By Antonio Bonaldi and Sandra Vernero
Originally published on February 2015: Bonaldi and Vernero, 2015
Summary. Italy’s Slow Medicine was founded in 2011 as a movement aimed to promote processes of care based on appropriateness, but within a relation of listening, dialogue and decision sharing with the patient. The mission of Slow Medicine is synthetized by three key words: measured ⎯ because it acts with moderation, gradually and without waste; respectful ⎯ because it is careful in preserving the dignity and values of each person; and equitable ⎯ because it is committed to ensuring access to appropriate care for all. In a short time, the association quickly grew at national and international level. It happened in response to the calls for change coming from health professionals, patients, and citizens who, in increasing numbers, realized that to face the health problems it would be necessary to resort to a new cultural and methodological paradigm. Professionals, patients and citizens are strongly affected by conflicts of interest, common sense and habits (often inadequate) to increasingly consume more health care services, under the illusion that doing more is always better. Moreover, the dominant reductionist cultural model ⎯ on which the concept of health and disease is based today ⎯ considers man as a machine, investigated by a growing number of specialists, particularly interested in the pathophysiological mechanisms of diseases. The interest is mainly focused on technologies, while the person, along with the relations with his/her family, and the social environment are completely neglected. The systemic approach adopted by Slow Medicine (on the contrary) teaches us that health and disease are complex phenomena and that the life of a person is more than the sum of the chemical reactions that occur in its cells. At different levels of complexity, in fact, new and unexpected properties appear, such as thinking, emotions, pleasure, and health. These properties are not detectable in the individual elements and can only be studied using methods of analysis and knowledge belonging to other knowledge fields, such as philosophy, anthropology, psychology, ethics, art, etc. Operationally, Slow Medicine has launched the “Doing more does not mean doing better” campaign, which is similar to “Choosing Wisely” in the United States. The aim is to improve clinical appropriateness through the reduction of unnecessary tests and treatments. With as the first step, the specialty societies involved (30 by now) should indicate five tests or treatments commonly used in Italy’s clinical practice that do not provide any benefit to most patients but may cause harm.
Key words. Appropriateness, choosing wisely, medical humanities, Slow Medicine, system medicine.
What is Slow Medicine?
Torino, 2010: Slow Medicine is born
On the 11th of December 2010, a group of friends involved in various capacities in the field of health (and equally concerned about the dangerous drift taken by the system of care) met in Turin, at the headquarters of the of the Change Institute. A few weeks later, an exchange of correspondence between them resulted in a document in which Andrea Gardini outlines a new way of understanding medicine: a less technological medicine; less prone to the market; more attentive to the person; and based on the systemic approach. Just a few words are enough to understand that we are on the same wavelength: we do not like the modern approach to medicine and we are convinced that there are better ways to deal with health problems, and that changes are possible. Thus begins a real storm of ideas, thoughts, and concepts to which it was necessary to shape, assign a meaning, and make it comprehensible to non-experts. After several attempts, the three keywords emerge which encapsulate the philosophy of Slow Medicine for a measurable, respectful, and equitable medicine. Measurable ⎯ because it acts with moderation, gradualness, and without waste; respectful ⎯ because it takes into consideration the dignity of the person and recognizes that his or her values and expectations are inviolable principles; equitable ⎯ because it intends to combat inequalities and ensure access to appropriate care for all1. Finally, Jorge Frascara, graphic designer of communication at the University of Alberta (Canada), designed our logo: two little snails talking to each other. Shortly afterwards we set up the association and started talking about Slow Medicine.
Someone had already talked about it
We quickly realized that someone had already identified a slow path for medicine. In 2002, Alberto Dolara (a cardiologist from Florence) came at with a highly anticipated article called “Invitation to slow medicine”2. A few years later, in 2008, Roberto Satolli, in the Corriere Della Sera, pointed out that slow should be understood as a soft and less technological approach to care, soft and less technological. Even in the United States, there is talk of Slow Medicine. Dennis McCullough in “My mother, your mother”3, Victoria Sweet in “God’s Hotel”4, and Katy Butler in “Knocking on Heaven’s Door”5: three bestsellers that have irrefutably demonstrated the impact of slow medicine in the care of the elderly and in end-of-life situations. With these three authors, animated our same interests, a fruitful exchange of thoughts, experiences, and reflections was built.
