Bernard Lown, MD
In the United States geriatrics is a neglected field. The reasons are not hard to find. Doctoring the elderly is intellectually taxing and extraordinarily time consuming. The elderly never present with a single problem. Their complaints are numerous due to co-morbidities involving different organ systems. In addition to addressing multiple symptoms, the doctor needs to sort out whether the patient’s ailments relate to a polypharmacy of drugs. If this were not taxing enough , obtaining a careful history is waylaid by the infirmities of old age. Patients are forgetful, are easily distracted from the key issues, and meander to the unrelated. Further, a doctor has to decipher whether the complaints are a consequence of the psychological stresses of daily living or augur some serious malady, while a depressed mood can magnify a commonplace disorder till it becomes a life-threatening condition.
Our population is skewing to the oldest. Those 85 and over are increasing by around 165 percent annually, far more than any other age group. The elderly account for much of the ever-mounting health care expenditures. One would surmise therefore that geriatricians would be intensely recruited and highly recompensed. The very opposite is true. They are an endangered species and the lowest paid among medical specialists. The reason for such perversity is straightforward: Market medicine, the system undergirding American health care, is oriented toward maximizing profits for investors. A far larger return can be extracted from intervening with tests and technology than from human interactions. The topsy-turvy economics of health care thus tilts toward procedures. The highest remuneration goes to specialists who are essentially technologists focused on particular organ systems. Over the past several decades, the far more profitable technological procedures have been replacing time-consuming history taking and listening to patients.
The essential thesis of this essay is that listening to patients is the bedrock of a sound health care system. It is especially important in caring for the older patient. My great teacher and cardiology mentor at the Peter Bent Brigham Hospital (now Brigham and Women’s Hospital) in Boston, Dr. S.A. Levine, taught me that listening is the quintessential art of clinical medicine.(1) It is the most difficult of all the skills in the physician’s repertoire. Even after five decades as a clinician I have not quite mastered that elusive art.
The Art of Communicating
The complexity of listening stems from the very inadequacy of language. Words are imperfect communication tools. They are freighted with different meanings depending on a host of factors. These include age and station in life, class, schooling, race, gender, and ethnic background as well as many others. In fact, language is both our prison and our major pathway for self-liberation. Facile and inexact, words rarely capture the deeper intent of what we yearn to share. Each of us has sensed the frustration of trying to communicate an unusually charged event. We constantly witness the breach between experiencing something meaningful and attempting to share it with others. Try as we may, we fail to impart the frisson of aesthetic rapture of first viewing Brunelleschi’s Dome or Botticelli’s Primavera, or listening to a perfect rendition of Schubert’s Trout piano quintet, or viewing a great artistic performance. We soon learn that the emotional and spiritual innards of our being are beyond the bland coloration of words. Yet, being human is defined by the very operation of our minds, largely shaped by moods, feelings, and sentiments.
To circumvent the limitations of language, evolution has endowed us with an additional venue to shape the meaning of words. We each possess a powerful nonverbal repertoire based on body language and facial expressions. Communication is thereby finely tuned with tonalities that words lack. This instantaneous messaging system operates across cultures and is even evident in infants and toddlers.
A conversation involves, besides words, complex subliminal tuning constantly adjusting to a host of signals. This may involve a tiny narrowing of gaze, a stare or diversion of eyes, a drooping of lip, a shrug of shoulders, a tightening or unfolding of hands, a shuffling of feet or uncrossing of limbs. The cues are numerous. Information guru Richard Wurman has written, “We make adjustments, simplify, repeat, and move between various levels of complexity based on continuous feedback. A quarter inch nod of a chin, the lowering or raising of eyes, strange guttural noises that say uh huh, uh huh, blinks, shrugs, turns of the head, loss of eye contact, making of eye contact — a symphony of signals occurs during even the briefest of conversation.”(2)
A Personal Journey
Neither medical school nor residency training taught me the art of communicating with patients. Dr. Levine sensitized my awareness of the rewards of a carefully taken history and a meticulously performed physical examination. However, my greatest teachers have been patients. Over many years, they helped me develop these skills, which multiplied like barnacles sticking to a vessel’s hull long in the water.
