By Marco Bobbio
Originally published on January 2018: https://www.slowmedicine.it/intervista-a-victoria-sweet/
Last October, the latest book by Victoria Sweet, author of God’s Hotel – a doctor, a hospital and a pilgrimage to the heart of medicine (2012), was published. In that book the author had foreseen the birth of a Slow Medicine, an unhurried medicine in which the doctor plays a role more like that of a gardener concerned about the health of his plants than of a mechanic who is engaged in the repair of broken cars. In the text Slow Medicine – The Way of Healing, Victoria Sweet (who was formerly a physician at Laguna Honda Hospital in San Francisco and dedicated to the study of medical history) analyzes her professional career by telling the stories of patients who taught her recognize the limits of medicine fast.
In view of the interest that his reflections have aroused in the members and supporters of Slow Medicine, we consider it interesting to discuss with her some aspects that also concern the Italian situation.
Marco Bobbio (MB): We defined the philosophy of Slow Medicine as a medicine measured, respectful and equitable. According to your experience do you think that the adjective ‘slow’ should be superfluous since Medicine, at least the one you studied and practiced at the beginning of your profession, should be like this?
Victoria Sweet (VS): “Great question. Yes, it should be superfluous. Really what I’m talking about, what we are talking about, is just Good Medicine, in the same way that Slow Food, really, is just Good Food. But the reason Slow Food is Slow is because of Fast Food; it is Slow Food by reaction against Fast Food; it is Not-Fast. And in that way the adjective Slow for Slow Medicine is useful. It highlights what it is not. Slow Medicine is Not industrial, Not based on a factory model of producing healthcare in the most efficient way. It sees the body NOT, or not only, as a machine to be fixed, or a computer to be debugged, but as a plant, and most of all, as individual, as sensitive, as complex. Slow Medicine because it is Not-Fast Medicine.”
MB: Which stroke me more reading your book are your considerations on the transition between Medicine and the Healthcare System. It recalls me the The Grapes of Wrath by John Steinbeck who masterfully describes the shift from a family oriented farm work to an industrial driven agriculture. Don’t you think that those changes in agriculture and medicine are the inevitable evolutions of the need of efficiency?
VS: “I question the concept of “efficiency” in farming and gardening, where of course, I am not an expert, and in medicine and healthcare.
What do we mean by efficiency, really? In agriculture, is it the most food produced by the fewest people? The cheapest as measured by….people hours spent producing that food? But that concept of efficiency leaves out most of the actual costs—destruction of soil, production of unused waste, and hours of labor not really counted. I question also the concept of efficiency in healthcare, since in my experience, healthcare “efficiency” leads to tremendous waste–unnecessary tests done, unnecessary medications taken, leading to unnecessary side-effects. It is actually inefficient, and so-called inefficiency is efficient.”
MB: How can Slow Medicine reverse this approach of medicine?
VS: “The biggest problem in trying to reverse this approach is that we have misunderstood the purpose of Fast Medicine. The purpose of Fast Medicine is not, even, the production of efficient healthcare, so-called. The purpose of Fast Medicine is to produce profit for the healthcare industry of Pharma, Marketing, Lobbying, Hospital Executives, Shareholders, Wall Street, Insurance companies. Big powerful sectors, and I think, therefore the best approach is a kind of judo, similar to what happened with Slow Food, and the Organic Food Movement. It was and is a slow movement. It didn’t fight fist to fist but rather started farmer’s markets, cooperatives, Community Sponsored Agriculture, etc. And that I think should be our model. A kind of Organic Medicine Movement. In the States that takes the shape of the concierge movement, and the direct pay movement.”
MB: When you arrived at the San Francisco’s Laguna Honda Hospital you decided to see your patient as soon as he arrived, even before looking into the records or talking with the family, Our project #buongiornoiosono (#hellomynameis…) focus exactly on what you have done. How do you think it is important to create a positive relationship just at the beginning of the patient-physician encounter?
VS: “I think it is not only the politeness involved, the eye to eye person to person shaking of hand and introducing of oneself. From a medical point of view, the most important thing to me is being-with the patient. Seeing him, smelling him, being in his presence–for diagnosis!
Someone wrote me that his mentor told him that 90% of the diagnosis should be clear to you by the time the patient has walked in and sat down at your desk. That may be a bit of an exaggeration, but the main thing is accurately getting whether your patient is sick, or well. And if sick, how sick. And in those first few minutes, that is what you can learn.”
MB: Throughout the book you make several consideration regarding the philosophy of Slow Food. The difference between food science and gastronomy is that the former studies individual components of food loosing the sense of eating and the latter explore the taste of what we eat as a whole. Do you think we can imagine the same contraposition between Fast and Slow Medicine?
VS: “Yes I do. The whole is way more than the sum of its parts. They come together in an interesting way with “spirits”–alcohol. So in medical school and in our pharma texts, all alcohol is the same. Beer, wine, spirits, no matter how made; the studies on drinking are lumped together. All that is paid attention to is the percentage of ethanol in the liquid. But when I discovered Hildegard of Bingen’s Medicine, and through her the whole tradition of the use of drinks as medicines, I was reminded of the obvious. Beer is not only ethanol. It has hops in it, which are medicinal; wine is complex with many other active and important medicinal substances, etc. Complexity that cannot be accurately taken apart and controlled.”
MB: All the cases you describe in the first part of your book represent the triumph of Fast Medicine. During those years of training did you ever bumped into cases that made you consider that medicine was going too far from the patients’ needs? At that time didn’t you have any doubt regarding the futility of clinical aggressiveness?
VS: “I was especially struck by that point on Obstetrics. Having seen a completely natural and healthy birth (which I describe at the beginning of the book), when I was on Obstetrics I was shocked by the mostly but not complete medicalization of the birth process. Mostly all that technology was unnecessary and invasive–until it wasn’t. And the trick was and is judging when Fast is needed.”
MB: Several physicians join the Slow Medicine philosophy but they have to work in the actual heath care system so well described in your book. What should they have to do to change their colleagues’ way of think and working? How can they survive in the Health Care system ?
VS: “I don’t know. That’s why I’m not in it at the moment. My friends that are surviving and flourishing have all started their own practices, which are supported by monthly fees.”
MB: In Italy many hospitals are introducing software for electronic charts as a way to make physicians work more efficiently. Do you think we can imagine a slow use of electronic charts or we have to fight against them?
VS: “The problem with electronic health records is not that they are made out of electrons. It is the way they are used–to harvest data–not to help doctors and patients. It is their structure that is wrong; based on an old billing platform which is clumsy and, frankly, stupid. They should be like books, modelled on the paper chart, with pages, and a beginning a middle and an end. It should be artificial intelligence that populates the boxes, not doctors.”
MB: What can the University do to prepare a new generation of Slow Doctors?
VS: “We need to have Slow Medicine Clinics, Slow Medicine Beds in our hospitals, and a Slow Medicine Consulting Service, so that students can learn how to practice Slow Medicine from those who know it, and so that patients can get Slow Medicine when they need it.”