Slow Medicine takes off
The concepts of Slow Medicine seem to capture a common way of feeling. So, in a short time around these first ideas; the requests for change of many health professionals, patients and citizens gathered. In May 2011, after a few months of meetings and debates, Slow Medicine made its official debut with the workshop in Ferrara (Italy) in which measurable, respectful and equitable treatments are declined in various fields. On that occasion, the association defined itself as a network of ideas in motion, to underline its dynamic, non-vertical aspect, respectful of the principles of complexity and of a rigorous ethical line. It is above all the interactions between members and sympathizers to trace the path and the road and promote change: there are no certainties but a continuous dialogue between people and the context to which they belong. The paths do not follow plans. They are never linear and they take advantage of the various opportunities as they arise. In this way, the movement grows and spreads. Its representatives participate in many conferences, workshops and public events in the national scenario that help to better define the slow thinking, thematic areas, projects and alliances. The national press and several blogs started to talk about it, including Richard Smith’s in the British Medical Journal, where Slow Medicine is defined as the best medicine of the 21st century6.
More recently, a Facebook discussion group was started, and today it counts over 2600 members from which a constant flow of reflections, ideas, hypotheses and proposals emerge. In 2013 the book-manifesto of Slow Medicine was published, with contributions and reflections by the founders7. The collaboration with Slow Food of which some of us (along with Carlo Petrini) were founders and with whom we share a respect for nature and the environment, and the value of the diversity, the sense of justice, the fight against waste and consumerism. With Slow Food we signed a memorandum of understanding for the development of main initiatives in the food field, for the promotion biodiversity and respect for the environment. New international relationships were opened with the American movement of Slow Medicine and Choosing Wisely8.
A crisis of values and methods
Why do so many people identify with the ideas of Slow Medicine? After all, over the last few decades, medicine has achieved wonderful things and achieved extraordinary success. The average life span has spread, infectious diseases have almost disappeared, transplants, prosthetics, new techniques in surgery and anesthesia save and lengthen our lives. With that, diagnostic imaging and molecular biology allow us to investigate the body in the finest details. Why complain?
If we stop for a moment to reflect, we realize that medicine has reached a critical point of no return. The system of care is undergoing a profound crisis and, differently from what we imagine, it is not restricted to economic issues. It is mostly a crisis of ideas, values, and methods. More and more people are realizing that the problems of health care are no longer governable on the basis of traditional cultural, scientific, and methodological concepts from which they are increasingly turning away to abandon themselves to other medicines. What is needed are new conceptual maps and a real shift of paradigm. Let’s take a closer look at what this is all about.
The poisons of fast medicine
Economic and market interests
We only need to look around us with a disenchanted eye to understand that medicine is steeped in inappropriate services, waste, conflicts of interest, and frauds that arise from the economic and financial interaction between those who prescribe, those who purchase health technologies, and the industry that produces and markets them. This phenomenon permeates the entire field of research and publishing. So much so that Marcia Angell, in an editorial published in Journal of American Medical Association notes that physicians will no longer be able to rely on the medical literature for valid scientific information9.
In most cases, commercial interests creep into our decisions, partly because we are not inclined to view medicine as a business. Thus, conveyed by commonplaces, an expression of the culture of doing more, there is a proliferation of attractive advice that tends to delegate to technology the solution to health problems. Slow Medicine has summarized these clichés into the seven poisons of fast medicine (see Table 1), for each of which we have given an example.
- New is better. Robot-assisted surgery costs a lot more and in many cases is associated with increased complications. Its use should therefore be reconsidered among the trials and patients should be informed about the risks they face10. Instead, despite economic difficulties, many hospitals, boast of being able to guarantee their patients the latest technology. They do it for misunderstood reasons of prestige and with the important complicity of the media.
