By Yung Lie :
In this overview article, we will discuss the Slow Medicine initiatives that have emerged in Italy, the USA, the Netherlands and Brazil. Although there are significant differences between the approaches in these countries, there is also a large common ground and shared values among the four national Slow Medicine movements. Whether the Slow Medicine practitioners will be part of a tipping point, leading to significant changes in medical practice, is a question than cannot be answered at this moment. The wide scope in geographical and in medical perspective of the international Slow Medicine movements deliver an interesting view on a new way of thinking about health, care and cure.
Origins of Slow Medicine: Italy
In 2002, the reputed Italian cardiologist Alberto Dolara published an article in the Italian Heart Journal. This was the first scientific publication where the term Slow Medicine was introduced. Dolara stated (translated from the original Italian): “In clinical practice, hyperactivity is often unnecessary. Adopting a strategy of ‘slow medicine’ may be more rewarding in many situations. Such an approach would allow health professionals and in particular doctors and nurses, to have sufficient time to evaluate the personal, familial and social problems of the patient extensively, to reduce anxiety whilst waiting for non-urgent diagnostic and therapeutic procedures, to evaluate new methods and technologies carefully, to prevent premature dismissals from hospital and finally to offer an adequate emotional support to the terminal patient and their families.”
This article led to the start of the Italian Slow Medicine movement. Italy’s Slow Medicine was founded in 2011 as a movement of physicians, health professionals, patients and citizens, aimed to promote processes of care based on appropriateness, in relation to listening, dialogue and decision sharing with the patient. Closely linked to the Italian Slow Food movement, Slow Medicine’s home is Turin. This ‘capital of slow food’ provided fertile ground for the steady growth of the Italian Slow Medicine movement. Not only do the Slow Medicine and Slow Food organizations share similar logos, they cooperate in scientific and popular publications. In the Italian Slow Medicine book, Slow Food founder Carlo Petrini wrote the preface. His popularity and media impact helped to further Slow Medicine on a national scale.
On the logos: The Slow Food logo is a snail. For Slow Medicine, two snails were chosen as logo. These two snails represent the three main principles of Slow Medicine and focuses on an equitable patient-physician relationship: Sobria, Rispettosa, Giusta (Soberness, Respectfulness, Equity).
Currently, the Italian Slow Medicine Society organizes and approves postgraduate courses and training sessions all over the country. It develops medical protocols as an alternative to ‘fast’ medicine and advocates evidence based research. The annual Slow Medicine conference has a growing number of attendees, whereas the regular members of the Italian Slow Medicine Society have surpassed the number of 250. Italian media (TV, newspaper) is regularly covering news items that originate from the Slow Medicine Association.
The medical impact of Slow Medicine in the Italian health care system
Looking at the post graduate training portfolio in Italy, conference themes and publications, the Italian Slow Medicine movement has been successful in shaping alternatives to traditional medical practice. Its focus on the importance of time as a crucial element in medical care is clearly visible in the various Slow Medicine protocols that have been developed under auspices of the Slow Medicine Association. In addition, the patient’s autonomy in choosing medical interventions and medication has been enlarged. The latter aspect is closely linked to the international Choosing Wisely movement, with which Slow Medicine Italy has professional relationships. The Italian Slow Medicine movement originated from doctors, therapists, social workers, and nurses with outstanding academic and medical records: cardiologists, internal medicine, surgeons, pediatricians. This helped in the acceptance of Slow Medicine as a full-fledged medical alternative to “fast” medicine. Therefore, Slow Medicine is by no means a form or derivation of alternative medicine but can be viewed upon as a new approach to the common medical practice in hospitals, GP practice et cetera.
