Medical Program: Slow Medicine: The Way to Healing

Dr. Russell:
In our fast-moving society where everything seems to happen in an instant, is there some wisdom in medicine for slowing down? Welcome to ReachMD Book Club. I’m your host, Dr. John Russell.  I’m joined today by Dr. Victoria Sweet, author of Slow Medicine: The Way to Healing.  So, Victoria, welcome to the program.

Dr. Sweet:
Well, thanks so much for having me. 

Dr. Russell:
So, you start your new book talking about the story of your father.  Can you share a little bit of that anecdote? 

Dr. Sweet:
Well, it was a shocking experience, because I’m a physician, he’s an old man and with a history of seizures.  He had a seizure, and my mom told me that he’d been admitted to the hospital for a seizure, which puzzled me, because at least in California, we wouldn’t admit somebody with seizure disorder for a seizure.  So, I went over to see him, and I discovered that there’d been a complete misunderstanding in the emergency room.  They thought it was his first seizure.  So, since he was in his 90s, they had him in the hospital with the diagnosis of stroke.  They’d done a whole stroke workup.  It was negative, but they still had decided he had a stroke.  And what was most shocking about it was, as a physician—not only as a physician, but the docs in that particular hospital had been reading my first book, God’s Hotel, in their book club, so I was a bit of a VIP, and even so, I couldn’t get his diagnosis changed in the medical record, in the electronic medical records.  And because I couldn’t get his diagnosis changed, he continued to be treated as if he were a stroke victim.  He had a Foley catheter inserted; he had an IV started; he tried to pull out the Foley; and the next thing I know he was on major tranquilizers and tied down to the bed and began within a couple of days of this wrong admission to deteriorate.  And even though I found the docs… I tried everything.  And I’m pretty wise in the ways of the hospital.  We tried to get ahold of the lawyer in the hospital.  I mean, we did all the things to get his diagnosis changed and get him out of there.  And finally, after 10 days, where he ended up septic with his Foley, in the stepdown unit getting 3 antibiotics—and I could see this whole death express spread out in front of me about one damn thing leading to another—we had a family meeting, and we decided that we would tell the docs that he was a hospice care, and that’s how I got him home, even though he wasn’t really hospice care, but that was the only way I could get him out of the hospital, the Foley out, the IV stopped.  And as soon as I got him home, he reverted back to his usual self once he was off all his medicines after a couple of days. 

So, it was a horrendous experience that made me think about how much worse things had gotten even in the last 5 or 6 years, where face-to-face with the doc as a doc I could not get the doc to look at my dad; I couldn’t get the doctor to examine my dad; I couldn’t get the doctor to focus on the fact that he was in the hospital with the wrong diagnosis, consequently getting the wrong treatment. 

Dr. Russell:
It almost sounds Kafkaesque.

Dr. Sweet:
It was.  It was like we were stuck in this nightmare situation that was only going to get worse, and I couldn’t get anybody to focus on what was really going on.  I couldn’t get his docs to go in his room and examine him.  So, eventually, I went through and I just decided, well, maybe I was missing something.  Maybe he did have a stroke I didn’t know about.  So, I got ahold of his medical records, which were all electronic medical records.  There were 800 pages of them.  And going through the electronic health records I realized that one of the problems was, of course, the doctors were spending all their time on the computer and that the electronic records were so confusing that even though I knew what had happened to him, you couldn’t tell from the medical records.  You could not figure out what was wrong with him, what had gone wrong by looking at that.  And when I really sat down and done a lot of thinking about it, I felt that something had really gone missing in medicine, and what that missing was fundamentally when I had to think about one sentence, it was that no one was taking responsibility for my father as patient, for his diagnosis, for making sure… No one took the responsibility.  Their responsibility was filling out the forms on the computer, which they did, but because no one took personal responsibility, there was no way to really get the kind of attention that he needed.  And when I thought even more about it, I realized that after my first book, God’s Hotel, I’d had a chance… I’d been all over the world giving talks and listening to people.  What struck me was, what I always assumed was obvious about medicine, that the doctor takes responsibility for the patient, was becoming a foreign concept.  When I would give talks, I could tell by the questions, this idea particularly from patients of what they should expect from their doctor was kind of mystifying to them, which is why I wrote the second book and called it Slow Medicine. 

Dr. Russell:
And all of this was really antithetical to who you were as a physician, correct?

