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.
Time and patient-centrism
What is the significance of a human presence? What does true patient-centrism entail when medicine is a calling rather than a business transaction? First and foremost a doctor affords adequate time for a patient. There is no substitute for time. Shortcuts, fractionated multiple brief visits, having aides fill out rarely-looked-at forms, do not substitute for solid time. A doctor typing away into the informational catacomb of a computer is not patient time. These, rather than confirming, mock much-vaunted declarations of patient primacy.
Time is our most valued possession. When shared abundantly, it is a precious gift. Time is the mortar that cements the bonds of trust. Time exposes the wider human terrain of the social and psychological detritus that frequently compels a medical visit in the first place.
In manufacturing, diminished time for producing a commodity is the mark of efficiency. Not so in clinical medicine. The briefer the doctor-patient encounter, the more inefficient the process. Human as well as financial costs grow exponentially when shorting the time spent with a physician. The more time a doctor spends in listening and performing a thorough physical examination, especially during an initial visit, the more the patient and the health system profit. Time enables the professionalism of a calling to prevail over the powerful dictates of the market.
When we talk of cost in our market-driven society, the numeric exclusively speaks of the cost to providers. Ignored in these mountainous discourses about health efficiency is the magnitude of time invested by patients. Surfing the Net and shopping around for a second opinion take an enormous amount of time. The time spent making appointments and shuttling between robotic telephonic voices, the time for traveling to clinics, the hours spent waiting in doctor’s offices—all impose costs to the patient. And what of time away from work, or the cost for babysitters? And what about the prodigious investment of time by caregivers who shoulder the medical and nursing tasks hitherto the exclusive province of professionals in attending to family members prematurely discharged by the hospital? These impose fiscal burdens on individuals as well as on our economy. The substantial psychological stresses associated with such an unproductive investment of time fray the very health that the medical care system is structured to preserve.
My thesis is that genuine patient-centrism would drastically reduce health care costs and result in more healed patients and more fulfilled doctors. (This will be considered in future essays.)
So what is true patient-centrism?
We need to return to the central issue. Time has other dimensions than duration. It has continuity, depth, and intensity. Continuity is disrupted when the patient is interrupted after a sentence or two, or the doctor is diverted by being paged or called to the telephone, or by seeing several patients simultaneously, or by obtaining the patient’s history while typing away on a computer. Such behavior truncates potentially vital dialogues and constitutes negative time. It communicates a lack of caring. It subtracts from a doctor’s ability to foster trust, promote confidentiality, and thereby facilitate discovering what truly ails the patient.
When the doctor sits facing a patient at eye level, physical proximity promotes psychological proximity. The exchange thereby is intensified. The doctor earns the privilege of hearing hidden content, at times not only from others but also possibly from a patient who is not fully aware of what is truly troubling. Frequently the all-knowing patient does not know. Healing is about such an act of discovery.
“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.”(1) Patient-centrism demands cultivating the extraordinarily complex art of listening. To be able to focus on uncovering the meaning hidden in pauses, on deriving subtexts from inflections, on harvesting the rich catch floating in the spacious interstices between words or on words uttered haltingly. Silences may reveal where problems are hidden. A doctor craves discovering the gestalt of the unique human being searching for help.
Patient-centrism denotes sensitivity to the infirmities of old age. It requires tuning more empathically to the dawdling, the discursive, the forgetful, and the confused. The more psychologically impaired the patient, the more gentleness is needed: less interrupting, less pushing and demanding, less rush. How often have I heard the phrase “Doctor, I have used too much of your precious time already.” A mark of fulfilled doctoring, these words entwine human beings as in Martin Buber’s “I and Thou.”
The absent physical examination
What I have experienced as a patient and have witnessed in a long career of doctoring is quite different. Many doctors first encounter a partially disrobed patient in an examining room. (I am reminded of an old joke. Two young people totally undressed and in johnnies are awaiting a doctor in a multipatient examining area. One turns to the other asking, “Why did I have to undress? I have only a dislocated thumb.” The other, appearing even more perplexed, says, “I came only to deliver a package.”)