Slow Medicine in the USA
In the United States of America, there is no significant recognized Slow Medicine organization. Instead, the Slow Medicine principles are advocated by individuals who share their views in books, publications, lectures and online. Indisputably, the founding father of the North American Slow Medicine is the late Dennis McCullough, a geriatrician and professor at Dartmouth College. As the author of the bestseller My Mother, Your Mother, he describes how the health care system in the United States all too often leads to over-treatment and redundant medication for people facing the end of life, in most of the cases of advanced age. He interweaves his viewpoints with personal narratives of his mother and of his own experience as a patient, being hospitalized. Dennis McCullough taught younger physicians how to find medical interventions that were sober, respectable and equitable, as proposed by Slow Medicine Italy years later.
“Thanks to advances in medicine, the lives of the elderly and the infirm can be significantly prolonged. But at what cost? Wrestling with the question “What’s the right thing to do for mom or dad?”, many of us become unwillingly caught up in the new “death by intensive care” epidemic in which the “care” is often more destructive than the disease. We want to do the best thing, but are overwhelmed with the staggering choices we face.
Dennis McCullough spent his life helping families to cope with their parents’ aging and eventual final passage, experiences he too faced with his own mother. In this comforting and much-needed book, he recommends a new approach: Slow Medicine. Shaped by common sense and kindness, grounded in traditional medicine yet receptive to alternative therapies, Slow Medicine is a measured treatment of “less is more” that improves the quality of patients’ extended late lives without bankrupting their families financially or emotionally. Expensive state-of-the-art medical interventions do not necessarily deliver superior outcomes, Dr. McCullough argues. Gentle, personal care often yields better results, not only for elders in late life, but for the families who love them.”
God’s Hotel
Dr. Victoria Sweet is an Associate Clinical Professor of Medicine at the University of California, San Francisco, and a historian with a Ph.D. in history. She practiced medicine for twenty years at Laguna Honda Hospital in San Francisco, where she began writing. In her book, God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine (Riverhead, 2012), she lays out her evidence—in stories of her patients and her hospital—for some radically new ideas about medicine and healthcare in the US. ‘In our attempts to get control of healthcare costs by privileging “efficiency,” she suggests, we’ve been headed down the wrong path. Medicine works best—that is, arrives at the right diagnosis and the right treatment for the least amount of money—when it is personal and face-to-face; when the doctor has enough time to do a good job, and pays attention not only to the patient but to what’s around the patient.’ Dr. Sweet calls this approach Slow Medicine, and she believes that, put into wider practice, it would be not only more satisfying and beneficial for patient and doctor, but also less expensive for everyone. Her proposed Ecomedicine Project hopes to prove this. Because it was off-the-radar, “over the hill to the poorhouse“, God’s Hotel (Laguna Honda Hospital in San Francisco) allowed Dr. Sweet to learn and then to practice what she now calls Slow Medicine—as opposed to Fast Medicine, just like Slow Food is opposed to Fast Food.
Sweet: ‘Slow Medicine is just taking the time: to talk to and examine and even re-examine a patient; to call other doctors; to go over lab tests and X-rays; to think about and muse over a diagnosis; to discontinue medications that are, perhaps, no longer needed; to try a new medication—but carefully.
I write about Slow Medicine in God’s Hotel but have not yet written anything specifically for other doctors. Most experienced doctors already know about it, although not under that name. Who doesn’t know about it, is everyone else. Well, our great-grandmothers knew about it. The thing is that the only way to really explain Slow Medicine is to show it, to do it, and that is I hope create some setting—an Ecomedicine Unit or a Second Opinion Clinic—where Slow Medicine can be systematically practiced, taught, and studied.’
Knocking On Heaven’s Door
The third influential Slow Medicine author is Katy Butler. In 2013, she published ‘Knocking On Heaven’s Door.’ When doctors refused to disable the pacemaker that enabled her 84-year-old father’s heart to outlive his debilitating stroke and dementia, journalist Katy Butler embarked on a quest to understand why modern medicine was depriving him of a humane and timely death. “Every day across the country,” she writes, “family caregivers find themselves pondering a medical procedure that may save the life of someone beloved and grown frail.” But, when is it time to stop intervening and let nature take its course? When is it time to say to a doctor, “Let my loved one go?” With a reporter’s skill, a poet’s eye, and a daughter’s love, Butler points the way to a new art of dying for our biotechnological age.