- All procedures used in clinical practice are effective and safe. Most people think that medicine is an exact science and that everything that is prescribed is scientifically proven. Unfortunately, this is not always the case. More than 50% of the procedures used in clinical practice are not based on scientific evidence and 3% are even harmful11. It wouldn’t be a bad thing if physicians adjusted their activities to what is scientifically proven (at least when such “certainties” are available).
- The use of increasingly sophisticated technologies will solve every health problem. Health services explain only 10% of preventable mortality. The other 90% is associated with lifestyle environmental, social, and cultural factors and genetic predisposition12. Yet, only a very small part of the resources allocated to research is directed towards the study of the sociological and behavioral components of health13.
- Doing more helps to heal and improves the quality of life. The extraordinary advances in diagnostics allow us to detect small abnormalities that we would never have heard of (incidentalomas). For example, almost 90% of asymptomatic people over the age of 60 years who have an MRI of the knee, show that they have at least one abnormality14. The problem is that after having found it, the patient will almost certainly undergo some form of (completely unnecessary) treatment, or rather he will demand it himself!
- Discovering a “disease” before it manifests itself through symptoms is always useful. It is proven that check-ups (e.g. laboratory tests, ultrasound, and radiological examinations) performed on asymptomatic people do not reduce mortality, nor morbidity, and expose people to serious harmful effects15. Nevertheless, they continue to be widely prescribed, often to satisfy the insistent patients’ insistent requests. Just
Google and type in check-ups to see the extraordinary business that lies beneath this flourishing activity. A trap, often without return, from which one should keep well away from, but from which it is practically impossible to escape.
- Potential “risk factors” must be treated with drugs. In recent years there has been a progressive trend towards lowering the thresholds of normality of many biological parameters (blood pressure, lipids, cholesterol, glycemia, vitamin D, bone density), and then bring them back to within normal through the use of drugs. A recent Cochrane review concluded that treating arterial hypertension <160/100 mmHg has no significant effects on morbidity and mortality of low-risk subjects16. Nevertheless, millions of people with systolic blood pressures between 140 and 159 continue to be treated unnecessarily with drugs that expose them to serious unwanted effects.
- To achieve better control of your emotions and mood is useful to rely on medical care. An extensive and progressive medicalization is underway which includes decisions about the most significant events in life. Many decisions about birth, sex, emotions, old age, and death are delegated to medicine and for some have even become even a very good “business”. The new edition of the manual for the classification of Mental Disorders (DSM-5) has raised many psychiatrists have been alarmed by a possible massive increase in diagnoses, as common somatic disorders have been classified as mental illnesses and consequently treatable with psychoactive drugs17.
Overdiagnosis and overtreatment
As we have seen, large areas of medicine are strongly contaminated by various forms of healthcare consumerism that tends to transform subjectively healthy people into patients in need of care. Check-ups, screenings, the reduction of the thresholds of normality, the invention of new diseases are all ingenious ways of pursuing this goal. Today, however, there is strong evidence that these interventions are harming healthy people. The main reason is the phenomenon of overdiagnosis, which consists of identifying and consequently treat abnormalities that would not have caused any disorder. This can have serious negative effects on health due to adverse effects of medications, surgeries, and radiotherapy to which such people are unnecessarily subjected to. For example, in populations where screenings for prostate and thyroid cancer are active, there has been a sharp increase in the number of diagnoses and treatments compared to populations where screening has not been adopted, but mortality rates have remained almost unchanged in both populations18. Early disease detection strategies should therefore be evaluated with great caution, as the percentages of overdiagnosis of cancer detected during screening programs are particularly worrying: 20-30% of breast cancers identified by mammography19, 50-60% of prostate cancers identified with the PSA test20, and 80-90% of thyroid identified by ultrasound21.