The doctor invariably stands, looking down on the recumbent patient while glancing at information gathered by an aide, poses a few perfunctory questions focused on the chief complaint, which frequently has little to do with what truly ails the patient. In the twenty hospitalizations that I experienced over the past five years, I haven’t had the house staff do a physical exam other than feeling my abdomen where I was hurting. At times it was preceded by placing a stethoscope on my chest, presumably to establish that my heart was beating. The hospital where this transpired proclaims unswerving dedication to the primacy of patients.
Rather than the manipulation of an aching shoulder, or the palpation of a painful belly, patient-centrism demands a comprehensive physical examination. Few exertions by a doctor resonate as well with a patient. Often after such an examination the patient is ready to expose what truly is troubling.
Memory prods me back sixty years. The lapse of time does not diminish the frisson of unease evoked by this remembrance. I recall the 85-year-old woman vividly. Though elegantly attired she seemed shrouded in mourning. An exhaustive history failed to divulge why she was full of aches. No bodily part was exempted from some complaint. Why had she remained single? Why was she evasive about her family — rarely the case with upper-class Boston Brahmins? Why the multiple charities that she was involved with?
After a thorough physical examination, in a leap of wild imagining, as I was gently squeezing her forearm, I asked, “If you want my help, why are you so secretive?” As these words slipped out, I regretted my brazen intrusiveness. Her body shivered. She looked like a cornered prey, head moving side to side. In a barely audible murmur she repeated several times in a funereal dirge, “No, oh no.” After an interminable pause, she half asked and half affirmed: “You know, then?” I remained silent, not aware of what I was supposed to know and not prepared for what was coming. Looking straight ahead, focused on some distant point of grief, she related a tale suppressed over a near lifetime.
Reared in a proper upper-class Boston family, she consorted at age 19 with a man in his mid-30s. Her parents vehemently opposed this relationship and warned that she would come to bad end. When she realized that she was pregnant, she obtained a job on a Vermont farm. There she delivered the baby by herself, then dropped the newborn down an old well. She remained a gentle, ghostly spinster, never revealing until this moment that she had murdered her own child. No amount of self-flagellation diminished the ache, assuaged the sleepless nights, or lighted the crushing weight of guilt. In this fateful examining room her lifelong search for absolution was now at hand.(2)
Prescribing drugs and patient-centrism
Patient-centrism extends beyond the initial diagnostic workup. It permeates every nook and cranny of doctor-patient interaction. That is what a calling is all about. Patient-centeredness involves minimalism in prescribing. I am convinced when a single drug is prescribed, the doctor probably knows what to anticipate. When two drugs are prescribed, uncertainty prevails. When three drugs are prescribed, a doctor hasn’t the foggiest notion how a patient will react. When four drugs are prescribed, God doesn’t know what might ensue.
During my cardiovascular fellowship with Dr. Samuel A. Levine at the Peter Bent Brigham Hospital in Boston, I was impressed with the magnitude of adverse drug reactions. When Dr. Levine had a new hospital admission, he stopped all drugs. At first I was horrified, anticipating a host of adverse effects. On the contrary, the large majority of patients rapidly improved.
At present poly-pharmacy is the fate of the elderly. By age 65 multimorbidity is the new normal, as are visits to numerous specialists. This inevitably results in a stash of drugs. In my experience ten or more medications are the rule. When a patient presents with new symptoms, the doctor is in a quandary. If the symptoms are related to the drugs, which of the many is not easy to unravel. Complicating the conundrum is that the same drug in its generic and brand formulations may differ in size, shape, color, and name. If the patient is shuttling to various consultants, identical medications may be prescribed. Sorting out what is going on requires sleuthing and infinite patience.
