December 03, 2017

Medical Care: Fast and Slow

Victoria Sweet is the kind of doctor I wish my mother had. For that matter, she’s the sort of doctor I’d want for myself or my husband: she’s knowledgeable, she’s compassionate, she’s thoughtful, and she’s thorough. Her new book about her evolution as a physician, Slow Medicine: the Way to Healingis a kind of prequel to her earlier, highly successful book, God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine, which tells of a remarkable, if a bit anachronistic institution, the Laguna Honda Hospital, where she worked for twenty years. Laguna Honda is a chronic disease hospital, a place where people who are too sick for a nursing home but not sick enough for an acute care hospital spend their days. But, in Dr. Sweet’s telling, it is also a place where physicians can practice medicine in a way that is seldom possible elsewhere, with the result that many patients stay at Laguna Honda even when they do become acutely ill, and some can be discharged to the community. God’s Hotel is a paean to “slow medicine,” the movement, like “slow food,” that challenges the contemporary tendency to focus on efficiency, technology, and science rather than deliberation, reflection, and art.
The new book, Slow Medicine, describes Dr. Sweet’s journey from psychology graduate student to staff physician at Laguna Honda. She explains, using many delightful case examples, how she came to understand what slow medicine is and what it has to offer. Her account serves to highlight the differences between slow and fast medicine in actual practice. While Dr. Sweet is at great pains to emphasize the importance of both fast and slow medicine, and in fact is herself able to move effortlessly from one to the other—to “think out of the box” by administering a surprising medication, the opioid-antagonist Naloxone, as part of an otherwise fast-paced resuscitative effort—the point of the book, as with its predecessor, is to glorify slow medicine. Without the deliberative, questioning, comprehensive approach to patients at which she excels, Dr. Sweet assures us, our highly regulated, protocol-driven technological medicine will disappoint.
But there is a problem with this view. It assumes that the reason so much of medicine has become fast medicine is that it has been commodified—“healthcare”  has replaced medical care and “providers” have replaced physicians. Dr. Sweet is partly right: device manufacturers and drug companies are in fact concerned with selling their wares, and economists do promote the reimbursement system for physicians and hospitals as the key to improving health outcomes. They view the interaction between a physician and a patient as a transaction rather than a relationship. But the regulations and the forms, the oversight and the accountability that she so maligns are a response to a reality that she glosses over: in times past, before medicine became so fast, quality was mediocre. It’s simply not true that in the good old days, physicians were healers and now they are technicians. In the bad old days, many physicians used remedies that didn’t work, even though scientific studies had shown they didn’t work, and failed to use treatments that did, even when there was ample evidence for the newer approaches.
What Dr. Sweet neglects to mention in the “slow medicine manifesto,” with which she concludes her engaging and provocative book, is that she can be a superb physician without the rules and the bureaucracy because she is very, very smart, and endowed with an outsize measure of both perspicacity and empathy. Victoria Sweet, as she reveals in her bio but not in the book, majored in mathematics at Stanford University (not an easy thing to do) while minoring in classics (quite likely an unprecedented combination). Then she was accepted into a PhD program in psychology at Harvard, but decided to go to medical school instead. When she became intrigued by Hildegard of Bingen, a nun in the Middle Ages who practiced a kind of holistic, herbal-remedy-based medicine, she didn’t just read what she could about Hildegard, she decided to pursue a PhD in the history of medicine (while continuing to work as a physician). 
Victoria Sweet has much to contribute to the world, and her description of her patients—how she examines them “from stem to stern” and, when she is puzzled by what she finds, spends hours in the library trying to figure out what ails them—is inspiring. But there’s a reason we have rules and regulations, and it has as much to do with the reality that most physicians aren’t like Dr. Sweet as it does with the commodification of medicine.

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