Dr. Sweet:
Well, totally, and it’s because I wasn’t a natural-born physician.  I think that’s part of… I emphasize that, because I wasn’t from a family that we’re docs and I grew up with a dad who was a doc or a mom was a doc.  It was very foreign to me, and I had to be convinced that modern medicine was fantastic.  I had to be convinced and understand from my mentors, who were not just doctors but sometimes they were patients, many times they were nurses, about what it really meant to be a doctor, what that really meant.  And it’s how I ended up writing Slow Medicine, because I felt I needed to be more explicit.  In God’s Hotel, I kind of assumed that our common understanding of medicine as a calling, medicine as a profession, that we all accepted that, and when things didn’t go right, that that was an issue that everybody understood.  By the time I’d finished for 5 or 6 years talking hundreds of different places, I realized this was kind of becoming a foreign concept, and I asked myself, “Well, how did I come to the conclusion that medicine was a calling, that medicine was a profession?”  And I realized it was from my experience as a medical student, as an intern, as a resident.  All these different experiences had added up to a deep understanding that I would say that being a doctor—and I include being a nurse in this—that it has something, that it’s more like being…  it’s an archetype.  It’s like a union archetype like being a parent, like being a mother or a father.  You take on an entire history that you can’t just push off to the next shift.  Let’s put it that way. 

Dr. Russell:
And you started out in psychiatry, correct? 

Dr. Sweet:
Yes, I did.  That’s how I actually got to medical school.  I’d started reading Jung.  I’d gone to college, and I didn’t know what I was going to do with myself, and I discovered Jung’s memoirs, Memories, Dreams, Reflections, by accident in a bookstore, and I just loved the way he’d set up his life.  He lived in Switzerland, and he saw these very interesting patients in the morning.  In the afternoons, he illuminated manuscripts and studied alchemy, and I thought, “Oh boy, that’s what I’m going to be.”  So, that’s how I got to medical school.  I was going to be a union psychiatrist, but then I kind of fell in love with the practice of medicine, which surprised me, because I was kind of a no-hands kind of person, but I ended up loving the physical exam of the patient because there was so much I could tell about the patient from giving him a thorough exam—which, of course, is what my father never had—and then the whole way of medicine, this sort of methodical step-by-step and analysis combined with intuitive.  I really fell in love with medicine as a practice.

Dr. Russell:
There was a certain beauty to when we really relied on physical exam, I think, and I think it was really rewarding, right?—like you had solved a mystery—that I don’t think the young people have today.  Do you agree with that?

Dr. Sweet:
Yes.  I think if I had to do one thing, if I could only do one thing with a patient, the one thing I would do was to be in their presence, physically just be in their presence.  And then if I had to pick a second thing, it would be to do a complete physical exam, I mean where you take their hands and you look at their nails and their palms and their lymph nodes, and you just do that whole thing, because over my lifetime, I would say almost all of my best diagnoses have been because of that physical exam, either because of what I found on the physical exam or what I didn’t find that I expected to find.

Dr. Russell:
If you’re just tuning in, you’re listening to ReachMD Book Club.  I’m your host, Dr. John Russell.  I’m joined today by Dr. Victoria Sweet, author of Slow Medicine:  The Way to Healing. So, after doing a year of internal medicine, you decided to embark on doing some locum tenens work, which really sounds like it was very, very fascinating and kind of enriched you as a physician, correct?

Dr. Sweet:
Yeah.  Anybody who’s listening who’s trying to think of how… One of the best things I ever did was these locum tenens for a year, because there you—I’d go for 2 weeks and take over a doctor’s practice and get to see, especially as a very young doctor who’d only had a year, get to see how that particular doctor practiced, especially in those days when we had paper charts and the paper charts were handwritten, so you got a sense of how the person thought, what they thought about, how they wrote their notes, what medications they used, their whole style.  And during that year I was maybe in 7 or 8 different kind of places over the course of a year, so I got a kind of very varied view of how as a doc you could become your medicine and practice in a style that developed how to view—a little bit like being an author, actually, now that I think about it.

Dr. Russell:
So, you wrote about the slow food movement and how that led you to be thinking about slow medicine.  Can you elaborate on that?

Dr. Sweet:
Yeah.  Well, I’d been practicing what I now call slow medicine for quite a while, but I didn’t have a word for it.  I didn’t have a way to kind of abbreviate what I meant until the slow food movement came out, and I liked the whole style of it, and I particularly liked the fact that the slow food was slow, not so much because it was slow in time but because it wasn’t fast food.  And in that same way, I felt that the medicine that I was practicing and seeing in God’s Hotel and seeing how worthwhile it was, it wasn’t so much that it was slow in time.  It was slow medicine in the same way slow food was slow.   By that I mean this idea with fast food and fast medicine is that how you get to your goal does not matter.  And the essence of slow food is that you can’t really have a beautiful meal by getting frozen food that has been created in the factory, shipped to you, that’s defrosted in a microwave.  It may look the same, but it’s missing something.  And in the same way, slow medicine… You really can’t apply the ideas that only the goal is important and how you get there doesn’t matter, so that’s kind of how I thought of the idea of slow medicine. 