I learned painfully, and close at home, the harm that so-called minor drugs can inflict. My father developed vertigo. He had to retire from work and give up driving. He consulted to no avail numerous Boston medical specialists. He grew profoundly depressed. It was heartbreaking to watch a vigorous and very intelligent man so disabled and in despair. He denied taking any medications or health supplements. Once my mother overheard my medical interrogatory about drugs. She volunteered, “What about the eye drops?” Indeed five years earlier an ophthalmologist prescribed tetracycline eye drops for lid inflammation. Shortly after the eye drops were stopped, the disabling vertigo disappeared, but the psychological damage could not be undone.
Since that experience I insisted that patients with new symptoms bring in all their brand and generic drugs, including health supplements, vitamins, minerals, eyedrops, ointments, and lotions. At times I found duplicates as well as medications I had never been informed about. Many times it enabled me to identify the hitherto elusive causes for inexplicably bizarre symptoms.
An astounding lesson of my many decades of medical practice was the commonality of adverse drug reactions. Strange that I myself over several years was a victim. I developed a neuropathy, consisting of shooting, stinging, sharp electric shocks radiating from buttocks to toes, waking me nearly nightly from sound sleep. Visits to doctors and neurologists were unavailing. I was on no new medications and had been taking the same pills for more than a decade. I began to believe that drugs were implicated. The likeliest was a statin drug, the ever-popular Lipitor. Based on my cholesterol level I had reduced it to only three times weekly. Every physician I had visited dismissed my suggestion. Statins had a low-risk profile and almost never induced neuropathic pains. I had been taking it over many years without symptoms and in a minuscule dose.(3) Though “irrational,” I stopped Lipitor. Within three days the symptoms disappeared. For the first time in several years I slept through the night without discomfort. It seemed miraculous. Ever the skeptic scientist, I restarted the Lipitor. Within three days, the very same symptoms recurred, only to disappear again on drug cessation.
It should come as no surprise that adverse drug reactions are a serious problem among the elderly, who commonly take a multiplicity of pills, vitamins, and diverse health supplements. After all, every drug is a potential poison. This was already recognized in antiquity. The medieval alchemist, astrologer, and physician Paracelsus noted, “All substances (drugs) are poisons; there is none that is not a poison.” The right dose distinguished a poison from a remedy. Shakespeare in “Romeo and Juliet” phrased the same more poetically. Friar Lawrence searches for a potion to put Juliet in a sleep simulating death. On encountering a flower with medical powers he reflects: “Within the infant rind of this small flower / Poison has residence, and medicine power.”
Attending to patients with multiple cardiovascular risk factors, I never started multiple drugs simultaneously but spaced them over many weeks. The most important drug was started first. Several weeks later the next drug was to be taken, and so on. This permitted prompt recognition of which agent or which combination was the cause of an adverse reaction. Patient-centrism consists in investing time to readily detect — better still, to minimize — adverse drug reactions.
Patient-centrism involves empowering patients to take charge of their own management relating to some drugs for oft-recurring symptoms. Patients are far more informed about their own physical and emotional selves than the most astute clinicians. For example, patients with angina pectoris know when to take the magical nitroglycerin to ward off chest discomfort. Not even a doctor endowed with Solomonic wisdom would be able to navigate these uncharted waters. One patient, the CEO of a large corporation, would have long-lasting chest discomfort, and sometimes broke into a sweat, during board meetings. He related that if he took two nitroglycerin sublingually as the board meeting got started and one when a board member whom he intensely disliked began to talk, he was free of angina.
Another example of patients in control relates to the use of diuretics. I have never understood why doctors are intent in tormenting patients who accumulate edema. Invariably a powerful diuretic, such as lasix or torsemide, is prescribed daily. For many elderly, commonly afflicted with urinary incontinence, this is life disrupting. If they take the diuretic in the morning, they are housebound with frequent urination. If they use the diuretic in the evening, sleep, ever fragile, is disrupted. Daily diuretics induce dehydration in many, favoring a reduced blood volume and postural low blood pressure. These predispose the elderly to the most dreaded complication, namely, falling and fracturing thinned bones. Additionally, excessive diuretic use may deplete bodily potassium and magnesium, thereby increasing the likelihood of life-threatening heart rhythm disorders.
