Festina Lente and the “Crab and the butterfly”

Medical care is changing rapidly throughout the world at many levels, and one of the changes that we are observing in various countries regarding various diseases involves the guidance that “less is better.” Specifically, in the treatment of differentiated thyroid cancer (DTC), “less” is frequently promoted as “better” with (1) less frequent surgeries, (2) if surgery is to be performed, then less extensive surgeries (e.g., lobectomy versus near total thyroidectomy), (3) less frequent I-131 therapies, and (4) if an I-131 therapy is to be performed, then lower prescribed activities of I-131 administered^[1].

Certainly, it is important to continue to assess our practice of medicine with the objectives of not performing unnecessary laboratory tests, diagnostic imaging tests, procedures, and/or therapies that may not only be inconvenient or harmful to our patients, but may also be costly to them and to society. However, in moving a practice of medicine toward “less is better,” the physician must be cautious about overcorrecting despite good intentions and that this contention may be completely unknown to that physician. Accordingly, as Augustus Caesar said, Festina Lente (hurry slowly; Festina Lente is also translated as make haste slowly). This oxymoron may be viewed as cute, catchy, or even clever, but it should not be dismissed. One clinical example helps put this adage in perspective, showing that we frequently have to learn— again—what has been known for millennia.

In the selection of I-131 prescribed activity (dosage) for the treatment of patients with suspected but unproven residual DTC to reduce the patients’ recurrence rates (adjuvant treatment as defined by the American Thyroid Association^[1]), Castagna et al.^[2] published a valuable study evaluating the effectiveness of 30 mCi vs. 100 mCi of I-131 for the treatment of such patients. In brief, the authors evaluated rates of recurrent disease, biochemical disease, metastasis, persistent disease, or death. The paper concluded, “Our study provides the first evidence that in patients at intermediate risk, high activities of [I-131] have no major advantage over low activities.” As good research, Castagna et al.’s statement seems reasonable. However, Festina Lente (fe-stē-nä-'len-tā). How many individuals will, or already have, used Castagna et al.’s statement to conclude that 30 mCi is equally as effective as 100 mCi in the treatment of intermediate risk patients with DTC? If individuals do conclude this, I submit that they have unknowingly demonstrated their bias toward a specific conclusion: “Less is better.” Instead, could one have concluded that 100 mCi is equally as INEFFECTIVE as 30 mCi in the treatment of intermediate risk patients with DTC? In Table 1, a distillation of some of the data from Castagna et al.’s article is tabulated. One could argue that the rates of recurrent disease, biochemical disease, metastasis, persistent disease, or death, which were reported as not statistically different, are an indication that both treatments are ineffective and that one should administer higher prescribed activities of I-131. To take this argument further, if one compares the administration of 30 mCi of I-131 to no treatment with I-131 and demonstrates that the outcomes are the same, would one conclude that they are equally effective or would one conclude that 30 mCi is not effective at all? Both are correct, but the inferences are distinctly different. By using this example, I am not promoting a determination as to whether less frequent surgeries, less extensive surgeries, less frequent I-131 therapies, or less frequent prescribed activity of I-131 are better; I am rather emphasizing that in our good intentions to do what is best for our patients and to be as cost effective as possible, we should practice Festina Lente. This is a cautionary note not only to the researcher, but more importantly to the practicing physician and the patient. We need to hurry more slowly regarding conclusions, not automatically accept what is being promulgated such as “less is better,” but to think before acting. Fallacious reasoning is one of the major reasons for Festina Lente in medicine.

The adage of Festina Lente is not new. Suetonius, a Roman historian, records in De vita Casesarum that one of Augustus Caesar’s favorite sayings was Festina Lente^[3]. Augustus thought that haste and rashness was “unbecoming of a well-trained leader,” and to help encourage this adage, Augustus minted gold coins with images of both a crab and a butterfly (Figure 1). The adage of Festina Lente did not end with Augustus Caesar; many other individuals encouraged it and handed it down through the centuries. Adlus Mnanutius, a Renaissance printer (1449–1515), used an image of a dolphin and anchor to communicate the maxim (Figure 2)^[4,5]. Cosimo l De’ Medicine (1519–1574), Grand Duke of Tuscany, illustrated it with a sail-backed tortoise^[6], and in the mid-1590s, Shakespeare alluded to the saying in his comedy Love’s Labor’s Lost by portraying the crab and butterfly imagery in two characters, whose names were Moth and Armado^[7].

Augustus Caesar’s Crab and the Butterfly

Adlus Mnanutius’ Dolphin and Anchor

So as we return to our practice of medicine, Festina Lente while visualizing Augustus Caesar’s gold coin. (Reproduced with permission by Douglas Van Nostrand and Keystone Press, Inc., Baltimore, Maryland, USA)