March 23, 2009

Slow Medicine

What is Slow Medicine?

Berkeley, California is the epicenter in America of the Slow Food movement. It has gradually developed over the past 20 years or so as a response to Fast Food.

The idea, I think, is that food should be very fresh, as local as possible, as organic as possible, and prepared just before serving. Michael Pollan has written a lot about these ideas in his books about food. Alice Waters has written cookbooks that emphasize these priorities and has a fabulous restaurant here that puts the concepts into practice.

I think it's time for a similar revolution in medical care. So I'm inventing the term Slow Medicine.

At business school, I first learned of the existence of Hamburger University, near Chicago. One of my smartest professors would often go and teach a course there. What he taught was Industrial Production, ways of ensuring the consistency and high quality of the final product, produced in the most economical and fastest way. Hamburger U. is run by McDonald's, and is where they send most of their best managers for training, and where they develop new systems for service. McDonald's makes great products--delicious food that's fast and inexpensive, and can almost always be counted on to be consistent in quality whether ordered in Berkeley or Brooklyn.

A few years ago, I had the honor to serve on a panel discussion about the quality of medical care. On the panel were health plan administrators, state health officials, insurance plan managers, a few professors of health policy and medical practice, and me. (I met one of the professors in the hotel elevator, and introduced myself. He asked what I did, and I said that I was a primary care doctor. He huffed and said that he didn't understand why they invited me, since he was an expert on primary care and head of the department of primary care at a major medical school. I asked him politely if he took care of patients. He said he didn't, except for the 3 weeks a year he has to supervise medical residents in their clinic. Though he was invited, I presume, as the expert in 'primary care,' I was the only practicing doctor.) The organizers went around the room, and I learned a lot! What is called 'quality' as it applies to medical care is really a code word meaning consistency, efficiency, and the lowest acceptable standard of care at the lowest average cost. In the back of my mind rang familiar echoes of chain restaurant strategy and Hamburger U. When it was my turn, I pointed out that this is not at all what my patients would think of if they were asked about the quality of their medical care. The view of patients on medical quality just didn't matter. The quality debates occurring at the moment are dominated by healthcare institutions and insurers. They want consistent, if minimal, results for the least cost.

This industrial model of the provision of medical care is everywhere in America. Because doctors are paid per visit (just as with sweatshop workers, it's called piecework), there's a lot of pressure on them to do as many visits as possible per day. That's why when we see our doctors (me, too) we sometimes get 10 minutes or less. In order to provide minimal standards of consistent results (quality), the medical assistant might have us fill out a questionnaire first or give us a lab form. Chances are that the doctor doesn't know us, our issues or questions, or our concerns. I have been to doctors where I was told that I can only ask about one problem. Another problem is another visit. In what I'm calling the industrial model, patients are the raw materials and payment is the factory output.

The people that run our healthcare companies and institutions are generally nice people with families like the rest of us. They know what good medical care is and they want it, too. But the qualities we all really want are difficult to measure and hard to define. We all want a doctor who knows us and cares about us, and tries to do their best for us. But what we get is Fast Medicine.

Do you want fries with that?

Next Post: Why Slow Medicine might actually work.

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