By José Carlos Campos Velho
Originally published on September 2022: Slow Medicine Brasil
The Italian Association of Slow Medicine has launched, on the occasion of its foundation, the Slow Medicine Manifesto, which proposes a form of medicine that is sober, respectful and fair to people. This kind of medicine is sober because doing more doesn’t mean doing better; respectful because patients’ values, expectations, and desires are personal and inviolable; and fair because it proposes a medicine of good quality that can be offered to everyone. In 2014, the Dutch Institute of Slow Medicine elaborated ten principles that govern the practice of Slow Medicine. For some time, we have been thinking about making a collaboration of the Brazilian movement to the foundations of Slow Medicine, and so we have proposed what we call The Four Pillars of Slow Medicine.
Time is our first pillar. Just as the first principle of Slow Medicine suggested by the Dutch initiative is time, we found that time really is one of its most important pillars. Time that doctor dedicates to patients becomes quality as it creates interaction and connection between physicians, patients, family members and citizens. Time allows for the exchange of information between protagonists of clinical relationship and a fruitful interaction between health professional and patients. We are talking about time as presence, time as a space for reflection and exchange of impressions, and time for sharing decisions. It also refers to a cautious analysis of scientific evidence and time that helps science to consolidate its constant discoveries. We are not only talking about the limited time of a clinical encounter, but time considered in its longitudinal perspective, as this allows for a prolonged coexistence between health professional, patients, and family members, generating bonds permeated with solidity and trust, and making it possible to reach a more harmonious decision-making that is compatible with values and expectations of patients.
The pillar of time already points to the second pillar of Slow Medicine, which is Decision Sharing. This is not a paternalistic view of clinical relationship. Shared decisions play an increasingly important role in medical care. Therefore, it is necessary that patient and family members are properly informed about clinical decisions and possible diagnostic and therapeutic options. Decision sharing is a process that requires health professionals to know patients’ reality, values, and expectations, which are used as a guide for proposed therapeutic strategies. The empathic communication of such therapeutic proposals favors patients’ participation in the process and increases their adherence to it. This should be the new mantra of medicine.
The third pillar of Slow Medicine is Cautious Use of Technology. Slow Medicine is not against technology at all. Far from it, we propose a cautious, thoughtful, parsimonious, appropriate, and rational use of technology. Technology refers both to diagnostic and therapeutic technologies and to new information technologies, the overuse of which can diminish true clinical relationship rather than enhance it. We have always claimed that Evidence-Based Medicine is the theoretical framework of Slow Medicine, and so it is. Overall evidence points to the need for greater rationality in the use of available technological resources, aiming for a better quality of care and sustainability of health systems (campaigns such as Choosing Wisely and initiatives such as Cochrane show this quite clearly). We believe that two things are equally inappropriate: underutilization of resources (underuse) and overutilization of resources (overuse). Slow Medicine is not a romantic return to an idealized past, but rather an updated combination of the assumptions of Hippocratic medicine with current diagnostic and therapeutic resources.
Finally, the fourth and last pillar of Slow Medicine is Doctor-Patient Relationship. We propose that protagonists of this clinical relationship (a term advocated by Spanish bioethicist Diego Gracia, which suggests a more comprehensive definition for a doctor-patient relationship, as other health professionals are also a part of patient care) seek to establish solid bonds of trust that allow a sincere and disinterested exchange of information and sharing of decisions.
It is no wonder that these pillars of Slow Medicine are four in number. These pillars (Time, Decision sharing, Cautious use of technology and Doctor-patient relationship) were chosen to symbolize the idea of support and stability that number 4 lends to anything that is built by mankind, be it a house, a temple, a health system or a deep and long-standing clinical relationship. We believe that this is the main idea of Slow Medicine and of all those who believe in a more humane medicine: support and stability to face obstacles and difficulties inherent to our existence in search for better health and quality of life.
This article was published in collaboration with Ana Coradazzi and André Islabão. The article was translated from Portughese by André Islabão.