Medicine becomes slow
From dictation to the whole: realigning science and humanism
Classical scientific thought is based on the reductionist paradigm according to which the explanation of the phenomena that we observe is contained in the properties of the elements of which they are composed. In this model, linear relationships of cause and effect through which are connected. This method, which has achieved extraordinary results in every field of knowledge, has deluded us that it could solve any problem.
In the biomedical field, this means that man can be “reduced” to a collection of molecules and that the diseases are the expression of something that does not work at the biochemical level. By these principles, the interest of research has focused on the pathophysiological mechanisms of diseases, on molecular biology, application of diagnostic techniques, and control of symptoms. It is as if men were machines to be overhauled and adjusted. Regarding the treatment, the individual organs are taken care of by an increasing number of specialists, each of whom focusing on smaller and smaller parts of the body. In this way, knowledge becomes fragmented and consequently, the processes of treatment are also fragmented in a myriad of acts and procedures to which no one seems to be able to make sense of them anymore. For example, an eighty-year-old patient with osteoporosis, arthrosis, type II diabetes, COPD, and hypertension would have to take 12 medications, in 19 administrations daily. In addition, he would have to follow dozens of dietary and behavioral recommendations, some of which contradict each other22. However, rarely does anyone bother to rebuild a new balance between their “metabolic state”, the person and the family and social environment in which he is embedded.
The systemic approach, on the contrary, teaches us that some phenomena cannot be explained simply by studying in depth the constituent elements because of their interaction, at a higher hierarchical level, completely different properties. Thus, the life of a person is more than the sum of the thousands of chemical reactions that are produced at every moment in their cells. At different levels of complexity, new and unexpected properties appear; so-called emerging, such as thinking, emotions, pleasures, health. These properties are not detectable in the individual elements and cannot be studied with classical scientific tools. It is necessary to use other methods of analysis and acquire skills and knowledge in other domains of knowledge, such as the humanities (e.g. philosophy, anthropology, psychology, pedagogy, ethics, art, etc.),
Broadly speaking, one could say that the reductionist method sees only the functioning of single molecules while the systemic approach looks at the properties that arise from their interactions23 (see Table 2). However, the use of the former does not exclude the use of the latter, because the scientific and technical aspects intertwine with the inclinations, desires, values, and preferences of the person in question. It is like a melting pot of actions and reactions in which it is not easy to orient oneself, but of which one should at least be aware. Patient, doctor, and context often represent an inseparable whole that one must know how to the plurality of languages and the communion of knowledge between biological, humanistic, and social sciences. To deal with complex phenomena, Edgar Morin reminds us, it is not enough to oppose fragments of knowledge. According to Morin, we need to find a way to make them interact within a new perspective24.
Physician and patient: a two-way relationship
The reductionist approach has brought great contributions to medicine, but paradoxically it ignores other areas that are no less important for people’s health, such as relational and communication aspects.
Now we know that to treat people it is necessary to use scientific data (traceable to the so-called evidence-based knowledge). However, one must also take into consideration the humanistic side, which has to do with feeling, states of mind, emotions, expectations. The physician must put his expertise in the field to formulate a diagnosis, indicate a prognosis, and propose possible therapeutic choices. Yet, he/she must also acquire specific skills in communication and relationships to take into consideration
the attitude to risk, values, fears, expectations, and social circumstances of the patient and those close to them. It is only through this encounter between knowledge, wisdom, and feelings that the process of care is activated and consolidated: in this sense, the attention to narrative medicine ⎯ which Slow Medicine places at the basis of the encounter with the patient ⎯ takes on a fundamental meaning.
Empathy, respect, an expectation of benefit, and hope of recovery play a crucial role in the treatment and act independently from the active ingredient being administered. Neuroscience has discovered, however, that the ritual and interpersonal relationships that accompany the medical act set in motion a chain of biological effects that are associated with those induced by the disease and treatments and that can influence positively or negatively on the outcomes of treatment25.
Recognizing the limits of science
Medicine is considered an exact science, and this is the reason why many professionals have learned that clinical practice must exclusively take into account data from scientific trials. Thus, anything that is not scientific is merely the product of opinion and gullibility.