I began my career craving to be a medical scientist. After a ten-year-long apprenticeship with Levine, I shifted gears, aspiring instead to become a competent practitioner. By age fifty I was convinced that I had reached the top as a clinician, certain of having mastered both the art as well as the science. A good deal of that arrogance disappeared when I reached seventy. I could not deceive myself that I was keeping abreast with the torrent of scientific advances. Increasingly I was falling behind in knowledge of new drugs and procedures. Yet, the older I became, the more patients were clinging to me. Referrals, instead of diminishing, were increasing, and they were largely from a global clientele. The patients I had followed for decades were insisting that I was helping them more than ever.
My patients were well educated, knowledgeable about the many recent scientific breakthroughs and the latest so-called miracle drugs. They did not seem to be craving cutting-edge science in their doctor; they valued something more. I am persuaded that the secret commodity was my interest in them as human beings rather than as a collection of malfunctioning organs.
With the passage of years my doctoring improved. Listening was a central aspect of it. Sound decibels may concentrate in our ears, yet the translation of words and body language into cogent meaning is made possible by empathy. The greater the empathy, the more the patient imparts and the more we understand. The more we understand, the more the patient imparts. The cybernetics seems boundless.
The Informative Pause
Interviewing a patient is never a stereotyped interrogatory. It is a dynamic interaction. The doctor constantly floats hypotheses. The patient expresses a distaste for something, an affinity for something else, or evades answering some question, raising new surmises to be explored. The following encounter a few years ago is illustrative.
The patient, a dignified man in his seventies, was enormously disabled by recurrent bouts of rapid heart action that had forced him to retire from his business. In the past five years he had visited numerous cardiologists and made many trips to the emergency ward. As I pursued the intake history, he responded briskly and succinctly. His gaze was direct and unflinching. I surmised that he was self-confident and successful. His lovely, still youthful-looking wife, sitting close by, adoringly held on to her husband’s every word. I reflected, what a happy marriage!
Then, an innocent question: How many grandchildren did he have? He bowed his head, avoiding my eyes; the hesitation, though momentary, seemed prolonged, for he had answered the previous questions snappily. A red light blinked. Maybe a grandchild had a behavior problem, was sick or disabled, or had died. Maybe he did not get on with a daughter-in-law. My curiosity was piqued. Clearly the matter demanded exploration. His wife, who up to this moment had been engaged and quite talkative, affirming or adding to what her husband had been telling me, now withdrew into mournful unease. My patient’s shoulders hunched into a posture of resignation. Surely a grandchild had died after a tragically long illness, I thought.
“Your grandchildren are healthy?”
Immediate response: “Yes, indeed.”
“No behavior problems?”
“No, they are well behaved.”
“They live close by?”
“Yes, we live in the same city.”
It was unclear to me why I posed the next question, but I felt compelled to ask, “You see them often?”
An oppressive silence was followed by a hesitant, “We have not seen our grandchildren during the last several years.”
I didn’t need to probe any longer; I needed merely to absorb. In staccato sentences, the enigma was exposed. The wife silently wept as he related that for a number of years their son had worked in the family business. He seemed well adjusted and was highly paid for his work. Then the business financed his getting an MBA in a leading university. Upon his return he wanted to transform everything. Disputes were constant. When his father refused to promote him as chief executive, he abruptly resigned and forbade his parents to visit their three grandchildren ever again. Our long ensuing conversation explored in painful detail why things unfolded as they had.
When I suggested we go to the examining room, he laughingly asked, “Why examine me? You have already solved the problem.” He puzzled out loud why the previous cardiologists never asked any questions about his family life. He was even more perplexed that he himself had never connected the strained relationship with his son to the malfunctioning of his heartbeat. The arrhythmia was thereafter easily managed. In the following decade he had no further recurrences.
Rethinking on this experience convinces me that life does not provide a deeper sense of fulfillment than healing a fellow human being.
Dr. Bernard Lown's Blog 
Doctor: It is no mystery to me that more and more patients cling to you as you are getting older…my experiences taking my elderly mother for appointments have proved to me that a doctor that listens is rare. You are a treasure.
Jan Heinen
LiftChairReviews.com
Dear Dr. Lown–
The Scottish psychiatrist R.D. Laing once quipped that Freud’s true genius lay not in his theory making, but in the fact that he convinced people to pay him for listening to them for an hour. Laing was on to something. To be listened to–REALLY listened to–is a transformative experience. I tell my friends that if you find someone who’s willing and able to do it for an entire hour, pay them whatever you’ve got.
Since I am a psychotherapist, not a physician, listening is the only tool at my disposal. It is the only diagnostic device I have and the only medicine I provide. And–I am convinced–when I am able to do it well, it is a remedy more powerful than anything manufactured by Merck or mass-produced by Medtronic.
