Dr. Bernard Lown is the author of The Lost Art of Healing: Practicing Compassion in Medicine, and has been a practicing physician for over 62 years. He’s also the co-founder of the medical organization called International Physicians for the Prevention of Nuclear War, which was awarded the 1985 Nobel Peace Prize.
Dr. Lown presented this talk at a Cambridge, Massachusetts medical conference called Avoiding Avoidable Care on April 26, 2012. The lofty goal of this unique conference was no less than the transformation of health care culture from one focused on volume and quantity to one centered on value and quality. Here’s the profoundly important message of Dr. Lown to his colleagues:
“From my earliest days in medicine, I have struggled against the prevailing model of health care.
“My opposition in part was provoked by the growing prevalence of overtreatment. Resorting to excessive interventions seemed to be the illegitimate child of technology in the age of market medicine. If more than a half century ago overtreatment was at a trickle pace, it is now at flood tide.
“Reflecting back on early days, the first overtreatment I encountered was not related to technology. It involved keeping patients with acute heart attacks at strict bed rest for 4 to 6 weeks. This was a form of medieval torture. It promoted depression, bed sores, intractable constipation, phlebitis, lethal pulmonary embolism and much else. Worse it augmented cardiac ischemia and predisposed to malignant arrhythmias. Physicians were aware of what was transpiring but felt it was necessary to protect patients against cardiac rupture which activity may provoke.
“The great Brigham clinician, Dr. S.A. Levine*, my teacher and mentor, believed that patients would fare better when nursed in comfortable chairs. Yet he was not ready to challenge established practice. With his backing, I launched such a study in 1951. The house staff initially was vehemently opposed, even greeting me with Sig Heil Hitler salutes. But soon they became avid supporters.
“Patient improvement was striking. In fact, hospital mortality from acute MI’s more than halved, depression diminished, pulmonary emboli nearly vanished, hospitalization was markedly shortened, rehabilitation and resumption of work was hastened. I am not aware of a single cardiovascular measure since then that improved survival of heart patients as much as this common sense change in medical management. We published two articles on our findings in 1952. They evoked no comments as though reflecting a shameful era best forgotten. One should mention, if only as a historical footnote, that there was not a scintilla of evidence supporting prolonged bed rest. While patients were harmed, doctors profited.
“Recognition that new technologies were driving overtreatment became evident with introduction of implanted pacemakers in the 1960’s. Compared to colleagues I was implanting about a third as many and inactivating like numbers. Pacemakers though were small cost items compared to what soon followed.
“The problem of overtreatment grew exponentially after Dr. René Gerónimo Favaloro at the Cleveland Clinic opened an innovative terrain by introducing bypass vein grafting. This was followed by technical virtuosities involving angioplasty and later stenting.
“Within 30 years after Favoloro, the number of revascularizations exceeded one million. Presently, a majority of newly minted cardiologists are adept interventionists.
“At the same time, significant developments were occurring in the medical management of coronary artery disease.
“These included effective anti-hypertensive measures in the 1940’s, introduction of beta blockers in the early 1960’s, and ever more effective lipid lowering agents thereafter.
“A profound advance was the recognition that risk factors largely tethered to lifestyle accounted for the progression of coronary artery disease (CAD).
“In a rational social order, preventive medicine would have been the focus of resource allocation and physician concentration.
“Instead, prodigious investments flowed to halfway technologies.
“No robust clinical evidence guided the onrush of revascularizations . The Coronary Artery Surgery Study (CASS), the first randomized investigation, published 16 years after Favoloro, provided no comfort for those trumpeting interventions.
“Instead of being a wake-up call alerting to irresponsible overindulgence, coronary procedures continued to escalate.
“Justification for revascularization is based on claims of increased survival, reduced toll of myocardial infarction and improved quality of life. By the late 1960’s, I learned that in a majority of patients, coronary heart disease was largely stable, and did not demand a rush for or even need for revascularization.
“I was persuaded that investigating this problem would be difficult once patients were hospitalized. As a result, I founded the Lown Clinic. Almost immediately, we launched a study. We intended to randomize post-angiography patients to either revascularization or medical therapy. The study aborted before it began. After patients were informed by interventionists and house staff of their coronary anatomy, coached in the lurid prose then and now in use, every patient opted for coronary artery bypass grafting (CABG).
