On slow medicine ================ * Jillian Horton ## Med Life with Dr. Horton ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/192/2/E50/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/192/2/E50/F1) ![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/192/2/E50/F2.medium.gif) [Figure2](http://www.cmaj.ca/content/192/2/E50/F2) **Jillian Horton: Anyone who has read your books has a sense of the many forces that have shaped you. Could you tell us about your academic path and how it led you to internal medicine?** **Victoria Sweet:** I had planned to be a Jungian analyst, but, in medical school, I particularly liked the work-up of the patient and especially taking the history because there was so much psychology to it. I had to listen to what the patient said, what they didn’t say and how they said it … and then there was examining the patient. I loved the physical examination and I still do; I find it such a powerful tool for diagnosis, and it’s falling out of fashion, which is a pity. **JH: You have what some would consider to be an unconventional view of medicine. How did it develop?** **VS:** The longer I practised medicine, the more impressed I was by its methodical, step-by-step way of approaching the body. But I was also impressed by what it left out, which was anything that wasn’t logical. I started looking around for other ways of looking at the body. I looked at Ayurvedic and Chinese medicine. I discovered a book in the library that changed my life. It was called *Hildegard of Bingen’s Medicine*. Hildegard was a 12th century nun and a medical writer. I decided to go back to school and get a PhD, but I didn’t want to stop practising medicine; I wanted to practise part-time. That’s how I got to Laguna Honda Hospital (in San Francisco), because it was the only place that would let me do that. It was a unique place where I had enough time with patients, enough time to do that medical school physical, to talk to the patients, to get to know their families. Not only did I have patients that had literally every disease in *Harrison’s Principles of Internal Medicine*, but I could get to know them. I could watch long-term care patients heal. It was an amazing place to practise medicine, and we were somewhat insulated from the growing efficiency drive in American medicine. **JH: In this era, we cannot escape the concept of efficiencies of practice. What does efficiency mean to you?** **VS:** I find it much easier to talk about inefficiency. In the United States, efficiency is a code word for doctors seeing more patients more quickly than humanly possible. My definition of efficiency is getting the right diagnosis and treatment, with the patient and doctor being happy with the way things went, for the least amount of money. None of that is in our efficiency measures. What could be less efficient than getting the wrong diagnosis? The really important thing to a patient when they come in is the right diagnosis. There’s not a single measure of that! **JH: Do you think we have moved away from useful archetypes related to physician identity?** **VS:** Yes! This is not an accident. This is deliberate. It was against the law (in the US) until the early 1980s for nondoctors to hire doctors. The American Medical Association (AMA) had a code of ethics that said that as a doctor you could not be employed by a nondoctor, the reason being that your allegiance would be split between your employer and your patient, which would be unethical. The AMA actually got sued by the US Federal Trade Commission to take that piece out of their code of ethics. It went to the US Supreme Court and the AMA lost. So, at that moment, medicine was reclassified as a trade and a commodity that “health care providers” provided. Within 6 months of this ruling, there were retail urgent care clinics popping up all over the country, some of them being run by fast food companies. I think that is the essence of what’s gone wrong. **JH: What do you want clinicians to take away from your work?** **VS:** The essence of medicine is personal. It’s person-to-person and face-to-face. You have to take the time to turn away from your computer and touch your patient, look them in the eyes and touch the part that hurts. Find time to do that. ## Footnotes * This is an excerpt from a longer podcast. You can listen to the full interview here: **[cmaj.ca/medlife](http://cmaj.ca/medlife)** * VICTORIA SWEET is an associate clinical professor of internal medicine at the University of California in San Francisco, a general internist and the author of two bestselling books, *God’s Hotel* and *Slow Medicine*. * The interview was conducted by Dr. Jillian Horton, director of the Alan Klass Health Humanities Program at the Max Rady College of Medicine, University of Manitoba, Winnipeg. She hosts *Med Life with Dr. Horton* on *CMAJ* Podcasts.