Below, Kent Bottles, M.D. reflects on the difference between “slow medicine” and what he calls “UCLA medicine.” (For the full post, see “Kent Bottles’ Private Views” )
“I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.
“Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing ‘Slow Medicine,’ The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care.
“McCullough describes slow medicine as ‘care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.’ Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine.
“UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, ‘If you come into this hospital, we’re not going to let you die.’ This is a statement that puzzles me as an old time anatomic pathologist.”
I would add that I find the UCLA CEO’s statement more than puzzling; I find it frightening.
I can’t help but think of the doctor who explained: “Once you’re in the hospital, you’re in ‘the system.’” I imagine a prison door closing behind me. I am now in a place where people no longer ask me what I want. Instead, they tell me: “This is what we’re going to do.”
Of course, Bottles goes on to acknowledge that “there are times (serious acute illness correctly diagnosed where there is an evidence-based treatment that has a good chance of success) when I hope I am treated in UCLA’s ICU or operating room by UCLA specialists. However, there are also times as I get older that I hope I end up living in the Kendal-at-Hanover retirement community cared for by a wise and experienced geriatrician like Dennis McCullough and the community’s nurse practitioner; I want my providers to take things slowly and listen to what I want out of life.”
few of us who aren’t acute care docs would argue with this, but it seems to me that it is optimistic and that trends push us in the opposite direction as hospitals and physician groups bulk up to become more competitive. these institutions will inevitably push to standardize treatment options a trend I believe will argue against less watchful waiting and more intervention if capitation is not involved.
“I would add that I find the UCLA CEO’s statement more than puzzling; I find it frightening.”
I agree, Maggie. It’s difficult for me even to comprehend how anyone in healthcare would say such a thing. It’s hubris, I suppose; it’s also arrogant stupidity.
Chris & Jim-
Chris– Yes, isn’t that statement incredible? It is, as you say, both hubris and arrogant stupidity.
It also tells me that the CEO is thinking like a hospital ad: “Come here and you will be saved.”
We need to re-think who we
select to run hospitals, and how they are chosen.
Jim– Going forward, most docs will either be on salary or receiving capitated payments. (I would guess that this will be largely true by 2018–maybe sooner–in Most parts of the country.
Younger doctors are already gravitating toward salaried positions. This will be, in part, a generational change. But as Medicare moves away from fee-for-service
private insurers will be more than happy to follow.
Hospitals also will no longer be rewarded for more aggressive, intensive treatments. The financial carrots and sticks in the ACA already point in that direction.
So the financial incentives for “more” won’t be there.
As for standardizing treatment options, comparative effectiveness research will be setting the standards. And that research already tells us that a great deal of aggressive intensive care buys people a few weeks, a month or two of poor quality life–at most.
Docs and hospitals in the private sector won’t be setting the guidelines for best practice. Health care experts working for the gov’t (including docs, medical reserchers, medical ethicists, etc.) will be setting the standads for Medicare, and private insurers will follow Medicare (as they do now.)
Also, I’m quite certain that we’ll see changes in malpractice law which protect doctors who show that they followd the best practice guidelines. So doctors will no longer feel they must “do more” in order to protect themselves against lawsuits.
The question is this: will patients still want the most aggressive, intensive treatment?
With time, (over the next 10 years), many patients will respond to the message in the media telling us that “more” is not ncessarily beter, and can be hazardous to your health.
Through word of mouth, people are beginning to realize that hospitals can be dangerous places.
But no doubt some patients will continue to want the most aggressive care.. Part of this is cultural and/or religious.
In some cultures, living as long as possible is very important–and there is a strong feeling that a higher power decides when we should die.
But as we live longer, more of us will be suffering from some form of dementia (Alzheimer’s etc.) Roughly half of people who live to 85 will have Alzheimer’s, as will a surprisingly large percent of those who make it past 65.
That’s the downside of living longer– more of us will live long enough to outlive our minds.
In those situations, neither the patient nor relatives are likely to push for intensive, aggressive care.
And as we see what happens to our peers, more and more of us will be making living wills stipulating that, if we have Alzheimer’s, we don’t want the pacemaker, etc. etc.
