COMMENTARY

ACC and Lown: Is There a Middle Ground for US Healthcare?

John Mandrola, MD

Disclosures

April 26, 2016

It's easy to take things for granted.

  • An unconscious, soon-to-be-dead person, awakes as if nothing happened after receiving a shock from an external defibrillator.

  • Within minutes of an injection of intravenous lidocaine, seemingly incessant ventricular tachycardia quiets.

  • Both the US and Russia have the means of global destruction, yet almost no one worries they will deploy their nuclear arsenals.

For these things, we have the nearly 95-year-old Dr Bernard Lown to thank. In cycling-speak, we say Dr Lown is a good wheel to follow.

I recently attended and presented at the fourth annual Lown Institute Conference in Chicago. Two weeks earlier, I was at the American College of Cardiology (ACC) 2016 Scientific Sessions. Technically, both gatherings could be called medical meetings, but that's where the similarities end.

The ACC meeting featured the banners and gleaming expo of industry. Lown featured keynote speakers who emphasized the conflicts, bias, and costs of depending on industry for funding.

At the ACC meeting, studies with statistically significant results made waves. At Lown, we learned to understand the clinical significance, costs, and trade-offs of these results.

At the ACC, we learned that life can be extended with innovative techniques. At Lown, we learned that life-prolonging therapies can doom proud people to spend their last weeks or months in nursing homes.

At the ACC, we learned that statin drugs given to intermediate-risk people are worthy because they reduce the risk of future cardiac events by about 1%.[1] At Lown, we learned that an intermediate-risk person without heart disease is a human being (not yet a patient) who has something to say about whether she wants to take a pill for the rest of her life for a small chance of a gain.

At the ACC, we learned that guideline-directed therapies improve outcomes. At Lown, Dr Jeffrey Brenner, director of the Camden Coalition of Healthcare Providers, taught us that these therapies do little to help those who live in poverty. "No amount of medical care can help a man who lives on a bench," he said.

At the ACC, attendees, mostly older white male doctors dressed in dark suits, spoke in the language of the vertical hierarchy of the medical establishment—careful, vetted, authoritative. At Lown, attendees reflected the vastness of our medical system. Earnest young medical students, emeritus professors, nurses, doctors, patients, policy makers, journalists, and activists mingled as equals. The language at Lown was candid, spirited, and fearless; at one point, folk songs blasted from the podium.

Don't get me wrong: I'm a proud electrophysiologist. I love EP; it's a beautiful calling. Ablation can cure with a single burn. It's barely hyperbole to use CRT and Lazarus in the same sentence. And our family's best friend (named Hans) lived years after an appropriate shock from his ICD. Just thinking about how blessed we were to get extra time with Hans makes me emotional about my profession.

I also don't mean to kick the ACC too hard. I'm optimistic that the current leadership will take the organization in the right direction. To be sure, the ACC deserves credit for a number of important, even brave, steps: First, they had population-health expert Dr David Nash deliver hard truths during the plenary session. Second, they elected a level-headed woman clinician, Dr Minnow Walsh, as their future president. Third, they allowed me to give a critical appraisal talk on ICDs—2 years in a row. Finally, and I hope this was on purpose, they had my wife, Staci, a hospice physician, speak between a talk on heart-failure meds and left ventricular assist devices.

I also understand that innovation requires industry collaboration. Take Pfizer, for instance, a drug company that has endured criticism. I care for a man who could not work or exercise because of atrial fibrillation. He failed all sorts of treatments. I admitted him to the hospital and 3 hours after swallowing the novel drug dofetilide (Tikosyn, Pfizer), he converted to sinus rhythm. During our annual office visits, he thanks me for giving him his life back. I tell him to thank Pfizer.

But friends, US healthcare is a mess. It costs too much and delivers too little health. It's unfair—and arguably, immoral. Casey Quinlan is a patient advocate and Lown Institute member. She stood up at the meeting and said, "The system isn't broken; it was designed this way." She's right. All of the forces in our system, and I mean every damn one, is aligned against patient-centered, efficient, humanistic care. (And some wonder why we have physician burnout.)

The problem list of US healthcare is obvious: fee-for-service fosters more care rather than RightCare. (In the interests of transparency, I am an unpaid member of the Lown Institute's RightCare Alliance cardiology council). Untested quality measures and electronic health records steal time from patient care. We look at keyboards rather than our patients' eyes. Disease creation has destroyed the normality of the human condition. Death denial combined with disease-based treatments exacerbate our crisis in end-of-life care.

Then there is therapeutic optimism run amok. Whether this is due to lack of statistical training and critical appraisal during medical education, a broken scientific rewards system, conflicts of interest, the simple desire to heal, or all of the above, one thing is clear: doctors falsely believe they control outcomes. Do patients live because they had heart surgery, or did they live despite the surgery? Years ago, I would have never asked that question; now I wonder.

The Lown Institute believes, and I agree, that overdiagnosis and overtreatment is a pervasive problem. We believe harmful wasteful care is a root cause of undertreatment and inequity.

Change is hard. Dr Donald Berwick, writing in the Journal of the American Medical Association,[2] identified the clash of two eras. Era 1, my era, "was the ascendancy of the profession, with roots millennia deep—back to Hippocrates." Essentially, in era 1, doctors know best—trust us, we will regulate ourselves. Champions of era 2, on the other hand, believe in accountability, scrutiny, measurement, incentives, and markets. As Dr Nash said at the ACC meeting, "We can trust in God; everyone else, bring your data." Berwick saw nine steps that could lead us to an era 3, which he called, the moral era.

In his conclusion, Berwick predicted both camps would be resistant to change. Some physicians—ones who practice and promote RightCare—made it known on social media that they were offended by the rhetoric of RightCare during the Lown Conference. There are allies of RightCare who believe medicine must change from within. Likewise, some of those at Lown felt strongly that no solutions were possible without era 2 reductionism, removal of fee-for-service, and industry influence. They believe change must come from the outside.

I feel caught in the middle. Both forces pull at me. All I know now is that I care a lot about medicine; so I'll stay engaged in the clash.

JMM

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