But “doing it well” is damn near impossible. Barred from expensive technologies, I have the great privilege of practicing this impossible art every day in my office, and still I fail more times than I succeed. Why is it so extraordinarily difficult? I fear that if the financial incentives of the healthcare system changed tomorrow so as to privilege the doctor-patient relationship, healers of every stripe would still find ways to avoid really listening to their patients.
I suggest that–in addition to the current financial realities that incentivize doctors to turn toward their technology instead of their humanity–the act of listening itself is something that all of us tend to shy away from, especially when the one asking for our attention is in pain. Listening deeply to a suffering human being requires us to open ourselves to him in ways that can shake us to the core. Again I’m reminded of Laing, who wrote that we lock people away in psychiatric hospitals not because they are suffering but because they are insufferable. To listen closely to anyone in distress–to let a patient in in such a way that she has the experience of feeling genuinely understood by a fellow human being–is at the same time to be confronted with the most anguishing facts of our own existence: the ceaseless parade of losses, disappointments, and failures that dog us all from cradle to grave.
But life’s terrible losses and disappointments are, of course, both poison and cure for both doctor and patient. They constitute the very wounds that must be healed. The inescapable facts of our brief lives often give rise to a deep and silent suffering that is difficult to hear behind the heart’s noisy arrhythmias. As healers, we can and must bear witness to the kind of despair that we ourselves naturally dread if we’re to provide that sense of human solidarity and companionship without which no human heart can heal. We must be the ones to remember–when our patients can not–that the painful transience of life and of our relationships and of all that we love is the very thing that makes makes this passage precious. We must know in our hearts that the inevitability of loss can confirm life instead of destroying it.
Our job is not to convince anyone of this, of course, but simply to know it–in a full, embodied way–as we minister to those who ail. Shakespeare reminds us of the essence of the thing in sonnet 73:
“That time of year thou mayst in me behold
When yellow leaves, or none, or few, do hang
Upon those boughs which shake against the cold,
Bare ruin’d choirs, where late the sweet birds sang.
In me thou see’st the twilight of such day
As after sunset fadeth in the west,
Which by and by black night doth take away,
Death’s second self, that seals up all in rest.
In me thou see’st the glowing of such fire
That on the ashes of his youth doth lie,
As the death-bed whereon it must expire,
Consum’d with that which it was nourish’d by.
This thou perceiv’st, which makes thy love more strong,
To love that well which thou must leave ere long.”
I wish a Happy New Year to you all.
-Archie Roberts
Archie Roberts, M.A., L.M.H.C.
Counseling & psychotherapy
http://www.archieroberts.net
Faculty – Graduate Program in Holistic Counseling & Holistic Leadership
Salve Regina University
I do not remember who first said that the art of medicine is knowing how and when to use the science of medicine.
As the author so aptly notes, it takes a life time to achieve the art of listening, taking and exploring a patient history to find the nuggets of silver and gold.
At seventy three and a half, I am still learning and every day I learn something new from patients.
Thank you for your very meaningful (and might I add beautifully written) prose. For almost 25 years I have studied and documented the great impact that true prevention can have on chronic disease risk reduction. We could likely reduce CVD by 70-80% with simple strategies that everybody is aware of by the time they are 30. Do you think the healthcare system and the doctor stopped listening in part because the patient stopped listening?
Professor Rimm’s important observation, that the overwhelming majority of cardiovascular disease (CVD) could be prevented, is appreciated by nearly all practicing cardiologists. As long, though, as social and economic policies are stacked in favor of the risk factors that predispose to CVD , no amount of persuasive locution by physicians will subdue the cardiovascular epidemic. One can easily be convinced of this observation by visiting a supermarket. Junk food is ten fold cheaper calorie for calorie than fruits or vegetables. A poor person is compelled by meager budget to go for junk or go hungry. Psychosocial factors, key in predisposing to CVD, largely ignored by cardiologists, are class related. Indubitably the poor are more stressed than the wealthy. Furthermore, if one looks globally, wherever governmental policies intervened for healthy nutrition, CVD strikingly diminished, for example North Karelia in Finland, in Poland, in the Seychelles, etc. The best example we Americans witnessed of social policy affecting injurious personal behavior is the striking reduction in tobacco consumption.
