"A dose of "Slow Medicine" may get us to our goal of system sustainability fast," writes Dr. David Moen. "Medication mishaps cause a huge number of hospitalizations and 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."
Dr. Dennis McCullough’s ideas about Slow Medicine for the elderly can be boiled down to three recommendations: regularly reassess the need for current medications/doses; pace decisions over time; and have another person in the room to listen and help explain.
These commendable recommendations should be held up to the light of concurrent trends in the external environment. Physicians can't handle 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, and the structure of 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, such physicians are paid less. Should physicians be asked 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 advocates.
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 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. If traditional primary care continues to be fragmented (hospitalists, coumadin clinic, congestive heart failure clinic, urgent care, e-visit care such as Virtuell etc—all good things when considered in isolation, but perhaps not all good when considered in sum) then soon the primary care physician will spend most of her day processing paperwork for patients she no longer quite recognizes.
Slow medicine, that is care that allows the physician, the patient and family to make thoughtful decisions in the full context of patient's stage in life and overall goals, requires a supportive environment. Slow medicine cannot depend on hero medicine, where the physician hero single handedly slays all of the dragons and clears all of the obstacles out of the way. Every stakeholder, from EHR vendors, to health system administrators to federal policy makers, has a responsibility to create an environment that supports physicians and their teams in the service of their patients.