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.

The great Brigham clinician, SA 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. 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 CHD 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.

Coronary disease
The problem of overtreatment grew exponentially after Favoloro 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 a 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 life style, 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.

Lown Clinic
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, CHD 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 multivessel 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 one thousand 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 multivessel 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 forty 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.

Health Crisis
Experience of the Lown clinic speaks to the uniformly acknowledged crisis in American health care. Politicians and health policy experts relate the crisis largely to run away costs.  In my mind the crisis is far more than fiscal, far deeper than economic. 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 2000 yrs.
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 technologic 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.

Prevention
The small role allotted to primary prevention is a major deficiency of our dysfunctional health care. Community support for healthy life styles are vastly underfunded. The largest investment goes to chronic illness when manifesting as acute disease. Prevention, the foundation of a sound health system, though honored in preachment, commonly plays second fiddle to the loud drumbeat for hospital focused care. This lacks medical rationale and is devoid of economic sense.

Looking around the globe there are numerous persuasive demonstrations of the effectiveness of government sponsored programs promoting community prevention of cardiovascular disease. In 1972 Finland had the highest CVD mortality rate in the world.  The Finnish government sponsored large scale programs educating the public  about risk factors. It promoted availability of low-fat dairy products, passed antismoking legislation, and improved nutritional quality of school meals. Within a quarter of a century, CVD mortality in Finland was reduced by 75 percent. Another striking example is what occurred in Poland. In 1990, as the iron curtain toppled, Poland opened trade with the West, increasing import of fruit and vegetables. The government also stopped promoting and subsidizing butter and lard consumption.  Within less than a decade CVD mortality dropped by a third.

I am persuaded that doctors devoting time listening to patients and shifting medical traffic to the proven road of prevention would profoundly reduce health care costs. Yet these two measures are largely ignored in the ongoing national debate.

Marketization of Health Care
A major factor accounting for these neglects relates to the dominance of market
forces which favor and even compel the industrialization of health care delivery.

An essence of industrialization is reducing cost of production by increasing
efficiency, namely, lessening the time to make a widget. Productivity is increased by speeding up assembly lines and replacing costly human labor with technology,  especially with robotics. The product, irrespective of how socially necessary or value laden, if not profitable, will not be produced.

Listening was an early casualty. Since listening consumes much time, but is minimally reimbursed, it grew cursory, circumscribed, and frequently completely bypassed. It left patients frustrated and doctors uninformed. The consequences for the health care system are ruinous. Aiming to foster increased productivity, industrialization shifted the focus of the debate to efficiency, to competition, to cost containment.  Industrial efficiency is in part obtained by rapid patient through-put during encounters with primary care physicians or during specialist referrals. In such a model of health care doctors are providers, patients are consumer/customers, hospitals are industrial plants and major profit centers.

Medicalization, and overtreatment are an essential part of a market system. As a result patients are morphed  into amalgams of dysfunctional parts, with the human dimension commonly shredded in the gears of innovative technologies. The more patients are reduced to widgets, the more amplified is the verbiage that the bed rock of the system is patient centered.

Limitations of Markets in Health Care
Market medicine is organized like any other business to generate profit.  Withholding care for those who can not afford it, as well as overtreatment of those with means, are profit maximizers and therefore sound business policy. In order to survive the well intentioned must hew to the competitive pressures of the market or get out of business. This was spelled out by the panjandrum of market theory, the ultimate market triumphalist, Milton Friedman, ”Few trends could so thoroughly undermine the very foundations of our free society as the acceptance by corporate officials of a social responsibility other than to make as much money for their shareholders as possible.” In the business model, like any other business, the major goal is profitability. Good intentions and high sounding principles are incidental. I believe that the market is not a solution. Indeed it is a major part of the problem.

Moral Issues
My objection to market dominated health care is on deeper grounds than economic. In a democratic society health care must be a right, not a privilege. The underlying issues relate to essential moral principles.  Medicine is a calling.  At the core it is a moral enterprise grounded in a covenant of trust between health professionals and patients.  The primary mission of a clinician is to heal, to care, to advocate for the sick and to work for the promotion of everyone’s health.  Central to the doctor patient relationship is the expectation that patient’s needs will be placed first, over and beyond personal interests or the interests of any third party.

