Journal of the Italian Federation of Cardiologists 3.1 (2002): 100-101
(Translated by Elizabeth Castelli)
…the haste that mars the dignity of every act…
Dante, Purgatorio, Canto III
In current society the constant impulse, even if not always justified, toward the acceleration of all aspects of daily life inevitably results in the birth of movements of opinion and/or the occurrence of concrete acts that tend to contrast with it. Analogous to what happens in food/eating, a fundamentally biological act (fast vs slow food), why not take into consideration a concept of “slow medicine” for health activities and in particular medical activities? Leaving aside those diagnostic-therapeutic interventions that have an urgent character [emergency medicine], the application of such a concept [“slow medicine”] could be useful in clinical practice, as illustrated by some examples.
It has already been confirmed in the preventive sector that the introduction of an early screening can induce states of anxiety and inappropriate therapeutic procedures if the foreseen event is merely probable. The positive result of the prostate antigene test [PSA test] may induce unnecessary interventions with at times poor functional outcomes, while we note the discovery of carcinomatic outbreaks in the prostate of asymptomatic subjects who died of other causes. It is already confirmed that the screening for early diagnosis of pancreatic cancer has no practical validity from the therapeutic point of view. The introduction of genetic screening can render this phenomenon more evident and in some cases stir up confusion and ethical questions that are not easily resolved: [genetic testing for] breast cancer, for example, identifies families and subjects at risk much earlier, sometimes raising dramatic questions about the therapeutic approach to follow.
In everyday medical practice there are numerous examples of pathological processes of infectious origin in which the apparent acceleration of the cure, obtained by modern medical means, contrasts with the slower biological rhythms of recuperation and convalescence of the whole organism, which ought nevertheless to be considered in the interests of the patient. This can also apply to degenerative pathologies: an episode of sudden heart failure from coronary artery disease, while resolved brilliantly and quickly by means of coronary angioplasty, does it not then require the intervention of “slow medicine,” that is of a patient and constant elimination or reduction in risk factors and modification of lifestyle to prevent a recurrence? The occurrence of a cardiogenic attack requires quick and efficacious measures, but in order for a patient to be included on a waiting list for a heart transplant there are usually required complex preliminary tests and a careful evaluations with an adequate period of follow-up to consider the possible results of alternative medical therapies. The incautious and hasty proposal of a heart transplant to a patient can provoke unjustified anxiety and unrealizable expectations.
The application of new methodologies requires a particular attention: one example among so many is that of the method of closing interatrial septal defects, possible today by means of a percutaneous technique, which avoids traumatic cardiosurgical interventions and prolonged hospital care. The more cautious cardiologists suggest however that it is not necessary to rush in applying such a procedure to children who are not in urgent need of the closing of the defect: it comes to be noted that to implant a foreign body in order to close a well-tolerated defect in a subject who has a long life expectancy contrasts with the lack of knowledge about the long-term effects of foreign material on the organism.
In hospitals there is constant pressure to reduce the duration of hospital stays; if these goals are wholly praiseworthy, nevertheless this contrasts with the type of care currently required by most of the recovering population, comprised of elders with chronic maladies. Are we always sure that in these cases the race for early discharge favors the patient and reduces health costs? We very often witness the phenomenon that these patients, quickly discharged from one department, are just as quickly readmitted to another department or to other hospitals. The end result is on the one hand the upsetting of the patient, who loses all continuity of care, and on the other hand the increase in the numbers of admissions, which cancels out the advantage of reductions in hospital stays. The multiple hospitalizations for heart failure are typical examples of this situation. A moderate prolongation of hospital stay could be and should be accompanied by a “protected” discharge, establishing from the start an ongoing relationship with the patient’s family, the family doctor, the referring specialist, establishing controls for subsequent outpatient care and home-based therapies with accuracy and calculation, offering patients effective measures of long-term care, from the optimization of therapy to rehabilitation. The practice of “slow medicine” finds a useful application in this case.
The problem of waiting lists, considered so urgent by public opinion as to make it actually a possible destabilizing element of a particular health care system, and considered resolvable by the too emphatic Unified Reservation Center, could use the concept of a “slow medicine.”
There are still too timid attempts to distinguish between “priority” waiting lists, comprising diagnostic and therapeutic interventions that cannot be postponed, and “schedulable” ones, in which a fixed delay is completely acceptable. The concept is dramatically obvious for some therapeutic options such as placement on a waiting list for organ transplants. And so the fundamental work of the family doctor, specialists and/or hospital staff who can exercise an effective filter action, relieving the anxiety of applicants through an adequate ability to listen and to direct the choice among the various possibilities offered by the healthcare structures.
The concept of “slow medicine” has implications also in relation to the terminal phase of life, an aspect with which health care activity inevitably comes into contact: death, like all biological phenomena, is a process that begins at birth and proceeds at different times until the end. For the majority of patients, it is preceded by a long, chronic illness. If therefore the prevention of avoidable death requires rapid and appropriate interventions, almost always the alleviation of suffering, the help of the family and continuous communication with the terminal patient requires time and emotional involvement rather than inappropriate technological measures. The concept is vividly illustrated by Bernard Lown, a prominent American cardiologist who was the “inventor” of heart rhythm restoration and the organizer of the first coronary unit, in his fine autobiographical book, The Lost Art of Healing (Milan, Garzanti, 1997). [Bernard Lown, The Lost Art of Healing: Practicing Compassion in Medicine (NY: Ballantine, 1996).] His mother, 96 years old and a terminal heart patient, had long been prepared in her home to a peaceful death, but cardiac arrest, which occurred during a temporary absence of her son, had triggered the activity of the resuscitation team. Lown, who rushed there immediately, describes the horrible spectacle and affirms literally that “the memory of her death evokes grief and tears in me, but I suffer even more because episodes like this one cast a shadow over my profession.”
An invitation to “slow medicine” should in the end be absorbed by those researchers and media professionals, who tend to publicize striking results in the biomedical sector, results that have not yet passed the scrutiny of experts, making the obviously utopian possibility of not only eliminating all diseases, but also the end of life, seem realistic to the population that they address. In conclusion, if it is true—as it is true—that health problems are not only organizational or economic, that those of the patient are not exclusively health-related but also emotional, family, economic, and social, and that their understanding requires on the part of health professionals time, the capacity to listen, reciprocal consultation, critical evaluations and continual bringing up-to-date, the invitation to a “slow medicine” appears to be entirely justified.
Hyperactivity is often unnecessary in clinical practice. The application of a “slow medicine” may lead to better results in many situations. It allows healthcare professionals, and in particular doctors and nurses to have enough time to examine personal, family, and social problems of patients, to reduce their anxiety while awaiting diagnostic procedures and non-urgent therapies, to evaluate procedures and cutting-edge technology carefully, to prevent premature discharge from the hospital and finally to offer appropriate emotional support to terminally ill patients and their families.
Keywords: Methodology; Total Quality.