Apart from writing, Katy Butler has helped to organize a large international online community of Slow Medicine enthusiasts. The Facebook page on Slow Medicine currently has almost 4000 members and these members share their knowledge and experience in the practice of Slow Medicine.
Although an American Slow Medicine organization does not exist, there is quite some coherence between the views and approaches of the US anchormen and –women of Slow Medicine. Although he did not write a book himself, Ladd Bauer, MD is the fourth American founder of Slow Medicine. In 2008, he published an article on Slow Medicine, the first publication on this topic in English. Later, he was the host of a radio show with Slow Medicine as the central theme. He worked closely with Dennis Mccullough in alliance with Katy Butler and Victoria Sweet. They explore the issue of overtreatment, especially when people are near the end of their life. Especially in the US healthcare system, where physicians are inclined to treat abundantly to avoid legal claims, the idea of letting things go, takeing time and reduceing interventions is quite disruptive.
Updates in Slow Medicine
A new platform has been introduced in the USA in 2014. Updates in Slow Medicine offer a wider perspective of Slow Medicine, that began as a series of discussions about developments in clinical medicine among students, residents, and faculty at the Cambridge Health Alliance and Harvard Medical School. These discussions led to regular email posts that gained a following among graduates of the program, colleagues, and eventually physicians and thought leaders throughout the U.S. A new term arose from these discussions — “Slow Medicine” — which, consistent with the broader “Slow Movement”, emphasizes thoughtful clinical reasoning, evidence based practice, and the importance of lifestyle changes for improving health. The originators of The Slow Medicine Updates, Pieter Cohen, MD and Michael Hochman, MD have further refined their definition of Slow Medicine as:
“The practice of medicine in which one is careful in interviewing (and examining) patients, careful to balance benefits and harms of diagnostic and therapeutic interventions, slow to intervene when symptoms are undifferentiated, committed to observation as an important diagnostic and therapeutic strategy, and cautious about adopting new diagnostic tests and therapies until the evidence establishes their value.”
The Netherlands: principles of Slow Medicine
Slow Medicine in The Netherlands started very modestly by launching a website, aiming to give a conceptual framework for Slow Medicine. Dick Koster, MD and GP, was planning to organize a workshop on ‘doing nothing’, as opposed to the Pavlovian reflex of physicians to get into the action mode whenever a patient is in front of them. This idea was met with such reluctance, that he decided to dig deeper into the idea of slowing down in medicine together with Yung Lie. Not long after that, contacts were laid with the Italian and American Slow Medicine colleagues, and they met in Turin, 2015. This was the first international meeting of Slow Medicine.
The Dutch approach is to bring together the Slow Medicine ideas in several central principles. This could help to integrate the experiences Italian and US medical practice into more universal lessons, how-to’s and theory. In 2014, it started with ten principles. As of 2017, the central themes whereupon Slow Medicine is based are:
Time is the most important value of Slow Medicine. Research shows that more time and attention from physicians for their patients leads to better diagnostics and a higher appreciation by patients.
Shared decision making and a focus on the patient’s values, expectations and preferences are key. This encompasses an embedding of the care program in the patient’s environment; family, neighbours, friends and other resources.
This means tailor-made care & cure, personal and individual care arrangements. Clearly, as opposed to generic and hospitable-centered care. This means not only an open attitude for physicians, but also from the patient. The latter will have to learn to be assertive, ask questions etc. This is called shared decision making.
Dutch researcher Machteld Huber developed a new concept to identify health, that lead to 32 aspects of health and six dimensions. The current definition of health according to the World Health Organization (the absence of physical, psychological and emotional sickness), is too limited. This WHO definition is focused on full recovery, whereas Slow Medicine stresses the relevance of adaptation and resilience. The latter approach improves self-management of disease which leads to a higher perception of health. Positive Health renders a conceptual framework and medical decision making scheme for quality-of-life centered medicine.