I consistently begin by prescribing a diuretic once weekly. The patient keeps a daily weight chart. A diuretic is taken only when body weight has increased by three pounds. The patient takes charge of diuretic management. Invariably diuretic use is markedly reduced. I have had patients shift from daily to monthly use. Monitoring their body weight instructs patients about high-sodium foods as a key factor in fluid retention. They learn also that frequent eating outside the home compels the use of more diuretics. Gaining control of the vagaries of one’s own body promotes a more secure life. In fact, much medical evidence, emanating primarily from Great Britain, suggests that being in control of one’s own life is a key factor in reducing the toll of heart disease.
Life style and patient-centrism
My father-in-law insisted that he wanted to die living rather than live dying. I have promoted this philosophic view among my patients. Living in the shadow of death’s imminence degrades and shortens life. I aimed to curtail hospital admissions, since these consistently deplete one’s sense of self-control. I have pontificated against seeing specialists, including myself! At times I took an extreme position. I still recall the frightened demeanor of GT, an athletic man in his 30s. He had visited multiple cardiologists on a monthly basis. GT’s family was indeed afflicted with cardiovascular disease. Episodic palpitations were his only cardiac complaint. A careful workup showed that he did not have a heart problem. GT had no risk factors for cardiovascular disease. He pursued a prudent and healthy lifestyle. When we finished, I did not suggest a revisit. Appearing perturbed, GT asked, “Are you firing me as a patient?”
My tart, seemingly reflexive, response: “Let me see you again in ten years.” GT grew agitated and inquired whether his situation was hopeless and my suggesting that he come back in ten years was a gentle way to get rid of him.
I responded, “You have no heart condition. You are not going to have a heart problem in the next decade. Tell me, how would I earn a decent living if I ‘fired patients’?” It evoked a laugh. I continued, “I want to see you frequently so I can send my three kids to college. But knowing how wholesome your heart is, my conscience does not permit exploiting the fears of a healthy man who will certainly outlive his doctors.”
GT left elated and I thought that was the last of him. He returned the same month exactly a decade later, proudly stating, “I have not seen a cardiologist in the past ten years.”
Patient-centrism demands not burdening a lifestyle with medical “don’ts.” These often relate to diet, work, travel, a change of job, or retirement. I counsel the principle of moderation. The ancient Greeks already comprehended the importance of “meden agan” (nothing to excess), as a way to achieve a healthy life. Another key element is deep engagement in communal living, beginning with family and friends and extending to bonding with neighbors, joining clubs, reading great literature, playing an instrument, and exerting oneself for the social good. A fulfilled life commonly is the best prescription for a long life.
The word “doctor” derives from the Latin“docere” (to teach). A doctor’s role ultimately is that of a teacher: educating and helping patients acquire healthy lifestyles. The primacy of the patient is affirmed when doctors practice their ancient art guided by modern medical science.
*This essay is dedicated to the many doctors who struggle throughout their lives to raise medicine above the dead level of a business and avoid assaulting patients mindlessly with technology.
Notes and Bibliography
1. Lown Blog Essay 14. “Reflections on a Half Century of Medical Practice: The art of listening to the elderly patient.” January, 2010, https://bernardlown.wordpress.com
2. Lown B. The Lost Art of Healing (New York: Ballantine Books,1999) p.26.
3. Statin drugs are reported to have an unusually low incidence of adverse drug reactions, ranging from 1 to 2 percent. These involve primarily muscle discomfort. The data appears solid as it is based on studies of tens of thousands of patients. In the Lown Clinics we found that one-fifth to one-fourth of patients who are on statins experience adverse reactions. Why this tenfold disparity? I can only conjecture. The Lown cardiologists take careful histories. Most so-called scientific drug studies are based on data gathered by technicians who fill out forms. The vast majority of these reported studies are sponsored by pharmaceutical companies who have scant interest in discovering the potential adverse effects of their drugs.
It is great advocacy for Patient-centrism. Thank you!
But don’t you think, that patient’s responsibility for collecting and managing their own medical records – “Patient Health Records” – is the only way for medicine to escape tyranny of medical technologies?