As to the question who stopped listening first doctor or patient, indubitably it was doctors. I lived through this transformation. The moment a test, intervention, or procedure rewarded a doctor many fold more than listening communication with patients was abandoned at flood tide. Proof that patients crave to be listened to comes from an odd reality. Patients are flocking to alternative medicine, whether it is chiropractors, homeopaths , acupuncturist, etc. They are paying out of pocket more than 50 billion dollars annually. The invariable explanation for this counterintuitive reality is encompassed in four words, “someone listened to me.”
As have been mentioned by professor Rimm, i have found that today’s patients have spent less time and patience while they are seeing doctor. What most of the patients want is ” superdrug” that can cure their illnesses as fast as eyes blink.
The comments about prevention and how it is affected by socioeconomic and other factors are spot on. This is what drives me crazy in the whole discussion of health care reform: there is little to no discussion of looking outside of the “health care system” to help prevent chronic disease (for example, changing farm policy to provide incentives for farmers to produce fruits and vegetables as opposed to astronomical quantities of corn that find their way, in highly processed form, into a long list of foods; as well as planning communities to encourage walking and cycling for transportation instead of hopping in the car for a one-mile trip or having all errands too far away to walk or bike) and in doing so reduce costs. There’s a time and a place for high-tech care, and we are very fortunate to have those capabilities, but we could greatly reduce the need for it, and thus health care costs, by preventing things like diabetes, obesity and of course cardiovascular disease. I am finishing my nurse practitioner program this year and, in my practice, would like to focus on helping my patients with prevention in addition to helping get them through their acute illness. However, all the patient education in the world only goes so far if the patient’s environment is not conducive to healthy habits. There needs to be more attention to this in all the discussions of health care reform–otherwise we will continue to have, simply, “sick care”.
Dear Dr. Lown,
Thank you for the words I heard from you this morning on the radio: you were being interviewed, Humankind #23. Your common sense, healthy attitudes, and attractive presentation are encouraging. As an older person (83 in July), I feel I can say: Keep on enjoying life, baby, and keep on giving yourself to us; we appreciate you.
Dear Dr. Lown,
I just read your book”The Lost Art of Healing” and am compelled to write to you. I am a Naturopath dealing in Alternative therapies and working in this field since last 25 years.Over the years I have seen the change in doctor’s attitude and approach as well as the patient’s expectations. Inspite of all the medical advances and superior drugs, we are a sicker world and unhappier human being.Your book has come as a fresh breath in the art of healing and should be gifted to every doctor who wants to be a ‘good humane doctor’.It should be read by all cardiac patients to understand their own problems as well as ways to deal with them. I thoroughly enjoyed reading the book and would be gifting it to a compassionate doctor working in cardiology to read it and pass it on to another potential doctor who still has not been caught in the maze of technology and rat race. I hope that we get to read more in this subject of healing from your end and learn from your vast experience in dealing with patients.Thank You.
Dear MODERATOR!
I sent comments a month ago and have no reaction.
May be I have to send money to support CENZURA expenses?
With best and kind regards.
Dr. Nikita Shklovskiy-Kordi
Dear Doctor Lown!
Is it possible to listen to the patient via Internet? How to do it? I wish you have inspiration for patient-doctor communications even on this new, but already ubiquitous platform.
The history of my question: I have fortune to work with outstanding doctor who palpate and auscultate all of his patients and listens to each of them. But 20 years ago I felt that medical records – “paper case history” is going to be destroyed under pressure of high technology methods. We started to build integrative computer interface for collecting and presenting of clinical information. We did it primarily for my teacher, but also to preserve any doctor time to listen a patient. On this way we constructed hospital information system with computerized “Temperature List” as the core element. We have chance as well to write The National Standard of Electron case records for Russia with possibility for a doctor to write a free text in any part of EHR. In the new Internet era we’ve developed the concept of “responsible patient” – collecting and storing medical information – is the patient’s work today. I was happy reading your book – it is the best introduction for the instrument we proposed for russian-speaking “responsible patients” – http://www.medarhiv.ru.
I found your blog through the publication of “The lost art of healing” in Russian. How to thank you for this book? It’s like pacemaker for my roughly beating heart – restoring the rhythm and reminding to the elderly person the reason to live and to work: after all, I have eternally young mistress – Medicine. Each of your “case stories” makes me want to shake your hand. It would be desirable to give you an essential gift – up to a kidney or a liver lobe – to prolong your life and, whenever possible, to take part in it.