Integrative medicine acknowledges that body and mind interact; this insight is crucial for prevention and treatment of diseases. In this approach, the patient has an active role and responsibility in the process of recovering. Often, treatment is a combination of classic medication and additional interventions. Typically, patients who suffer diseases that cannot be clearly diagnosed in regular medicine, show positive effects when practicing Mindfulness, Yoga, Accupuncture, Homeopathy and dietary interventions.
Brazil: a medicina sem pressa
In 2015, the Brazilian Slow Medicine website was launched. The philosophy of Slow Medicine was brought to Brazil by cardiologist Marco Bobbio, one of the founders of the Italian Slow Medicine. His book Il malato imaginato (2010) had been translated into Portuguese in 2014, and was sold out soon after its launch in Brazil. Soon thereafter, a series of lectures in Brazil followed and this inspired José Carlos Aquino de Campos Velho (geriatrician and GP), Dario Birolini (professor in surgery) Kazusei Akiyama (GP) to establish the Brazilian branch of Slow Medicine.
The website contains a wealth of translated content from the Italian, American and Dutch Slow Medicine sources and the three Sāo Paolo based physicians regularly organize workshops and lectures, on topics such as Choosing Wisely and palliative care. Also, they aim to adapt the themes of Slow Medicine anchors like Alberto Dolara and Dennis McCullough to Brazilian medical practice. As such, the Brazilian approach is a combination of the American that mainly focuses on geriatrics and palliative care in the end of life stage, and the Italian approach that has a wider scope.
International perspectives of Slow Medicine
In March, 2015, Dennis McCullough, Dick Koster and Yung Lie attended the Slow Medicine Conference in Turin. Both lectured to their respective approaches and exchanged views. This was the first international meeting of Slow Medicine. After that, plans to establish an international Slow Medicine Movement were discussed. Very unfortunately, Dennis McCullough passed away on 3 June 2016. His passing meant a great deal for the still young international Slow Medicine movement. The combination of his wisdom and strong yet kind and mindful personality shocked many and he is still missed dearly.
One of the first projects was to have a Slow Medicine handbook in English. This would help to broaden the reach of the Slow Medicine movement. The most comprehensive and suitable source is the Italian book “Slow Medicine. Perché una medicina sobria, rispettosa e giusta è possibile” (2013) by Giorgio Bert, Andrea Gardini, Silvana Quadrino. In the process of translating the Italian Slow Medicine book in English, it turned out that much of the information and protocols are very specific for the Italian context. The major differences in national health care, the financials and insurance systems further blur a clear insight in common issues from Slow Medicine perspective.
To give an example: in The Netherlands exist National Guidelines for GP’s. These guidelines have much in common with the protocols of the Italian Slow Medicine Association. And the palliative care and hospice infrastructure is already pretty common in Holland whereas in the USA this is a major shift in health care/geriatrics.
The approach in the USA is very hands-on, personal and case-driven. In the books of McCullough, Sweet and Butler all connect personal stories with principles of palliative care. Italian Slow Medicine offers a more systemic perspective. In the publications and lectures, we often see philosophical considerations, apparently, an important prerogative for further steps to take. The very thoroughly worked out learning programs and practical courses throughout the country are but one example. Having said that, these differences make it hard to discern common principles that go beyond the ‘mere words’ stage.
Discussion issues
Note: – the texts that accompany the comments of the 3 american authors are quotations from their websites.
PS: José Carlos Campos Velho, MD, collaborated with suggestions and with the edition of the article on the website.
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Yung Lie (LLM, MSc) is co-founder of the Slow Medicine Institute in The Netherlands. Yung is an innovator in the public realm. He has worked on citizen participation projects in the field of urban renewal and regeneration. In the early days of Internet, he developed online toolkits for bottom-up policy making and originated online debates. He has advised and trained politicians of local and national government in co-creation and ‘peer-to-peer politics’. Being the son of two doctors, he has for long been fascinated by the medical practice. In a way, the distance between a politician and a citizen is comparable to the distance between a doctor and a patient. Slow Medicine could serve to bring these two ends together.
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