Dr. Nikita Shklovskiy-Kordi, National Center for Hematology. Moscow
A lucid and brilliant narrative, as usual. It reminds me of client-centered therapy, which Carl Rogers developed in the 1940s and 50s and which I and most writing center folks have learned from and employ in what we call a student-centered approach in our work with students and the writing issues they present. After reading the blog, I am first left desperate to know more of the tragic life story of the 85 year-old woman who drowned her newborn. And second, perhaps a blog that describes and critiques the care received and the interactions with medical staff that occurred over the course of those 20 hospitalizations over the past 5 years. Surely we could all learn much from such a report.
Brilliant, brilliant, brilliant! Much food for thought. I find that even many cardiologists do not know that statins can cause neuropathy.
What a fantastic article, listening to and journeying with patients is I have no doubt the key to reducing costs and improving quality. We must find ways to use technology to enhance the doctor patient interactions and allow us to use time to it’s best advantage: “Time is our most valued possession. When shared abundantly, it is a precious gift. Time is the mortar that cements the bonds of trust. Time exposes the wider human terrain of the social and psychological detritus that frequently compels a medical visit in the first place.” This says it all. Thank you
Professor Shklovsky-Kordi raises an issue that is increasingly popular among patients and doctors in the USA. While I see some virtues, I harbor grave reservations. The process is driven not with the intent to promote true patient centrism, but to further medicalize patients. The end result is an increasing commodification of human beings. I am stimulated by these remarks to devote a future essay to this very important subject.
Warren Green educates me about student-centrism. I am embarrassed to confess ignorance about the work of Carl Rogers. The tragic 85 year old woman visited me one additional time and then suddenly died which I learned from a newspaper obituary notice. As regard my own recent numerous hospitalizations, the experience colors every one of my blog essays dealing with medical issues.
A compliment from Dr. Roberts is very meaningful. An accoplished physician she is an authority on statin drugs. Recently she has authored a popular book on the subject, entitled “The Truth about Statin Drugs.”
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I read your essay with great interest and agreement. I was a disciple of yours, practically memorizing your book on coronary care. Although a GP, I designed, promoted, and raised the money for our local coronary care unit and taught the principles to the nursing staff. It was the second small hospital unit of its kind in Michigan. It was the best thing I ever did, and you have been a hero to me ever since. I note that I am one month younger than you. Congratulations on a meaningful,productjve, and effective life. John R. Carney MD, Ludington, Michigan
Dear Doctor Lown!
Thank you very much for your answer. I am fully agree with your statement that «the process is driven not with the intent to promote true patient centrism, but to further medicalize patients”. But we can’t fight against the “medicalization”, if we don’t propose instrumental realization of true patient centrism in modern circumstances (my estimation of your works – about 20 million years’ worth of surviving patients who have used your instrumental decisions).
We were involved into informatization especially by the desire to fulfill honestly the classical demand of Medicine: systematic approach and good knowledge of the whole case history of each individual patient by the doctor. We tried to show the events of case history on the “piece of electronic paper” as we were taught to do on the paper at Propaedeutic. We have collected all results and events on the united time line and we have received “the image of disease”. We have created the electronic case history management system for the Hematological Centre in Moscow.
And then we realized that the doctor and the medical institution didn’t want to know more than necessary for the isolated case treatment and didn’t have the desire to keep the medical long-life information, which we had collected in our data base. We were able to invent the rule that the patient himself was the only person who could answer for both collecting and saving medical records. But the patient must remember that he collects these records not for himself, but for the doctor: to help the doctor to treat the patient in the best way. And that is the responsibility of the patient again — he is responsible for the choice of the doctor, whom he gives his collection of the medical records and whom he asks for the medical help. It is brilliantly illustrated by the story of Hasid in your “The Lost Art of Healing”.
We are inspired by the fact, that a lot of people have been led to the same decision by the development of Patient Health Records (PHR) as main stream in many countries nowadays. We have to know your vision of the dangers we can face moving in this direction.
Nikita Shklovskiy-Kordi, MD,PhD
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I very wondered after read this lecture .