However, I should tell to you that translation of your book into the Russian can concurrence with the English version of Russian Academy of Sciences website where the “Institute for Protein Research” were translated ”Institute of the Squirrel”. Instead of “anal sphincter”, the patient massages the thermometer by “oral sphincter” and many other funny things. However it hasn’t prevented from enjoying the book more than any other on medicine in my life. “The art of being patient” – is the treasure that I advise now to my patients before any prescription.
I would like to thank you specially for attention to the Russian literature and try to give you a small gift immediately: to alleviate your feelings arising in the first encounter with a corpse on patanatomy, beg you to re-read a lines about «mermaid on a dissecting table» from “Doctor Zhivago” (Book 1, part 3, 2).
Thank You
National Center for Hematology, Moscow
Dear Dr. Lown,
With great interest I have been following your publications beginning from the epochal “Digitalis Intoxication” back in 1960 till “The lost art of healing”. Like you I also have more than 50 years experience of constant work at bedside. All these years – first in Russia, then in Israel – I have paid great attention to psychological aspects of doctor’s activities. May be my recollections would clarify reasons why digitalis had lost its popularity.
With great respect and sympathy
N.Magazanik MD
Israel
SIC TRANSIT GLORIA MUNDI
(So the worldly fame passes away)
An old doctor’s recollections of Digitalis
N. A. Magazanik
I like to visit secondhand book stores. So once in 1960 I came across an old book, published in St. Petersburg in 1842. It was a Russian translation of a book «ENCHIRIDION MEDICUM» by German physician Hufeland(1762 – 1836) with an intriguing subtitle “Fruits of fifty years’ experience”. I immediately bought it, which turned out to be something like a short reference book for general practitioners. Hufeland was a contemporary of Napoleon. He was an ardent follower of the old Hippocratic school; new-fangled things like percussion and auscultation did not interest him. The Russian translator who belonged to the younger generation of doctors mildly reproached him for this and in his footnotes corrected misconceptions and prejudices of the venerable old man. At the end of the book Hufeland devoted several pages to a few means, which according to his vast experience were especially useful. He recommended them for young doctors as superb and universal resources. They were: bloodletting, emetics and opium. However, the Hufeland’s set was not original: the authority of this splendid trio had been immutable since the days of Hippocrates and Galen.
I read these lines filled with enthusiasm, gratitude and reverence, smiled indulgently and thought how far we have advanced from our glorious predecessors. I was proud that our generation lived in an era of unprecedented scientific progress; we have been armed with truly effective, miraculous medicines; at the same time we have got rid ourselves from outdated, useless, and sometimes even harmful remedies.
Time went by and now my own medical experience has lengthened up to more than half a century. During this time, the progress has accelerated even more. Almost each year we learn about some new epoch-making discovery and about powerful new drugs. As a result, the physician’s arsenal in the past 50 years that is on my memory has changed almost beyond recognition. However, into oblivion sunk not only the old but many new drugs too. I have seen how some of them had rocketed suddenly, enjoyed for a time being an enormous popularity and then dropped into oblivion notwithstanding numerous praises in prestigious medical journals.
At first glance there is nothing surprising that one drug replaces another: after all, the best is always an enemy of the good. We can only rejoice in the relentless improvement of medicine. But upon a closer examination it turns out that our preferences are changing not only because of scientific progress. The most striking feature in the decline of the Hufeland’s three superb remedies is that their popularity began to wither long before they were replaced by truly new drugs, which had really changed our medicine.
In fact, Hufeland had written his book in about 1830, while the scientific revolution which transformed the old Hippocratic medicine into a modern one began 40 years later, after Pasteur had discovered the enormous role of microbes in many diseases. Only then began a revolution in surgery due to introduction of asepsis and antisepsis, appeared first vaccines and serums; the first purposefully created antibacterial agent was proposed only in 1910 (Ehrlich’s salvarsan).
But already 20-30 years after Hufeland’s death, when still nobody knew anything about germs the famous French physician Trousseau already did not use the old “splendid trio”, as testify his clinical lectures. By the way, Trousseau used to quote frequently Galen, van Swieten, Boerhaave and Sydenham with greatest respect. He was perhaps the last representative of the same old Hippocratic medicine, to which belonged Hufeland too. It turns out therefore that an old, tried and tested agent may lose its former prestige without having been replaced by a new and better one. What then causes such a change? For half a century I have witnessed a gradual transformation in the attitude of physicians towards digitalis, and I believe that these observations may help to clarify this question.