That medical practice should adhere to the best scientific knowledge is beyond question, but it is also necessary to resign oneself to the fact that many aspects of treatment are not investigable by the scientific method and that, despite extraordinary progress, much of what concerns diseases and their treatment remains unknown. People are lead to believe that medicine has no limits and that there is always a solution to all problems. The lack of response or failure to heal is therefore considered the result of professional incompetence and triggers medical-legal claims. Especially when a relationship of mutual trust between the professional and the patient has not been established.
Managing uncertainty and ignorance
When faced with problems for which medicine has no scientific answers, the “scientist” doctor finds himself completely disarmed and forced to resort to the tools they have been taught to use: to request tests, ask for specialist visits, and prescribe drugs. They do that even when these tools are obviously useless. In addition, his scientific culture, apparently prevents him from using a powerful tool of relief and healing: the placebo effect, for which we still have no “scientific” explanation, but which can awaken the extraordinary capacities of defense and healing present in each of us. It is not for nothing that more than half of the population turns to alternative medicine. In fact, their devotees (more or less in good faith) have understood that it is useful to manage even what they do not know and that, in any case, it is always worth listen to people and give them comfort and hope.
The “Doing More Doesn’t Mean Doing Better” Project
On the operational side, in December 2012, Slow Medicine promoted the “Doing More Doesn’t Mean Doing Better” project26 (in analogy to what was started in the USA with “Choosing Wisely”)27. The project aims to improve clinical appropriateness, reducing the overuse of tests, and treatments through an assumption of responsibility of healthcare professionals. As a first step is provided that the scientific societies that have joined the project indicate five diagnostic tests or treatments commonly found in clinical practice in Italy that often do not offer benefits to patients, but rather expose them to unnecessary risks. These practices should be the subject of information and dialogue between professionals and patients.
Towards a new alliance
This is a big gamble because in medicine the concept that “doing more doesn’t mean doing better” is not taken for granted and goes in the opposite direction of the prevailing culture. For a physician and for the organization in which he or she works, doing more often means earning more, satisfy the patient, and be less exposed to medical-legal disputes. In this context, saying no to the patient who asks for a CT scan for lower back pain, antibiotics for colds, or a check-up to achieve peace of mind may be very wise, but hardly feasible. Nobody alone can do it: that’s why we need a strong alliance between professionals, patients, and citizens.
The project is also advancing internationally
Despite these problems, the Slow Medicine project has received the support of FNOMCeO, IPASVI, Altroconsumo, Slow Food, and some associations of citizens and patients and, to date, the support of 30 national scientific societies, 10 of which have already published the list of 5 procedures at risk of inappropriateness (see Table 3). Six of them were written by patients, already published by Altroconsumo, and others are in the process of publication28.
Some hospitals are also moving in this way, starting with the hospital in Cuneo, which has already drawn up lists for various specialist disciplines29, and that of Messina, which is about to start a two-year project approved by the Region of Sicilia. In Turin, in collaboration with the Italian Society of General Medicine (SIMG), an initial experiment is underway to evaluate its impact on clinical practice. The trial called “Let’s choose with care”, provides for an intense activity concerning knowledge exchange and involvement of the population on issues about appropriateness and conscious choices.
The project is officially part of the movement Choosing Wisely International. It was structured in June 2014, during the International Roundtable on Choosing Wisely in Amsterdam, with representatives from the U.S., Canada, Netherlands, Italy, Great Britain and Wales, Germany, Denmark, Switzerland, Japan, Australia and New Zealand30,31.
The definition of practices represents, however, only the first step. The project proposes other important objectives, such as comparing different professionals to avoid the risk of providing divergent or contradictory indications, improving the dialogue between doctors and patients, and make patients and citizens understand that more is not always better and that a doctor who prescribes more tests is not necessarily the most competent32.
