As Dennis McCullough’s mother made the journey from being a vibrant, healthy 85-year-old to a critically ill 92-year-old, the Harvard-trained geriatrician found himself increasingly critical of her care.
Over and over, the well-intended medical professionals treating his mom advocated for more invasive, more aggressive treatment. They offered the best knowledge and drugs avail- able, all in their determination to cure her.
But she became less and less engaged in the fight to cure her of old age.
“All the things you know as a doctor when you’re sitting on the other side of the desk—they don’t matter much when it’s your mother,” McCullough says. “The nature of aging is that, in a significant way, you are disempowered and it’s hard to be grateful in accepting that lessened role.”
A soft-spoken and neatly groomed man with more than 30 years of practicing medicine and an affection for poetry, McCullough found himself pulling away from the rush to cure and, instead, looking for medicine that was attuned to the patient’s desires, especially the patient in this case, his mother.
In that search, McCullough became a pioneer of the slow medicine movement. His book, My Mother, Your Mother: Embracing “Slow Medicine,” the Compassionate Approach to Caring for Your Aging Loved Ones, sparked a discussion among caregivers, from doctors to families, about the need for a better, more thoughtful and less reactive way to care for patients.
“Slow medicine is a special commitment undertaken by families and health professionals working together to achieve the very fullest understanding of aging loved ones and their complex, ever-evolving needs,” he explains. “This in turn leads to wiser decision making regarding formal medical interventions.”
Though it originated in geriatric medicine, the idea of slow medicine—patient-oriented medicine based on carefully building a relationship that takes into consideration the patient’s goals and wishes and what healthy means to them—is creeping into mainstream medicine. The slow medicine movement is a polite rebellion against a cumulative tidal wave of forces—a flood of insurance requirements, the same quality standards being applied to very different patients, the practitioners’ profitability goals and advancing technology.
“We need to build another road other than the one that runs repeatedly through the intensive care unit,” McCullough says. “It’s time we start partnering with families, with palliative care, and especially with our patients to redesign the care continuum. Because until we grasp the emotions and experiences of old people, we can’t make decisions that really serve their interests.”
At the heart of slow medicine, he says, is making time to know the person you are caring for—and not just as a patient. And, he says, it means ensuring that care is centered on the patient rather than the treatment.
His mother, for instance, was taking a beta-blocker, one of the most commonly prescribed drugs. “We thought she was just getting old because her naps were getting longer, but when she stopped taking the beta blocker medication for blood pressure, which she’d been on for many years, she woke up,” he says, noting that beta blockers are sedative.
Layers of Treatment
Returning the focus of treatment to the patient, the heart of slow medicine, works across all ages. Victoria Sweet is a San Francisco physician who is viewed as one of the movement’s leaders along with McCullough and Danielle Ofri, M.D., an at- tending physician at Bellevue Hospital and associate professor of medicine at New York University. “The idea that a doctor would spend time with a patient to figure things out is revolutionary,” Sweet says. “But it was the gift of time that did my patients the most good.”
Sweet spent 20 years caring for patients at Laguna Honda Hospital and Rehabilitation Center in San Francisco. The hospital, founded in 1867 and run by the city’s Department of Public Health, has 700 to 800 live-in residents in its care programs. As a staff doctor, Sweet cared for patients with AIDS, diabetes and hepatitis C, and for those recovering from strokes and grappling with layers of conditions. Whereas most practitioners at Laguna Honda would see a patient once a month, she could see them every day. “They were very sick and very poor. They were the poorest of people,” she recalls.
Sweet regularly spent two hours on initial physical exams. It takes that long, she says, to get to the bottom of what’s really wrong, especially in complicated cases. Her patients came in with regimens of 16 to 25 medications, she says. Sweet calls much of her work with them “untangling.” They were long-term patients, at the hospital for months, even longer.
