TTT versus The Red Queen

Over the last 44 years I have witnessed an unfortunate transformation in my chosen field of medicine. I have watched with increasing sadness (tinged increasingly with horror) as a patient centered and clinically focused profession has devolved into a revenue centered and efficiency focused business. In the words of Dr. Ofri the practice of medicine has become the delivery of health care.

Folk wisdom recognizes the benefits of a slow and mindful process: “Haste makes waste.” My father used to remind me that if I didn’t take the time to do it right the first time, I would lose more time when I was forced to undo my errors and start from scratch a second time. Piet Hein has captured this elegantly in a Grook:


Put up in a place where it’s easy to see.

The cryptic admonishment 


When you feel how depressingly slowly you climb,

It’s well to remember that 

Things Take Time.


Quality medicine takes time. Geriatricians have been writing  often and well about Slow Medicine for a while, but Slow Medicine is not just a geriatric need. It is a human need. 

What is slow medicine? It is an approach that focuses on the patient rather than on the provider or the system. It uses the foundation and context of a relationship between the patient and a clinician, preferably one that is durable over time, to identify patient needs and preferences, and then fosters clinician-patient collaboration to address those needs according to the patient’s preferences.

What is the contrasting efficiency centered business oriented model of medicine? It uses science and evidence, not to help the patient understand and meet her needs, but to establish an agenda and then sell its product, a product that values the needs and preferences of the system over those of the patient. It is revenue and volume driven rather than care driven, and it too often resembles the Red Queen’s Race:


"Well, in our country," said Alice, still panting a little, "you'd generally get to somewhere else — if you run very fast for a long time, as we've been doing."

"A slow sort of country!" said the Queen. "Now, here, you see, it takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that!" 

The result is poor care, unhappy patients, burned out clinicians and an expensive system that does not give good value for the money spent. Examples abound. I see them daily in practice, and will discuss some in greater depth over the coming months in subsequent posts. My hope is that patients, reading about this, will tell their clinician: “Take a deep breath. This is my visit, not yours. Slow down and let me think.” The commonality is that these activities, while essential for patient centered quality care, are not billable.


  • Getting unnecessary consults
  • Not giving the patient time to absorb one piece of information before moving to the next
  • Not allowing questions, and then ignoring them if asked.
  • Answering questions poorly
  • Not explaining options
  • Not getting to know the patient and the patient’s context
  • Not taking the time to look at a blood smear, a gram stain, an X-ray, but depending on someone else’s report.
  • Not reviewing discharge summaries and consult notes in detail
  • Not calling consultants to ask questions or discuss cases

As Simon and Garfunkel said: “Slow down, you move too fast.”



Links to more on this topic::