We live in a fast-paced society. It seems that new technological advances happen every day. We see commercials for better cars, new TV sets, super fast phones (which are pretty much computers in our pockets). I think some of the expectations are transferring to the medical care. Patients expect a fast fix for most diseases. They ask: doctor, do you have a pill to fix this or that? Or an injection, or maybe a surgery?
I think it is worth trying to look at the bigger picture. The time scale in biology is very different than in technology. Little changes happen in our bodies every second and some times these little changes accumulate over many years to cause a disease. Furthermore, we do not live suspended in a vacuum. We interact with our environment; we are part of the environment. During history different trends in medicine tried to make sense of the bigger picture. In 1960 George Engel published “A Unified Concept of Health and Disease”, a paper that I would recommend to everybody (it was recommended to me in a book by Lorimer Moseley and David Butler). George Engel promoted the biopsychoscial model of disease. He criticized the medical practice at that time, medical practice which is still the same today. A few key paragraphs from his paper:
“To be able to think of disease as an entity, separate from man and caused by an identifiable substance, apparently has great appeal to the human mind. Perhaps the persistence of such views in medicine reflects the operation of psychological processes to protect the physician from the emotional implications of the material with which he deals.”
“Patients, certainly, regardless of their level of education and sophistication, prefer to blame their illness on something they "caught" or ate or that happened to them and to think of disease as something apart.”
“A disease, then, has substantive qualities, and the patient can be cured if the diseased ("bad") part is removed. That this often proves to be the case, as attested to by the successes of surgery, is actually not evidence for the validity of such a point of view”
In more recent times the trendy terms are mind-body medicine and integrative medicine. I would argue that both of these new terms are trying to accomplish the same thing as the biopsychosocial model, take the patient as a whole person interacting with the environment. Diseases are caused by a combination of genetic factors, lifestyle and environment. At this point we cannot control most genetic factors, but we have the power to change the lifestyle and the environment. However, changes come through education and with effort. Last national program with meaningful results was the campaign against smoking. Since then other issues took over, one of the most important being the obesity.
Once a disease develops I think it is worth looking again at the cause of the disease and work very hard to change the contributing factors. Also we have to be cognizant that it will take time to reverse biological processes. Usually a disease does not develop overnight and the solution takes time too. This is what I would call slow medicine. Of course, there are medications we can give to patients in the meantime, but the medications should be only a short term solution for most conditions. Medications have many predictable and unpredictable side effects: see my blog post (Side effects of medications). Small incremental positive changes for long term benefit are not that appealing in the current culture. I think we really need a change in culture. In my case I treat chronic pain conditions. I have many patients who come to me and say they had pain for over 10 years. At this point their whole nervous system is changed, their social lives are different, their psychological status is different. One medication or injection is not going to change everything. I tell them that there are things I can do for them (e.g medications, procedures, referral to physical therapy/psychology) and there are things they can do for themselves (e.g. lifestyle changes, weight loss, healthy diet, quit smoking, participate in physical therapy/psychology). We will work together as a team and manage their pain.
The other type of medicine I would call fast medicine. This is very dramatic and appealing to the doctors/patients/general public. Fast medicine includes surgeries, treatment of cancer, curing of possibly deadly infectious diseases. There is definitely a place for fast medicine, we need it. I love fast medicine myself. I am an anesthesiologist and enjoy practicing fast medicine in the OR, fixing things fast. It is very rewarding. Every now and then I am blown away by what fast medicine can accomplish. Recently I read this article in the journal Nature: “Regeneration of the entire human epidermis using transgenic stem cells” (Nature volume 551, pages 327–332, for a general public version of the story here). Basically they had this kid with a genetic disease (Junctional epidermolysis bullosa) that involves the skin (superficial layer called epidermis) and mucosa. His skin had a lot of wounds (60% of his epidermis was lost). They took biopsies from his skin, engineered his skin stem cells to get rid of the genetic mutation, grew epidermis in the lab and transplanted it on the kid. In the end, they were successful in replacing 98% of his skin. It felt like reading a Sci-Fi short novel, truly remarkable stuff. But in the big picture if they stop here it will still be a failure. First, they did not fix his mucosa. Then, the kid likely has already tremendous psychological baggage and that is likely true about his parents. His social situation is also different after living with this disease.
In the big picture we have to understand when to use fast medicine approaches and when to use slow medicine approaches. I would argue that fast medicine needs slow medicine to take over afterwards and look at what caused the situation to occur in the first place, reverse what can be reversed and take care of the long term consequences.