In the middle of XX century, digitalis was still considered to be the most effective and truly specific treatment for heart failure. This reputation was well deserved. For us, young doctors it had been both an every day experience and at the same time a constant wonder to witness again and again how after a few digitalis pills or intravenous injections of Strophantin quickly – in a couple of days – decreased dyspnea and edema, slowed pulse, and the patient’s general condition transformed miraculously. I felt myself a winner and understood only too well the words of the famous cardiologist Edens: “I would not want to be an internist, if there were no digitalis”. Back in 1978 it was said in the classic textbook edited by renowned American cardiologist JW Hurst: “There is a simple, reliable, and old rule: digitalis is indicated for each patient with heart failure, whether it is right-or left-sided, with low or high cardiac output, with atrial fibrillation or with a normal rhythm or heart block”. A French physician had even coined an aphorism: “The only contraindication to digitalis is absence of indications for it”.
Cardiac glycosides have been among the most frequently used drugs. In the 60-ies of the twentieth century, digoxin ranked the fifth in the number of prescriptions by doctors in USA (cited by Therapeutique Medicale, J. Fabre Ed., Flammarion, Paris, 1983). The widespread use of this medicine corresponded to an over-abundance of proposed drugs. In pharmacies one may choose between a simple powder of the dried leaves of foxglove and different extracts (water or alcohol) either from Digitalis purpurea or D. lanata. There were also various purified crystalline glycosides – digoxin, digitoxin, lanatosid C. There were also digitalis-like cardiac glycosides from other plants (strophanthin and ouabain from Strophanthus, adonisid from Adonis vernalis, corglycon from Convallaria, etc.). Each producer praised his drug and cited relevant scientific research results – exactly as today we are being offered different varieties of the same antibiotic or slightly different beta-blockers, calcium blockers, etc. This situation is well characterized by French expression embarras de richesses – confusion of plenty, when one does not know what to choose because of an overabundance…
Not only was the market overfilled with digitalis. The literature on digitalis was almost boundless. The striking effect of this drug occupied the minds of many researchers, and the flow of scientific papers on this topic continued unabated for decades. But this very abundance testified some mystery of its action. Many authors have not been able to prove objectively the positive heart inotropic effect of digitalis in spite of everyday clinical experience. Reading such skeptical articles, I just shrugged and continued to use digoxin and strophanthin with an unshakable confidence, knowing that they would not let you down.
Withering, who first introduced digitalis in our medicine in 1785, explained its healing properties exclusively by its diuretic action. Later on it was found that digitalis eliminates only cardiac edema. Still later it became clear that it is not at all a true diuretic, and that its beneficial effects are caused by the improved contractility of the weakened heart muscle.
The first truly powerful diuretics, which directly augmented the water excretion by kidneys, were synthesized only in 20-ies of the twentieth century. These were organic mercury compounds. But their use was hampered by two factors. First, they were effective only as injections. Secondly, the presence of mercury in the drug’s molecule created a risk for a severe kidney damage. When I began my medical career (1954), the main remedy in the fight against heart failure was still digitalis. Only if it did not help, or if we wanted to liquidate edema more quickly, then an intramuscular injection of mercusal or novurit was added. In order to achieve the maximal effect, one had to give to the patient to drink for some days before the injection a ten- or even fifty percent (!!!) calcium chloride solution – a bitter nauseous liquid … It is clear that under these conditions, diuretics were only an additional aid in the treatment of heart failure. Moreover, everyone understood that digitalis acts directly on the principal underlying cause of heart failure, namely, on the weakened heart muscle, whereas diuretics simply eliminate excessive water, i.e. the consequence of the heart failure. In fact therefore it differs little from the ascites removal by paracentesis, a procedure that so liked to perform Peter the Great in Russia in 18th century….
The situation changed dramatically in the early 60-ies of XX century, when a fundamentally new diuretic hydrochlorothiazide (disothiazide) has appeared. These little pills quickly reduced edema; they were well tolerated and did not seem to have serious side effects. I remember a patient with a severe heart failure; I gave him this new drug which had been sent to our clinic for clinical evaluation. He was, so to speak, an experienced patient with long cardiac history, familiar with our entire medical arsenal. The effect was so great that at his discharge from hospital, he literally with tears implored me to give him a few extra pills …
From now on, it has become possible to combine digitalis treatment with a regular – several times a week or even every day – addition of disothiazide and thereby to maintain a more stable improvement. About ten years after that doctors had received yet another, even more powerful diuretic furosemide. He caused as abundant diuresis as a mercury diuretic, but in this case the patient was not tied to an injection needle; it was enough to swallow simply a pill. In the case of pulmonary edema, furosemide intravenously proved to be indeed life saving.