For example, a patient who once needed treatment for diabetes and hypertension when she was obese, but had since lost the weight, was still on medications for now absent conditions—and on more medications for the side effects. Another patient, who had suffered a bout of depression with a life-threatening diagnosis, was taking a fistful of antidepressants and then more drugs for the serotonin syndrome side effect. All of this contributed to other medical problems.
“There is so much overtreatment, there are so many unnecessary tests,” Sweet says, while recognizing that many tests are valuable. But often patients had had too much of a good thing, or a good treatment had gone on too long.
One at a time, with weeks and months between the changes, Sweet would wean her patients off medications that didn’t necessarily help anymore. She was able to reduce most patients to about five drugs, she says. Often, the symptoms of the primary illness would become milder, and the patients’ health would improve.
Those recoveries, Sweet says, came from the gift of time with the patient. “It has to do with the doctor having enough time to do a good job, the patient having enough time to heal,” she says.
Because her patients were so ill and often didn’t have reason to harbor high hopes for a perfect recovery, Sweet’s experience with applying slow medicine and paying attention to the patient’s goals translates to older patients.
“I learned how much better it is to practice by listening to my patients and by giving them time to be affected by the treatment,” she says. “Most of my patients were two standard deviations from the norm, so I learned a whole different kind of practice with a different set of expectations from what main- stream physicians do.”
Sweet is now on sabbatical, promoting her book about how her 20 years at Laguna Honda taught her the value of a slower, patient-centered rather than treatment-centered approach to medicine.
Danielle Ofri has also become a slow medicine thought leader—a result of having a very similar experience in a similar hospital on the opposite coast. The New York doctor is also an author and a mother who plays cello in her free time.
“Patients need to understand what is taking the doctor’s time away from them, and doctors need to find better ways to practice,” says Ofri. “The idea is getting a lot of support from people—on both sides of the examining table—from all over the country.”
Ofri has practiced at Bellevue Hospital Center in New York City since 1998 and concurrently writes essays examining her experiences with her patients and exploring her thoughts on the practice and intimacies of medicine. She has published four books and writes for the New York Times health section.
Ofri says that her work at Bellevue, the nation’s oldest public hospital, paradoxically allowed her to give her patients better care. Many of her patients are very poor and very sick, and the hospital hasn’t always had the budget to run extensive lab tests to discover what was making them ill.
“You had to figure it out,”Ofri says. “We’ve gotten a lot less good at that.”
The health-care system, shaped by insurance companies, encourages testing. Paradoxically, Ofri says, that sometimes means her poorer patients get better care.“ When my patients can pay, I have to follow insurance protocols and order tests. But if my patients can’t pay at all, I can do what I want, and take the time to get to understand them and find what it takes to make them feel better. Often, that’s less medicine, not more.”
Buying Time, Building Relationships
Recent research suggests that the doctors don’t have enough time with their patients. A 2013 study published in the Journal of Internal Medicine found that doctors in training spend about 12 percent of their time with patients. That’s significantly down from previous studies, such as one in 1989 that found doctors spend 20 percent of their working hours with patients.
“We all wish we had more time with our patients,”Ofri says.“[In the clinic] I’m booked for every 20 minutes, so I hope a few patients don’t show up so I have 40 minutes. It’s the worst feeling in the world that you can’t spend that time with the person who came to see you.”
For Ofri, that personal diagnosis starts with a physical exam, which she describes as clinically ineffective most of the time, but still extremely helpful because that’s when the details about health concerns and history emerge. “It’s the only time the doctor is talking to and touching the patient. It is intimate, and that makes better communication. That’s when people talk about domestic violence, about depression and eating disorders, about the things troubling them and affecting their health.”
“We spend a lot of time typing into the computer with our backs to our patients,” says Ofri. “They don’t feel seen or heard, and they don’t talk candidly to us.”
One sign of the slow medicine movement that Sweet and Ofri point to is the emerging concierge-style practice of medicine. Doctors are abandoning large group practices and patients with insurance coverage in favor of a stable of patients who pay a monthly retainer and then additional costs as they go along. In January 2013, Forbes reported that a survey of 14,000 U.S. doctors found 9.6 percent of medical practice owners were planning to convert to concierge care by 2016. Even mega-practices, including Scripps and some University of California hospitals, are establishing concierge practices.