And also your title -Power to the people: Patient in command- is very nice .
I invate you to see my personal blog here : http://arahimi.ir/en
But I’m not a Dr like you
very good thanks admin
Dear Dr. Lown,
You are an inspiration for us! My husband and I are in our mid 60’s having only seen doctors two or three times in the past 40 years. Our friends consider this reckless. But as full time artists we chose a life of art and healthy choices rather than the treadmill of health insurance premiums.
Speaking of treadmills and to underline your thesis, my husband and I have been accepted to the Peace Corps and but for my “borderline” EKG which turned up in the required physical, we would have had the pleasure of serving. For all the reasons you have so eloquently laid out in this piece, I am terrified to go near a cardiologist to get the necessary clearance both because of the fear inducing structure and the unknown cost. Is there a list of cardiologists who adhere to a philosophy similar to yours? I have until the end of February to get a cardiologist’s stamp of approval.
Thank you for all you have done for humanity.
Dear Dr. Lown: I’d like to add a question – In this situation of ‘real doctors desert’, what kind of patient self-support system could be recommended? We have translated British “Family Doctor” (Dorling Kindersley, Ed. by Tony Smith).The diagnostic algorithms described in this book can lead the patient to right steps, for example, straight to the cardiologist. It can protect the patient as well as the collection of EKG in his hands.
Nikita Shklovskiy-Kordi, MD
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I just read your squib on the absence of the subject of climate change in the US election. Things have not changed very much since and Obama’s fine speech on the subject this week is belied by how very little he has done to really confront the crisis. If he accepts the Keystone pipeline, then all his fine talk is little more than talk, and to quote James Hansen’s position on Canada’s dirtier oil, I’m afraid it may be game over.
Keep up your good work on healthcare anyway. Here in Canada we have free healthcare, but it remains commodified. To bad you Yanks can’t go to Cuba where they have done wonders on this front.
Patients tell me: “No one talks to me, they talk at me. How come no one takes the time to listen?” And in my head I think: and how come no one observes the patient? The body language, the type of verbal response – tone – delivery, etc, the family member in the room. Thank you for doing such a wonderful job of communicating this issue.
Patti Heaps, Inpatient Palliative Care Nurse
I sense in this article not only the wisdom of an experienced physician trained in an earlier age (as was I), but one who has had more recent experience as a patient (again, ditto). Hear, hear, doctor. I hope you send this to all the med schools in the country.
Carl Rogers presented us with the concept of “continuing positive regard” as a major portion of the treatment of people with poor self-esteem. It worked wonders for me.
Dr. Bernard Lown: I have retired from cardiology at age 70. I am reading my library of books, finally. I picked up the Lost Art of Healing, which somehow in Tucson, Arizona, you must have autographed in February, 1992. I have lived your insights of connecting to the patient, answering appropriately, and being a positive influence. I have had many reprimands about not ordering enough tests for the affluency of the practice. I have worked at a lesser salary to spend more time with each patient. My patients have been uniformly grateful, and seemed to die at a rather slow rate! Reading your book confirmed my career. Have to keep the book now, you are “Winner of the Nobel Peace Prize,
” just noticed it on the cover. So grateful for your book and our mysterious meeting, as well as your successful arrival into your 90’s. My father was Bernard Ramm, a successful theologian who wrote 22 books, and I consider Bernard the finest name ever. Thanks again, Liz Attig, Tucson, AZ.
Dear Dr Lown,
I am an old physician too (88 yrs) and for many years I am a constant reader and admirer of you. I also believe in immense power of a humane contact with patients and always try to convince my young collegues in importance of it. I ask for your permission to publish in a Russian language
professional website for young doctors my translation of your brilliant essay “Power to the People”. I consider my activity as a humanitarian act without any payement.
Dr Norbert A. Magazanik MD.
My address Israel, Ashdod, Ovadia Str. 8/6
Brilliant article written, nows day doctors forgotten art of complete physical examination and significance of physical examination , pops up multiple medications to patients without proper instruction