By Ana Coradazzi
Originally published on January 13, 2019: https://www.slowmedicine.com.br/slow-medicine-fast-medicine-de-maos-dadas/
When JCV, 61 years old, poorly controlled hypertensive and obese, arrived at the emergency room complaining of intense “burning” pain in his chest about 50 minutes ago, irradiating to his left arm and associated with cold sweats, he barely had time to think. Within minutes, the doctor on duty had already ordered blood tests and an electrocardiogram, which showed a supra-ST-segment elevation, confirming the suspicion of acute myocardial infarction. In less than an hour from his arrival at the hospital, JCV started fibrinolytic therapy that would allow the restoration of coronary circulation and minimize the myocardial sequelae of the infarction, allowing a full and productive life after an event that could have taken his life.
Situations like this allow everyone (patients, families, and healthcare teams) to witness the almost miraculous results of modern Fast Medicine. Technology and the rigorous implementation of guidelines for the management of these cases have saved thousands of lives and allowed patients not only to return home alive but to live fully after such serious events. The gains have been so significant that is difficult, if not impossible, for anyone to defend the idea of using fewer tests, procedures, and treatments in our medical practice. Amid so many advances and such amazing results, it is heresy to talk about “slowing down”, about spending more time with patients, about giving up tests and procedures in favor of excellent clinical history and physical examination. It may seem a somewhat romantic or even irresponsible idea, and it is, if the context is like that of JCV in the emergency room, with its typical clinical signs of acute infarction and the plethora of data proving the benefits of acting quickly in this context. The issue here is precisely this: the context.
The idea that adopting a “slow” posture implies being contrary to modern medicine is, unfortunately, a common misrepresentation of its principles. There is nothing retrograde about Slow Medicine, and it firmly supports the use of new technologies. The proposed challenge is to use them in those who will benefit from them, instead of distributing fibrinolytic agents, mechanical ventilators, broad-spectrum antibiotics, or state-of-the-art chemotherapy to any patient who, by chance, falls into our hands with a symptom that might fit into some conduct guideline. The proposal is to be more judicious and responsible with our diagnoses and treatment strategies, avoiding the terrible vicious circle that begins with the request for tests that have nothing to do with the symptoms that led the patient to come to us, and ends with the evaluation of 8 specialists, with 12 different diagnoses, and the prescription of 22 different medications (whose possible drug interactions no one has seen). The patient? No, he hasn’t improved from his initial symptom…
Slow Medicine’s warning is not against the advances in medicine but against the obstacles to good quality medicine: laziness, carelessness, fear of lawsuits, lack of time, negligence, and of course, lack of common sense. The alert is to remind us that using “everything” for “everyone” is, to say the least, naive. What is worse: it can be deleterious and even cruel.
First point: no cutting-edge technology can solve a problem if the diagnosis of the problem is wrong (and, believe me, the chances of a misdiagnosis increase exponentially as the time spent on medical history and physical examination decreases). To minimize the importance of the process that leads us to an accurate diagnosis is to waste valuable time (ours and the patients’) and devalue our many years devoted to medical training. It is the shortcut to prescribing only a gastric protector for that patient who is having a heart attack; an antispasmodic for the girl with acute appendicitis; or an antiallergic for the child with scabies. Second point: requesting an infinite number of tests and evaluations from specialists, accumulating prescriptions for medications, and collecting indications for procedures may ease our conscience, but it doesn’t make us better doctors. It just reduces our patients to “users of the health care system”, and we doctors (greatly) restrict our ability to help them. There is already more than enough literature proving the inferior results of medicine practiced without common sense and individualization of patients. Third point: yes, we should use all the technology we have available (please, if I am in the emergency room having an acute myocardial infarction, don’t hesitate to start thrombolysis!) But there is always time (even if it is seconds) to ask ourselves the “golden questions” of good medicine: “What else can it be?” and “Can this patient benefit from what I am doing?” These simple questions require us to try harder to confirm our diagnoses and avoid the trap of making hasty decisions based on our own beliefs and experiences. They force us to take a step back. Even in emergencies, the “golden questions” can make a brutal difference, and they take only a few seconds (the time the nurse is providing that EKG is more than enough to ask them).
Finally, our greatest challenge, as physicians, is not to choose whether to be “fast” or “slow”. The challenge is to have, in our brains, both ways of practicing medicine, and to know how to accurately recognize which one the patient in front of us needs. It means adopting common sense, parsimony, and discernment to guide the thread for all our conduct in any situation. To be FAST when we need to be FAST, to be SLOW when we need to be SLOW. This is the formula (not magic) to achieve excellence in this profession that has so much to offer, not only to patients but also (and perhaps mainly) to ourselves.