John Mandrola, MD

Disclosures

February 25, 2021

A life well-lived would include just one of the many achievements of Bernard Lown, MD.

There are the eulogy values: he and his wife were married for more than 6 decades, he earned the adulation of the many clinicians who learned from him, and his clinical career was defined by how much he cared for the people he treated.

There are the resume values: he overturned the dogma of keeping patients on bedrest after a heart attack; invented a (literally) life-saving device in the external defibrillator; and organized the International Physicians for the Prevention of Nuclear War, which helped broker peace between the United States and the former Soviet Union during the Cold War. Lown accepted the 1985 Nobel Peace Prize for that work. This is a short list; there is more.

Dr Bernard Lown

 

Lown touched my life through the Right Care Alliance—a sister organization of the Lown Institute. For a slow-adopting, skeptical medical conservative, the annual Lown meeting was nirvana.

Lown meetings were the opposite of cardiology meetings. Cardiology conferences celebrate the science, congratulate the scientists, and promote the latest technology. Lown meetings tackled what is wrong with medicine: overdiagnosis, overtreatment, fractured specialty-centric care, biased evidence, and the crisis in end-of-life care.

An invite to speak at Lown transformed my life. I couldn't believe this many people thought exactly as I do. I met clinicians, editors-in-chief, and researchers who study the state of medical evidence. My modest foray into academic work traces back to the connections I made.

I now realize this was by design. Lown knew that bringing like-minded people together was vital. If somebody takes the initiative, others will see it and follow. A movement grows, then change happens.

This method worked well for brokering peace between nuclear superpowers but has yet to change U.S. healthcare. Pause there. Lown could stand down nuclear Armageddon but struggled to reform U.S. healthcare.

I think he would have argued that this was because reformers underestimated the strength of entrenched interests and settled for too little change.

In a keynote at the 2014 Lown Institute meeting, the then 92-year-old cardiologist first praised the universal care models of the United Kingdom and Canada, then said of the Affordable Care Act: "If one solves the problem improperly, one generates more problems than one bargained for."

In other words, Lown criticized the ACA (Obamacare) from the left—a view that anyone who has visited hospitals and clinics in Canada or Britain would find rational.

The feat that impresses me most about Lown was his utterly contrarian, now proven correct, view of coronary artery disease (CAD) as a stable condition. In Essay 28 on his personal blog, he wrote: "I not only harbored dangerously unorthodox views during my career; I practiced them.… Forty years ago I stopped referring most patients with stable coronary heart disease for cardiac angiography."

I have no idea how he got an uncontrolled study published in the New England Journal of Medicine. But in 1981, before disease-modifying drugs like statins were discovered, his group published 5-year follow-up data on more than 200 patients who had profound ischemia on treadmill testing. They reported very low mortality rates, with only 1% of patients receiving coronary artery bypass surgery. They concluded that CAD did not confer a poor prognosis, medical management was successful, and revascularization was rarely needed.

I remind you that the recent ISCHEMIA trial enrolled only patients with significant ischemia on stress testing and found that an early invasive strategy did not lead to reductions in death. And before ISCHEMIA, there were COURAGE and BARI-2D. Lown could not have been more correct.

I've often heard people attribute the lack of benefit from revascularization in stable CAD to the benefits of modern medical therapy. Okay. But how do your account for Lown's success in 1981?

My theory: it was the intense caring. Lown believed that to help people with heart disease you had to be intertwined in their life. His book The Lost Art of Healing details anecdotes that would sound foreign to modern clinicians, who spend most of their time looking at a computer during the typical 20-minute encounter.

At the bedside, Lown would sit down at the same level as the patient, listen attentively, and take the time to explain the true nature of atherosclerosis. He railed against fearful phrases, such as "heart failure," "widow-maker," and "time bomb in your chest." Lown despised the use of fear to gain a patient's adherence; better to build trust with reasoned explanations. He felt words could both heal and harm.

Building trust and removing fear were especially useful in 1981, when the only heart disease–modifying therapies were exercise, diet, and stress reduction. A person with a time bomb in their chest is surely not going to exercise or feel less stress.

His approach resonates with me because of its relevance to the electrophysiology clinic. Patients with arrhythmia often come in with intense fear. You can almost feel the relief when you simply explain the nature of the problem. Education cannot be overstated as an intervention.

I will end on a human note. In 1972, Lown, the inventor of the external defibrillator, coauthored a strongly-worded critique of efforts to develop the internal cardioverter defibrillator (ICD). This sparked a rebuke from the inventors of the ICD, led by Michel Mirowski, MD. This was clearly a heated disagreement among giants in the field.

Gervasio Lamas, MD, reported on Twitter shortly after Lown's death that "his feud with Mirowski was an error. I was there when they made up."

Being wrong, admitting it, then making amends with a colleague: that only enhances my respect for this great man.

John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

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