Finally–and this is the good news–as we live longer, we’re more likely to accept death. Palliative care specialists tell me that by the time they get into their 80s, patients are less likely to want to “do everything possible.”
Here, in a NY Times story about backlash litigation over overuse of coronary artery stent placement by some (or many?) cardiologists, is a possible early sign of why “UCLA medicine” and its cohort will one day be considered “the bad old days.”
The article: http://www.nytimes.com/2010/12/06/health/06stent.html?_r=1&ref=health
I loved this article. I prefer slow medicine.http://www.youtube.com/watch?v=eyr_KC2dbao Although they are slow they give a definite remedy and UCLA is a bit dangerous and they give their own side effects.
Joe Says, Pat S., First Aid Kits & Slow Medicine
Joe Says-
You’re right, and I don’t think this will change as younger docs grow older.
Younger doctors (those who went to med school in the mid-1990s and later) knew that medicine was not likely to be as profitable in the future . . .
By the mid 1990s, “managed care” had taken hold, and going forward it became apparent that Medicare would run out of money if we didn’t do something to rein in inflation.
Meanwhile more and more employers and individuals could no longer afford health insurance, and premiums were gonig up becuase costs were going up.
Over the past decade, doctors’ fees for particular services have not, by and large, gone up, but they’ve been doing more– more tests and treatments– and the cost of those tests and treatments has been going up. So the total amount we’ve been paying docs has been rising, and it’s been apparent that we’re heading for a wall.
Finally, by the early 1990s,, it was apparent to most brigiht young people thinkng about med school that they could make more money– more easily– on WAll Street, or in some parts of corporate America.
Bottom line: few chose medicine as a profession primarily for the money.
By contrast, in the late 1970s and early 1980s, the fees physicians were paid were climbing, medicine was booming . . . At that time medicne looked like a very lucrative career, and appearing to someone particularly interested in securing a good income.
Finally, in an earlier era (the 1960s); there were many fewer subspecialists, medicine wasn’t nearly as profitable, and doctors who went to med school in the 1960s tended to pick medicine because they loved the science and/or wanted to help people and/or wanted to please friends and relatives. Doctors were very well regarded by the communitiy.
Pat S.
When I saw the NYT stent story yesterday, I began writing a post about it.
The post will be up tomorrow.
Yes, we’re finally waking up to overuse of stents. In fact, Medcare payments for stents have been sliding since 2007.
But some doctors (like the one in the NYT story) have been ignoring the reserach and have increased their use of stents.
Dr. Nortin Hadler offered to write a guest-post on the subject–an opinion piece which we’ll be running along with my essay. His post is, as usual, excellent–provocative in the best sense of the word.
I also write about how health care reform is likely to reduce over-use of high-tech medicine.
Slow Medicine & First Aid Kits–
Thank you!
I would say medicine is still a very lucrative profession at 650,000 base salary in a certain specialty and geographic location.3
Tony,
There is no question but that $650,000 in income is handsome pay.
But of course only certain spescialists earn that much (or more)
It seems I have to give my 2 cents here. I’ll quote my parents, “you have to have a balance”.
There are standards of care that should be pushed and followed within the framework of a hospital system. These standards can make the difference in your outcomes. For example, why would you want a cardiologist ordering specific physical therapy or respiratory therapy, when they haven’t the knowledge to order the right thing. Hence, bring in the standard of care. Let those with the most knowledge be utilized by the physician. Presto, better outcomes with standardized practices.
But, I don’t think that is indicative of “rushed” healthcare. We just want everyone on the same page. But we don’t throw the baby out with the bath water. The patient still gets evaluated as an individual and decisions are based on their personal healthcare scenario. So we give the team tools and resources to maximize their contributions.
I have worked in a large teaching hospital which is part of a large healthcare system and I can honestly say, we as a system, always desired what you all are defining as slow medicine.
If someone did rush through and gave slip-shod care, then they would be promptly removed and replaced with a type of person who better fit in with the culture we were trying to create – that is, safety, satisfaction and extraordinary outcomes.