New diuretics were so effective and convenient that soon doctors began to use them in almost every case of heart failure together with digitalis. Such a combination gave a more complete and long-term remission. Improvement occurred even in those cases where digitalis alone had been totally ineffective before, despite the use of maximal doses up to the intoxication. Some doctors, encouraged by this success, tried to treat the heart failure only with diuretics, without digitalis at all. The results seemed to be good, but I well remember my first reaction when I have read such an article in the American Heart Journal: “Well, it is too much!”
Any diuretic removes from the body not only water but also various salts. Therefore, by increasing the proportion of diuretics in the treatment of heart failure, we were increasingly confronted with disorders in the electrolyte composition of blood; particularly frequent was hypokalemia. In this changed environment, digitalis was often toxic even in moderate doses, which had been previously considered as completely safe. Fifty or even forty years ago we rarely saw digitalis intoxication. Usually it was just a bigeminy, which quickly stopped after discontinuation of digitalis. As for deaths from digitalis intoxication, I have not seen even one such case.
Now the people began to treat digitalis with caution. To avoid toxicity, patients were given potassium salts, or the dose of digitalis was reduced; sometimes doctors preferred to withdraw it from the treatment completely. Suddenly came in vogue medicines, that allegedly also had beneficial effects on the heart muscle metabolism, but which saved doctors from anxiety associated with the use of digitalis. These were different preparations of potassium (in particular, tablets of Panangin – asparginate of potassium and magnesium) and a precursor to vitamin B1 – Cocarboxylase. I had been repeatedly invited to consult a patient with a full blown picture of heart failure (edema, shortness of breath, atrial tachyfibrillation), who did not yield to the treatment. At the bedside I used to find out that the patient had received only Panangin tablets and injections of awfully scarce at that time Cocarboxylase. I shrugged in astonishment, recommended digitalis and furosemide, and after a few days the patient’s relatives thanked me enthusiastically for a “miracle cure”. My popularity (and private practice too), increased markedly. But in fact I simply prescribed the standard treatment, known to any medical student of senior courses. I could not help not to recall a sad joke of the once famous Moscow physician professor D.D. Pletnev: “I live on doctors’ ignorance…”.
Soon appeared drugs with completely new mechanisms of action – beta-blockers, calcium blockers, angiotensin-converting enzyme inhibitors. Formerly we could act only on the initial and the final points in the complex mechanism of heart failure (heart muscle and kidneys). Now these new medicines have allowed us to interfere in many intermediate points that previously had been inaccessible to us.
The decline of digitalis has begun. If in his classical treatise on heart disease (1956) C.K. Friedberg devoted to digitalis 23 pages out of 60 (38%) in the chapter on the heart failure treatment, so in the textbook of J.W. Hurst (1978) to digitalis was allocated only 26% in the relevant chapter and in the monograph of E. Braunwald (2000) – only 10%. Practitioners began to prescribe digitalis less and less frequently. For example, answering to my question a manager of an ordinary local regional pharmacy said that in 1996 the patients had bought 10,150 tablets of digoxin according to prescriptions of local family doctors; in 2000 had been sold 6,210 tablets, and in 2005 only 4,690 tablets. It should be emphasized that during this period, the family doctors’ arsenal against heart failure did not changed. Why, then, digitalis continued to lose its position? Often I see that it is being replaced with new drugs, not only in cases where these remedies are more effective and better meet our therapeutic aims, but even in the situations where it is still the best choice. Thus, in a case of rapid atrial fibrillation in conjunction with heart failure doctors usually prescribe now a calcium blocker or a beta blocker together with diuretic and angiotensin-converting enzyme inhibitor, although in this situation digitalis seems to be the most appropriate response and by the way much cheaper one…. Therefore, one is forced to conclude that the continuing decline in the digitalis popularity is caused not only by the fact that new drugs are better, but because to use digitalis has become unfashionable.