The doctors tend to be primary-care physicians.
“The average doctor has a staff of five to deal with records and insurance,” Sweet says. “A doctor with 200 patients who pay $200 a month can attend your surgery, read your pathology reports, stop by to see how you are doing.”
Ofri and Sweet are part of a growing rebellion among doctors, who say that doctors’ practices are increasingly about record keeping and efficiency, at the expense of the patient.
“Doctors are taking back their practices,” Sweet says. “And the studies are starting to show that it’s actually cheaper and better for the doctor and the patient. If you get a patient off 20 of 25 daily medications that aren’t helping, that’s thousands of dollars you’ve saved while your patient got healthier.”
Though patient “retainers” were initially very expensive, the costs are dropping, says analyst Mark Smith, president of Merritt Hawkins, an employment agency for physicians.
“It’s not just for the rich and famous anymore,” Smith says of concierge medicine and direct primary-care practices. “If you can afford a gym membership, you can afford this kind of care.”
Merritt Hawkins surveyed more than 13,000 physicians across the United States, and found that more than two-thirds have a negative or somewhat negative view of their practice of medicine.
The common themes for discontent: the erosion of the doc- tor-patient relationship, cited by more than half of the doctors as a very important factor, along with too much paperwork, cited by nearly 80 percent. Just 7 percent of the surveyed doc- tors rated these two issues as unimportant.
Their solution: Some are seeking fewer hours, some are closing their doors to Medicare patients, and many are looking at concierge-type practices in the next three years, according to Kurt Mosley, Merritt Hawkins vice president of strategic alliances.
California has the highest rate of physicians who are concierge practitioners and the highest rate of those who plan to become concierge practitioners in the next three years, Mosley says, and California hospitals have started to court doctors with concierge practices.
“Patients like concierge medicine because, for most patients, the issues are time and access—they need to know today if they should be getting something looked at by their doctor,” he explains.“ With concierge, you have better access to your doctor and sooner—concierge patients report the lowest wait times.”
“The satisfaction scores [for concierge patients] are astronomically high,” Mosley says. And patients are more likely to follow instructions because of the personal connection they experience. That, in turn, keeps costs down and lowers the number of repeat visits for the same problem.
Interestingly, more than 80 percent of doctors cited developing relationships with patients as one of the satisfying parts of being a doctor. Relationships with patients were the highest- scoring factor, above intellectual stimulation, which came in at just under 70 percent.
“The mantra we hear from doctors is ‘reestablish relation- ships with the patients,’” Mosley says. “They say, ‘I got into medicine to take care of people, not to fill out paperwork, fight with insurance companies and manage a staff of clerks.’”
Relationship building, especially without the worries and demands that insurance company requirements, bills and paperwork bring, results in patients who are more satisfied with their doctors and report they’re getting more personal care.
That’s why building relationships is taking root in treating the complexly ill poor and the elderly. “Because we are in an evidence-free zone, it’s worth trying something to see if it works,” Dennis McCullough says. “We don’t have to believe in the ‘promise’ drugs—I promise you’ll do a little better than if you weren’t taking it,” McCullough says. Instead, doctors have to pay attention to their patients. They watch for side effects and for the vague symptoms that are often treated with layers of medication. That takes regular, focused visits.
“So often, my elderly patients are telling me that maybe they don’t want those aggressive treatments, but they don’t want to disappoint their families and their doctors,” McCullough says. “They’ll say, ‘Gosh, I don’t think it’s going to make a big difference for me, but everyone is so intent on this.’”
Hearing that ambivalence should make the race for treatment slow down.
“Older people make good decisions, but older people take a longer time to get to the excellent decision,” he says. “It’s normal to vacillate. It’s normal to wake up thinking one thing and change your mind later in the day. We should be prepared to meet with people a dozen times while they are going back and forth on making those decisions.”