And I’m not the only one.  It’s really interesting.  In the past, oh, 10 years, I’ve known about 6 or 7 different docs who came up with the idea of slow medicine independently but coming from the same place, that it’s a process, it’s a method, it’s a style of being a doctor.

Dr. Russell:
One thing as I’ve advanced in my career, I’m much comfortable with doing less.  Do you think that that’s part of slow medicine? 

Dr. Sweet:
I do.  I do.  I was thinking about it the other day.  There’s the wonderful Einstein quote about how you explain things, and you try and get an explanation that’s as simple as possible but no simpler.  And I thought really slow food is about doing as little as possible but no littler, doing exactly the right amount, because what you’re trying to do is—except in an emergent situation, and even sometimes in an emergent situation—you’re trying to remove what’s in the way of the patient being healthy, so it’s this idea of thoughtfulness, of first… I don’t know if you remember House of God.  It was wonderful, wonderful, very influential in my career I must say.  And one of the rules of the House of God was, in an emergency, the first pulse to take is your own.  And I love that because it’s actually true.  Even in a code blue, the first thing you want to do is nothing.  You want to get there and you just want to spend 1 second to look of doing nothing, and then what you decide to do is as little as possible, right?—as little or as much as the situation needs but not any more. 

Dr. Russell:
So, if you look at what I think are some of the big issues that are plaguing us in medicine, I think it’s burned-out physicians, bad outcomes, unhappy patients, medical errors.  If we slowed down, do you think a lot of that stuff gets better?

Dr. Sweet:
I would like to be able to say yes.  I mean, I will say yes, but what I become concerned with is how we got into this situation, because it’s not an accident that things are the way they are, and so if doctors can get enough time to do what we’re talking about here, they will save money, the patients will get better and feel better, and the docs themselves and the nurses will feel much more rewarded by their profession for sure.  So, I guess yes is the answer. I think though that what I’m finding is there’s a reason why we’re on this treadmill.  There’s a reason why doctors spend between 70% and 120% of their time sitting in front of the computer.  I mean, that alone prevents… We’re spending all of our time on the computer, which nothing could be less good for patients, less good for doctors’ morale, and less good for getting the right diagnosis and the right treatment. So, if you come back to the beginning, when you look at what happened with my dad, all it would have taken was for one of his hospitalists, who were rotating, to walk into the room with me and examine him, and they would have gone, “Oh, he hasn’t had a stroke,” but none of them had the time to do that because they’re all running up and down the stairs doing all of the regulations and rules that have been foisted on us for many different reasons.  So, he’s a perfect example.  He had a 10-day hospitalization and almost died for something that he should have been discharged from the ER within an hour—so, if you just look at cost, not to speak of his suffering, the family’s suffering and the waste of effort.

Dr. Russell:
And you embarked upon your study of medical history in Hildegard of Bingen.  What would she think about medicine today?

Dr. Sweet:
She would be completely shocked.  She wouldn’t even know what to make of a system where you don’t… She had this concept of Viriditas, which she got because she was not only the—because she was a 12^th Century abbess, and she lived in the Middle Ages, and she ran a monastery, and she took care of the people that were sick in the monastery, but in those days, the person who took care of the sick, the monk who took care of the sick, or the nun, also did the medicinal herb garden that produced the herbal medicines that they used.  So, she had this idea that just like with plants that she took care of, her patients had what she called Viriditas, which is this sense of… It means greening.  That’s really this name for what it is that causes plants to become green, to produce fruit and flower, and that the gardener usually removes what’s in the way of Viriditas.  Her idea was that human beings have the same power of feeling, which we know—everybody knows that—and that the role of the doctor was to remove what’s in the way of that natural power, A, and B, to support that natural power with the basics, and those are things, very simple things like what the Middle Ages called Doctor Diet, Doctor Quiet, Doctor Merryman.  Those were the things that you used, in general.  So, if she would look at us, if she would look at our over-medicalization of everything and our under-spiritualization of everything, she just wouldn’t even know where to start. 

Dr. Russell:
So, what would be the one bit of advice you would give someone in medicine who wants to try to slow their mind down, slow their practice down a little bit?  What would be the first step?  What would be the one tip you would want to give people?

Dr. Sweet:
It would be a very practical tip and would be: when they walk into a room to see a patient, that they sit down and take one breath in and one breath out. 

Dr. Russell:
And so often we don’t do that, and to listen and connect with another human being, I think, is what draws us all to medicine.  So, the book is Slow Medicine, a really beautiful read, Dr. Victoria Sweet.  Victoria, thank you so much for being back on the program.

Dr. Sweet:
Thank you so much for having me.  It’s a pleasure. 

Dr. Russell:
Thank you for listening today.  To listen to more programs in this series, please visit ReachMD.com/BookClub.