Aside

Nature has the upper hand. So far it has “gently” protested, but …

Bernard Lown, MD

Essay 33, Part 1

The planet is warming. Facts are marching in battalions, their steps in cadence, their destination known. The few contrarian scientists who in the past demurred are now overwhelmed by the sheer weight of confirmatory evidence. It is certain that Earth will grow hotter and less hospitable to life. Not a day passes without new warnings. Among scientists, the optimists profess that global warming will inflict dislocations, misery, and colossal social costs. The pessimists envision doomsday scenarios.

The recent quadrennial national election, the costliest spewing of political speech in human history, provided a democratic catharsis. Presumably all key issues confronting our society got an airing. There was ample opportunity in the four major “debates,” with 60 million or more viewers, to raise the salient issue of our age. Yet the phrase global warming did not cross the lips of any of the four moderators, nor did the presidential or vice-presidential candidates mention this seemingly proscribed subject. Once elected to a second term, President Obama said that his first priority would be jobs and that he intended only to foster “a conversation” on climate change.(1)

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Power to the people: Patient in command

Blog Essay 32*

Bernard Lown, MD

Benedictions to patient-centrism, patient privacy, patient autonomy — everything-for-the-patient rhetoric — flow from the pervasive PR of the health establishment. The more I hear these jingles, the more my heart skips a beat. At my age I can’t afford arrhythmia’s. My experience as a cardiologist murmurs that these extra-systoles may be auguries of the hereafter.

I have learned that in our market culture, whenever a message is oft repeated, you can suspect a sales pitch. Indeed the patient looms large as a commodity to be seduced by medicalization, to be showered with drugs, subjected to endless tests, imaged to expose hidden recesses of anatomy, probed by magical genetic analyses for the Ur-self, and salvaged by so-called life-saving interventions. At the same time the patient has grown ever more Lilliputian. You the patient, with real or imagined dysfunctional biological machinery, is largely present; but you the sentient human being is largely absent. The contradiction is beyond Hegelian dialectics.

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The Coronary Artery Entrapment

The Coronary Artery Entrapment

Bernard Lown, MD

 

Essay 31

What propelled the transformation of medicine from a humanitarian profession to a costly technocracy? It has seemingly happened in a single lifetime, and I witnessed much of it. Let me relate what transpired. Be forewarned, however: history is more accurately perceived as a Rashomon experience than garnered from near-deathbed confessionals.

In the metamorphosis to medical modernity cardiologists led the charge. The focus of their concern was the epidemic prevalence of coronary artery disease (CAD). For the past fifty or more years CAD has been the leading cause of death. It kills and disables people during the most productive period of their lives. Women lag about ten years behind, with CAD manifesting usually after the menopause. By age 70 about a fifth of Americans of both sexes are afflicted with some form of heart disease.

The overwhelming power — nay, seductive charm or even stranglehold — of technology in medicine was manifested first in relation to CAD. The Faustian bargain was as insidious as it was all-consuming. The devil’s emissary promised wealth, scientific pretensions of unimpeachable verisimilitude, leadership in the cutting edge of medical innovation, and most irresistibly, the transformation of work into child’s play, with novel, unimaginably versatile toys. In return the doctor promised adherence to the demands of workplace industrialization, thereby augmenting both efficiency and profitability. While the cardiologists were triumphant, something vital was leached from doctoring. It meant spending less time with patients and abandoning the ancient skills of listening as well as the consummate art of the physical examination. Some doctors felt an ache like the passing of a dear friend. Most, though, never experienced even a quiver of loss. These humanitarian skills, not being taught in medical schools or mentored in hospitals, were never acquired, thus never lost.
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Aside

Doctor as scientist, healer, magician, business entrepreneur, small shopkeeper, or assembly line worker — which is it?

Bernard Lown, MD
June 26, 2012

In the tumultuous debate about health care convulsing public discourse, the focus is on escalating costs and possible economic remedies. But the innards of the ailing system have not been adequately exposed to searching analysis.

Health care systems are stressed by a burgeoning global population, multiplying in my lifetime 3.5 fold, to seven billion. They are distorted by the increasing dominance of market forces, focused primarily on profitability rather than patients’ well-being. They are mal-aligned by growing inequities in wealth between developed and developing countries, and by the decimation of the middle classes in industrialized countries. They are challenged by adverse ecological transformations that afflict us with puzzling new diseases as well as with drug-resistant microbes and viruses. Life on earth is undermined by the chemicalization of ecosystems, the pollution of air and water, and climate change threatening the planet as a comfortable habitat for human civilization. This veritable witches’ brew has other malign elements, most noteworthy the commoditization of everything within market reach, including art, education, and religion — ensnaring the most intimate of human interactions as well as our inner selves. The result is the alienation of people from their communities, families, friends, and ultimately themselves.

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Social Responsibility of Physicians (Essay 29)

Bernard Lown, MD
Address presented at

Avoiding Avoidable Care Conference

April 26, 2012

Introduction
Ever since starting clinical practice 62 years ago I have looked forward to this conference. Mercifully, good fortune and good genes enable me to attend.  From my earliest days in medicine I have struggled against the prevailing model of healthcare. My opposition in part was provoked by the growing prevalence of overtreatment. Resort 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 MI’s 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.

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A Maverick’s Lonely Path in Cardiology (Essay 28)

Bernard Lown, MD

As I have just passed my 90th birthday, writing this essay reminds me of Machiavelli’s admonition when he was receiving final Communion on his deathbed. “Renounce the devil and embrace the Lord,” intoned the priest. A long silence. Then came Machiavelli’s whisper: “This is no time to make new enemies.”

Let me start with a confession: I not only harbored dangerously unorthodox views during my career; I practiced them. Being allowed to voluntarily retire from the practice of medicine in 2007, rather than having had my medical license revoked decades earlier, was either an egregious establishment oversight or an act of divine intervention. Though my medical transgressions were never obfuscated or hidden, few are aware of them.

My deviant behavior consisted of sharp departures from the accepted norms of medical practice. I deemed such behavior an act of civil disobedience, for which I was ready to accept punishment. Yet sadly no one in or out of authority took note.

So what is this all about? If you are not in the health profession, I urge you nonetheless to wade through the swampy terrain of medical jargon. (The endnotes aim to clarify some obscurities of medicalese.) This essay addresses the onrushing industrialization of health care, a critical issue for the long-range well-being of the United States.

Forty years ago I stopped referring most patients with stable coronary heart disease (CHD) for cardiac angiography.(1) This procedure permits visualizing the extent of obstructed coronary arteries. What occasioned my deviation? The problem was that nearly all those undergoing angiography ended up having surgery, namely, coronary artery bypass grafting, or CABG (pronounced “cabbage”).

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Enormity of US Military impedes nuclear abolition (Essay 27)

Bernard Lown, MD

Among antinuclear activists there is a sense of jubilant expectation that at last a demonic class of genocidal weapons will soon be consigned to the junk heap of history. Left behind will be a shudder of memory of how close humans came to an abyss of self-extinction. Outlawing the nuclear genie will not rebottle it. The potential nuclear nightmare will need to be secured everlastingly against perverse miscreants. Nonetheless, the removal of nuclear weapons from military stockpiles will be a mighty civilizing step for humankind.

Whence the current optimism? It arises because some most unexpected voices are joining the antinuclear fray. The new allies are former leading power brokers of the national security establishment. They were among the major architects of the nuclear age who in prior times favored adding megatonnage to the already existing obscene overkill.

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