Table 1. The seven poisons of Fast Medicine
|New is better.|
|All the procedures we use in clinical practice are efficient and safe.|
|The use of more sophisticated technologies will solve every health problem.|
|Doing more helps with healing and improves quality of life.|
|Discovering an “illness” before it manifests itself through symptoms is always helpful.|
|Potential “risk factors” should be treated with medications.|
|To better control emotions and moods, it is useful to rely on medical care.|
Table 2. Characteristics of the reductionist and systemic methods.
|FAST – Disease oriented||SLOW – Health oriented|
|Method||Reductionist, based on the principles of classical science, newtonian.||Systemic, based on the principles of complex systems.|
|Physician||Observes and decides.||Informs, guides and advises.|
|Patient||A body to be investigated, that works like a machine.||A unique and unrepeatable resource that thinks, produces knowledge, experiences emotions and feelings.|
|Objective||Oriented towards research and symptom control.||Based on patient priorities, expectations and preferences.|
|Treatment||Centered on the correction of pathophysiological mechanisms of disease.||Centered on the set of factors that affect health.|
|Cure||Entrusted to specialists who work, for the most part, in isolated.||Entrusted to professionals who work in teams and exchange information.|
|Decisions||Established by standardized procedures and protocols.||Personalized, mediated by scientific knowledge and the context of reference.|
|Results||Depend on linear cause-and-effect relationships, static, isolated, repeatable and reproducible.||Depend on dynamic, unstable, interconnected systems, multidimensional, open to change.|
|Conclusions||Quantitative analyses centered on the average pursue homologation.||Qualitative analyses that take variance into account value diversity.|
|Health||Complete state of well-being, physical, mental and social.||Ability of the individual to adapt to the physical environment.|
Table 3. Scientific societies that have joined the project “Doing more does not mean doing better”, of which the first 10 have already published their practices.
|1. Associazione Italiana di Dietetica e Nutrizione Clinica – ADI|
2. Associazione Italiana di Radioterapia Oncologica – AIRO
3. Associazione Nazionale Medici Cardiologi Ospedalieri – ANMCO
4. Collegio Italiano dei Primari Medici Oncologi Ospedalieri – CIPOMO
5. Cochrane Neurological Field – CNF
6. Società Italiana di Allergologia e Immunologia Pediatrica – SIAIP
7. Società Italiana di Medicina Generale – SIMG
8. Società Italiana di Radiologia Medica – SIRM
9. Società Italiana di Allergologia, Asma e Immunologia Clinica – SIAAIC
10. Società scientifiche di IPASVI: AICO, AIOSS, AIUC, ANIMO
11. Associazione Culturale Pediatri – ACP
12. Associazione Dermatologi Ospedalieri Italiani – ADOI
13. Associazione Italiana di Medicina Nucleare – AIMN
14. Associazione Italiana di Neuroradiologia – AINR
15. Associazione Medici Diabetologi – AMD
16. Associazione Medici Endocrinologi – AME
17. Associazione Nazionale dei Medici delle Direzioni Ospedaliere – ANMDO
18. Associazione assistenza appropriata in ostetricia e ginecologia – ANDRIA
19. Collegio Italiano dei Primari di Chirurgia Vascolare
20. Coordinamento Medici Legali Azienda Sanitarie – COMLAS
21. Federazione delle Associazioni dei Dirigenti Ospedalieri Internisti – FADOI
22. Federazione Italiana Medici Pediatri – FIMP
23. ISDE – Medici per l’Ambiente
24. Società Italiana di Cure Palliative – SICP
25. Società Italiana di Genetica Umana – SIGU
26. Società Italiana di Medicina di Laboratorio – SIMeL
27. Società Italiana di Nefrologia – SIN
28. Società Italiana di Pedagogia Medica – SIPeM
29. Associazione Italiana Fisioterapisti – AIFI
30. Altre società scientifiche di IPASVI tra cui ANIARTI e AISLEC
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This article is translated from the Italian by using Deep L and Grammarly apllications. Karlijn van Eersel Kindly reviewed this translation. We are very grateful for her contribution.
The translation was done after the permission of the editor of the journal “Recenti progressi in medicina”.