How to make practicing slow medicine a reality

“Medication mishaps cause a huge number of hospitalizations and in fact the majority of hospital readmissions.  Making more time for visits with aging and complex patients is critical to avoid mishaps of poor communication and rushed decisions.  A dose of  ‘slow medicine’ may get us to our goal of system sustainability faster,” writes colleague and fellow blogger Dr. David Moen.

Dr. Moen distills Dr. Dennis McCullough’s ideas about slow medicine down to three recommendations:

1. Never alone.  Elderly patients should be encouraged to bring a trusted person to all medical visits.

2. Pace medical decisions. Allow more time for reflection and the generation of questions, time for talks with family and friends, time for research on-line helps all of us to better understand our situations.

3. Reassess medications. The value of medications can change over time (true also for the value of “prevention strategies” and “early disease detection”).  What was wise and useful to take when younger in hopes for a healthier future can diminish in value as one ages.

In response

There are many good recommendations here, such as regularly reassess the need for an elderly patient’s current medications/doses; pacing decisions over time; and having another person in the room to listen and help explain.

These recommendations, though, should not be made out of context, rather we should hold them up to the light of concurrent trends in the external environment. Physicians shouldn’t be handed yet another mandate  — “Go slower, take more time with each patient, especially the elderly” — without the environmental changes that can support this approach.

Changes in payment, staffing, ideas around non-visit care are needed.

Payment. If older patients require more time for the same care, then physicians who care for the elderly should be paid more.  As it is now, we are paid less. We should not ask physicians to pay a financial penalty for caring for the elderly.

Staffing. Physicians can’t do this work alone. Yet payment rates, staffing models and meaningful use (MU) regulations often suggest that they should. The EHR is marketed as a tool to cut back on staff: work previously done by a receptionist, transcriptionist and pharmacist has been pushed to the physician. EHRs and MU mandate that work, such as submitting the billing invoice or recording the requested labs, be done only by the physician. Physicians are drowning in this low-level work, and find it harder to do the slow contemplative medicine Dr. McCullough describes.

I’d suggest that “not alone” also apply to the physician in the room; that there be another healthcare worker, such as a nurse or MA who can stay with the patient from the beginning to the end of the appointment, helping set the agenda, contribute to the conversation, and remain after the physician component of the visit to again explain the medication changes, the exercises, the diet changes … and to provide a written summary of the recommendations for the patient to take home. The physician can not do this work alone.

Non-visit care. Non-visit care is a wonderful way to augment care between visits. But when it is seen as a substitute for in-person care, as a short cut, a way to manage more patients, there are some downsides. It is hard to truly practice slow medicine and relationship-centered care if you seldom see the patient. An in-person visit allows the physician to assess a patient’s functional status and goals, to discuss with them deceleration of their medication regimen in ways that can’t happen by email.

Fragmented care. It is harder to practice slow medicine in primary care if primary care is provided by different people in isolated buckets. To practice slow medicine you need to actually see the patient, but if traditional primary care continues to be fragmented (hospitalists, coumadin clinic, congestive heart failure clinic, urgent care, e-visit care such as Virtuell — all good things when considered in isolation, but perhaps not all good when considered in sum) then soon the physician will spend most of her day processing paperwork for patients she no longer quite recognizes.

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations

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