Here we are coming to a very serious problem. The assertion that the doctor’s choice of a drug depends not only on clear and understandable scientific evidence, but on the vogue too may seem ridiculous or even offensive. But the author is not inclined to paradoxes. The practical or clinical medicine is of course a science because it is based on such precise and objective sciences as physiology, pharmacology, biochemistry, etc. But in order to apply the scientific knowledge to a specific patient and to choose from a variety of treatments an option which is the most suitable for this particular case requires personal experience, intuition, common sense, the ability to see simultaneously each small detail and the whole picture as well; all this requires a special medical art. Hardly a notion of art is applicable to mathematics or physics, but the Brooklyn Bridge in New York or the Eiffel Tower in Paris, are universally considered as examples of engineering art. The official journal of the American Medical Association JAMA announces in its title the aim to “promote the science and art of medicine”. That is why clinical medicine, being also an art, is not free from erratic influences of fashion, and is not governed exclusively by scientific progress only. A good example is the fate of cupping glasses. Obviously, if an acute bacterial pneumonia is diagnosed, the drug of choice would be, of course, an antibiotic, and not antiquated home remedies. But what may offer the modern medicine in case of an acute bronchitis, which is caused usually by viruses? – Rest, drinking plenty of fluids, a little of aspirin or acetaminophen, and, perhaps, codeine. As to expectorants, all textbooks are unanimous in cooling the doctors’ enthusiasm, stressing that there is no credible evidence of their effectiveness. In other words, we recommend only an appearance of treatment in order simply to ease the patient’s condition and to help him to wait comfortably until the disease would pass by. Such tactics are often quite reasonable. But any old doctor or a patient may confirm with their own experience the undisputable and marked relief following medical cups application. Their symptomatic effect certainly had been no less than that of aspirin (I may witness: much stronger!). But the medical cups are outdated, outmoded and it is simply improper to recommend them now … If this example does not seem to be convincing enough, one may recall tonsillectomy, which was once extremely common, but is now almost completely forgotten.
But let us not blame doctors. Their adherence to the vogue has nothing to do with the vain desire to show off. Too hard are conditions of our work. We constantly have to make diagnostic and therapeutic decisions in the fog of uncertainty, and to base them on incomplete and not always reliable information; often we do not have time enough for further observation before prescribing the treatment. Not without reason the first aphorism of Hippocrates says: “The life is short, the way of the art is long, the opportunity is fleeting, the experience is often misleading, and the judgment is difficult”. Therefore, doctor has a constant need for some psychological support while doing his work. Dispensing the treatment, he must be convinced of its usefulness. Otherwise, he not only deceives the patient, but he also causes to himself a heavy internal crisis – the feeling of his own worthlessness. The belief that he does what is really correct and useful he draws from several sources. First, it is his own experience: he had used this treatment in the past with success. Alas, patients are rarely identical. Secondly, to his side are the results of scientific research. And finally, it is very encouraging to know that another doctor in his place would have acted just in the same way. This last factor may be called with the name of Mozart’s opera “Così fan tutte” (everybody does the same)… Exactly this explains the role and influence of fashion in clinical medicine.
In addition, when the doctor selects a specific drug or a medical procedure for the treatment, his decision is influenced also by public opinion, i.e. by our patients’ expectations. For their part, the patients themselves are strongly influenced by fashion and by advertising. For example, many patients are convinced now that in a case of fever the doctor simply must prescribe antibiotics, although we know perfectly well that fever is caused by microbial infection only in a part of cases. Similarly, many patients use to demand a just released and a heavily advertised medicine, and it is not always easy to go against the tide…
Thus, the growth or the decline in the popularity of a drug depends not only on its real pharmacological values, but also on its reputation in the eyes of doctors and patients, that is, on “fashion”. To withstand completely such a psychological pressure is hardly possible. Besides it is even not necessary: we all need some encouragement, “Così fan tutte”. But it is very useful to be aware of the existence of this important factor, because then we may follow the fashion not blindly, and if it is necessary, we may act in defiance of it.
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These recollections about the digitalis decline were already written in 1999 when I came across an article in JAMA (2002, vol.288, No 23, Dec. 18, p.2981-2997). The authors present the results of comparison of two recent heart drugs (lisinopril and amlodipine), on the one hand, with an older and more familiar diuretic (chlorthalidone), on the other side. The observations were conducted on 33,357 (!) hypertensive patients. The main conclusion is that these new drugs have no advantages in comparison with the already well-known diuretic. The authors even claim that “thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less expensive”. But the most interesting point seems to be this. It turns out, that diuretics which had ousted digitalis, also began, in their turn to lose ground under the onslaught of new drugs: in 1982 diuretics in the United States accounted for 56% of all prescribed antihypertensive drugs, while in 1992 – only 27%. The authors conclude with melancholy that if doctors would still remain faithful to diuretics and would continue to prescribe them at the rate of 1982, then the U.S. health care would have spared $3.1 billion. Each fashion – and not just in clothes – demands a lot of money…
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