There is a moral absolute in medicine to help and never to wrong the patient.
No such moral absolute can be found in the marketplace. Caveat emptor, let the buyer beware, is its underlying admonition. The warm and fuzzy rhetoric that “patients come first” is a transparent marketing ploy.  For-profit health care is essentially an oxymoron. The moment care is rendered for-profit it is emptied of genuine caring.  This moral contradiction is irreparable by any conceivable palliative. We talk of overtreatment as though it was merely an improper financial transaction. Overtreatment harms patients thereby negating the first principle of doctoring, primum non nocere.

I am reminded in Herman Melville’s Moby Dick; Captain Ahab, experiencing a terrifying moment of illumination, cries out, “All my means are sane; my motives and object mad.”

Where do we go from here?
Any challenge becomes doable when it is shown to be possible. A four minute mile was deemed impossible until Dr. Roger Bannister broke the record. Now it is common-place. So first, the good news. In the present adverse health environment it is still possible to drastically circumscribe overtreatment. For more than 40 years the Lown Clinic has substantially curtailed cardiovascular interventions. The possibility is no longer in question. We have done it!

The bad news relates to the acrimonious partisan health debate now convulsing American politics.  When I was in medical school, 70 years ago, universal health insurance seemed a certainty. The Wagner, Murray, Dingell Bill was assured passage through Congress and would have been enacted except for a misbegotten wartime compromise. To maintain a work force in the face of a national wage freeze, industry diverted some wages into health benefits. We are still afflicted with the unintended consequences of that Faustian bargain.

We need to get back on the track of history. Medicare has proven to be a remarkable advance in improving health for the elderly. It grants dignity to old age. It operates at lower cost than market driven health systems. Everyone would be covered regardless of employment or health status.  It is constitutional.

Half measures will no longer suffice. A single payer health care embracing the model of Medicare for all deserves to be at the forefront of consideration in addressing what now constitutes close to a fifth of our economy. It would bind our nation, improve health care, contain costs, and lessen moral ambiguities for health workers.

A crisis affords an opportunity for deep changes. We should not demure by resorting to creeping partial measures. Self regulation, presumably works among saints.  Appeals to our better nature is welcome. History teaches though that curtailing incentives for misdeeds and providing recognition for good outcomes proves far more effective.

Creating a more just health care delivery system will not solve a host of other vexingly difficult issues. Unless fee for service is replaced, we will not restore the  centrality of the patient nor lessen reimbursement driven over treatment.

More is better, or less is better are improper catch phrases. The ultimate litmus is what is best for the uniquely individual patient. In 55 years of practice I recall but a single patient who insisted on having coronary angiography. Fully informed patients, trusting their physicians, do not insist on tests or procedures. In overtreatment the patient is victim not instigator.

Health care with a human face requires drastic restructuring of medical education. Promotion of personal communication skills has to be part of a core curriculum during each of the four years. Furthermore medical education should be subsidized. Health security is integral to our national security. Among other gains it would reduce the pressure for specialization in order to cope with mammoth student debt.

Beyond the breakdown of health care is a far deeper phenomenon.  It relates to the onrushing marketization of all human activities. The result is to denature fundamental human values and tear apart ties that promote communal life. We in the health field, who nurture science for the sake of human health and well being, need to be in the forefront in promoting respect for the dignity of human life. This has to begin with listening to the patient.

One final thought: about three decades ago a small band of doctors contributed to a historic transformation. They spoke out against the stockpiling of nuclear weapons capable of destroying the world many times over. They believed that there is no greater force in modern society than an educated public, aroused and angered to effect change. This Gideon army of passionately committed physicians made millions aware that medicine had nothing to offer in case of nuclear war. They maintained that the two super-powers either lived together or died together. They offered humankind a prescription for survival. The involvement of multitudes in the antinuclear movement compelled governments to serious negotiations which ultimately lifted the Damoclean sword.

At present we physicians are challenged on our home turf. We need to offer  people a prescription for health. Each American deserves dignified, person centered, and affordable health care. At the same time we must convince a wide public that our principles embody responsible stewardship of finite national resources. I have always believed that those who see the invisible can do the impossible.