Overtreatment for heart conditions: You were right, Dr. Lown

A box of Florida oranges arrived on retired cardiologist Bernard Lown's doorstep last winter from a patient he had seen more than 40 years earlier.  The man had come to him for a second opinion after another doctor had recommended valve surgery, he recalls.  Dr. Lown told him it wasn't necessary, that it would be decades before he needed it.  In fact, it would be four.  The oranges came with a message:  you were right.

Back in the early 1970s, Dr. Lown and his colleagues had realized that blockages in heart arteries weren't the ticking time bombs that people perceived them to be.  Indeed, they could be treated effectively with medication, a healthy diet, and exercise.  They found that advanced testing and the surgery that frequently followed were rarely necessary, and published their findings in the New England Journal of Medicine in 1981.  Accordingly, his medical practice had stopped referring patients with significant but stable heart disease for imaging tests.  

Dr. Lown is the grandfather of a movement in medicine today to spotlight and reduce overtreatment.  In April, nine medical specialty groups, including the American College of Cardiology, published lists of tests or treatments that doctors should avoid, in a campaign called Choosing Wisely, launched with support from the American Board of Internal Medicine Foundation. 

Read one of Dr. Lown's stories on overtreatment.  Thanks to Chelsea Conoboy, from whose article of July 29 in the Boston Globe Magazine this is adapted.  

Before he raced off to work: Perceptive listening about ventricular tachycardia

Dr. Bernard Lown describes how he found "The Hidden Clue:"

A college president consulted doctors over a decade for ventricular tachycardia, a very serious heart-rhythm disorder. He had been hospitalized in many of this country's leading centers and more than a dozen different medications had been tried, all to no avail. On his first visit, I asked at what time of day the arrhythmia occurred. He responded that it was almost consistently in the morning, before he raced off to work. When questioned further, he stated that it happened between about 7:30 and 8:30 am.

After gathering more information, I told the patient that his problem would be solved if he set an alarm clock to 5:30 am and as soon as he awoke, took a double dose of an anti-arrhythmic medication before going back to sleep. Following this counsel for the next eight years, he was totally free of arrhythmia.

It is astonishing that no doctor had tried to identify the precise time the arrhythmia occurred. Taking a much larger total dose of the same drug at intervals around the clock, as he had been told to do, provoked many adverse symptoms without containing the arrhythmia. The reason for the failure was straightforward. His evening dose had dissipated by early morning. The morning dose was taken too close to the onset of the disordered heart rhythm for the drug to have reached an effective therapeutic blood level. Furthermore, he needed a higher dose at that time to prevent the arrhythmia from breaking through. No amount of technical wizardry could have resolved his difficult problem. The solution would never have been unearthed without the information the patient provided.

Frequently a patient not only tells what is wrong but provides information suggesting how best to manage the problem.

Advice to patient and patient advocates: Be sure you have a doctor who asks you enough questions to perceptively diagnose your condition.

Read more from Dr. Lown's essay, "The Hidden Clue," in The Lost Art of Healing.

Without questioning this intelligent woman: Angina misdiagnosis

From Dr. Bernard Lown on "Getting Doctors to Listen:"

One experience illustrates the mayhem wrought by self-diagnosis. Mrs. T., a woman in her mid-eighties, had been completely crippled by postural hypotension for the past five years. Each time she stood, dizziness and light-headedness caused a near faint. She became bedridden, burdening family and growing depressed as a result. She was on a bevy of drugs for angina that indubitably contributed to the drop in blood pressure when she stood.

On careful discussion, it was evident that this woman did not have angina; her chest pain was caused by arthritic and musculoskeletal problems.

I tried to determine how the diagnosis of angina had been arrived at, and the patient admitted to having suggested it to the doctor. Comparing notes with a friend who had experienced a recent coronary heart attack and suffered thereafter from angina pectoris, Mrs. T. grew convinced that her problem was identical. After further discussion with her sick friend, she absorbed some of the appropriate descriptive terms. On the initial visit she told the cardiologist that she was certain her condition was due to angina. The doctor, without questioning this intelligent woman, prescribed the usual anti-anginal fare. Since none of the medicines helped, more drugs were added on many subsequent visits. When she became totally disabled, Mrs. T. sought a second opinion from me. When all medicines were discontinued, the vertigo and the other symptoms disappeared, except for the chest pain, which she now took in stride.

There is no excuse for a doctor's not going beyond a patient's labeling of a problem. Nonetheless, caveat aeger, "let the patient beware.”"Avoiding the role of accomplice in self-victimization is a modest first step.

Advice: Be informed, but let the doctor make the diagnosis.

Read another happily ending misdiagnosis story here, or read more from Dr. Lown's book, The Lost Art of Healing: Practicing compassion in medicine.

Miracles reside in comforting and healing: Dr. Bernard Lown

Dr. Bernard Lown on healing without curing

Even when cure is impossible, healing is not necessarily impossible. The miracles reside in the capacity for comforting and healing.

This was brought home to me by Mrs. J., a well-composed, articulate woman in her mid-seventies. Over the preceding five years, she had become increasingly disabled with weekly paroxysms of atrial fibrillation, although a multiplicity of tests revealed a structurally sound heart. Several drugs tried singly or in combination were largely unavailing, and a number of them caused troublesome complications. The episodes of arrhythmia left her drained for days, and fear of unpredictable recurrences circumscribed her activities and kept her homebound. As I listened to her problem, it was eminently clear to me that no stone had been left unturned. I could think of no easy measures to effect a cure, and I was therefore astonished to hear myself express a certainty of resolving her problem. I did, however, leave a clever escape hatch by indicating that it would take time.

When Mrs. J. returned some months later, the problem was largely ameliorated. I was impressed with this remarkable turnabout, though the basis was self-evident. I had reassured her that the arrhythmia, while troubling, was not dangerous, and I had discontinued many of the drugs that were responsible for a host of symptoms previously ascribed to the heart. She was now able to sleep through the night, and with more sleep, arrhythmic recurrences were reduced in severity. I had prescribed a larger dose of digitalis whenever a paroxysm did emerge, so her heart rate during the arrhythmia was slowed and the bout became more tolerable. While the fundamental problem remained unresolved, she was able to resume a normal lifestyle.

Yet I could not give myself credit for the outcome. The patient herself had largely effected the extraordinary change. She could be helped because she had become reconciled to an improvement rather than a cure. She welcomed small changes for the better and was ready to exploit these to the hilt. I could expeditiously come to grips with essentials because she was sharply focused and not hypochondriacal.

If a patient is ready to be helped, even a little, and grateful for the marginal, it enhances the doctor's commitment to fostering a relationship between equals. Only such a relationship, bonded by understanding and respect, can deepen into a true healing partnership. This encourages, in the words of Lewis Thomas,
"the capacity for affection," the essential element for healing.

Advice to patients: Be ready to be helped, even if a cure is not possible.

Read a story on physician/patient rapport, or read Dr. Lown’s book, The Lost Art of Healing: Practicing compassion in medicine.