“Coronary angiography was a funnel for interventions. Its purpose was largely to guide the operator to the narrowed vessel. To diminish coronary procedures required bypassing coronary angiography. We decided to study patients with multi-vessel disease over a long time frame without resort to angiography.
“During the ensuing 35 years, we published four studies in high-profile medical journals involving about 1,000 patients. Outcome data were remarkably consistent. Cardiac events were extraordinarily low, about 1.0 percent annual mortality rates. Our referral for revascularization increased from 1.1 percent annually during the CABG era to around 5 percent during the stenting era. Since a majority were second opinion patients, nearly all would have been revascularized.
“Let me repeat. Over any five-year period, we referred less than 30 percent of patients with multi-vessel coronary disease for revascularization.
“Our medical management was individually tailored. We rigorously treated risk factors. We encouraged optimism. We addressed social and family problems.
“We discussed significant psychosocial stresses. We minimized shuttling patients to other specialists. Foremost, doctors spent much time listening, thereby fostering trust and adherence to prescribed lifestyle changes.
“We did much for the patient and as little as possible to the patient.
“One commonly hears that fear of malpractice litigation is a significant reason for doctors resorting to overtreatment. The Lown Group, with its minimalist approach, should have been deluged with malpractice suits. After all, we deviated from community norms. We did not adhere to the standard of practice prevailing nationwide. Yet during the past 40 years we have not had a single malpractice suit for denying a patient with coronary artery disease a revascularization procedure.
“We remain a tiny minority voice. Our observations have been ignored by mainstream cardiology. This has not been due to an absence of randomization in our investigations. Large randomized studies from CASS to COURAGE likewise have had no impact on the scale of interventions.
“For the past half century, doctors have been distancing from patients.
“Four points, well known to you, deserve emphasis.
1. Outside the hospital environment, one becomes aware that problems bringing someone to a doctor are mostly minor. They largely derive from the rough and tumble of living. They don’t augur far advanced disease. These are healed by the passage of time. This is largely the reason that Hippocratic medicine held sway for nearly 2,000 years.
2. A carefully taken history and physical exam identify the underlying condition in the overwhelming majority of patients.
3. Much clinical information is epidemiological and statistical. But statistical fact is not the same as individual truth. Data, irrespective of how comprehensive, may not be relevant for the individual patient. Each person is not only different, but different in a unique way.
4. The more time invested by the doctor at the outset, the more cost-effective is the encounter and the more satisfied the patient. The number of specialist referrals and requests for technological procedures are inversely related to the time spent with a patient especially during initial visits.
“Sixty years of doctoring has taught me that taking a history, namely listening, is the
quintessential part of doctoring.
“Proper listening is a skill, an art and a core element of medical professionalism. History taking is far more than providing key elements for a diagnosis. It is the basis for nurturing trust. I am persuaded that nothing of science taught to medical students is as difficult to master as is the fine art of listening.
“Numerous adverse consequences follow if a doctor does not listen. If time is short shrifted, the doctor treats the chief complaint. But the chief complaint is merely an admission ticket and frequently has little to do with what is troubling a patient. If you were a theater critic, it would be foolhardy to write a comment about a play merely from the scanty information on an admission ticket. Yet that is what doctors far too frequently do.
“Treating the chief complaint commonly leads to unnecessary and costly interventions. When the chief complaint is unrelated to what truly bothers a patient, whatever medication prescribed will prove ineffective. As a result polypharmacy multiplies as new complaints are assaulted with still more drugs.
“When doctors do not spend enough time listening, they become triage officers for specialists, as the patient is reduced to an assemblage of dysfunctional parts – each part being served by some expert. Interest in the patient is replaced by preoccupation with disease. The human dimension is leached out from the clinical encounter. Dissatisfaction by the patient with the visit aggravates symptoms and adversely affects outcome. It encourages internet foraging and second opinion shopping.
“When a doctor doesn’t listen, the focus necessarily shifts to the acute and emergent.
“Since preventive medicine, though the most cost-effective approach to illness, is time intensive, it is largely neglected.”
* Dr. Sam Levine, coincidentally, is the same doctor who first observed that many patients suffering from chest pain hold a clenched right fist over the chest to describe symptoms of heart attack. This reaction is now known as Levine’s Sign.
Q: What are your impressions of Dr. Lown’s presentation?