Dr. Bernard Lown and the first rule of doctoring

I knock, then enter the exam room.

“Hi. My name is John Mandrola.” (Maybe it is my age but I am moving away from calling myself Doctor Mandrola.)

“I am a heart rhythm specialist. I have looked at your chart so I know a little about your medical history.”

“Can you tell me how you are? What complaints bring you to see me?”

What follows is increasingly (and painfully) common:

“Doc…I feel good…I have no complaints. The doctors say…”

At this point, I reflexly make a questioning face. The patient sees it. He repeats: “No, really, doc, I am okay. I walk three miles a day. I play golf. I do yard work.”

“No chest pain?’

“Nope.”

“Shortness of breath, dizziness, racing heart?”

“Nope.”

“You must feel fatigued?”

“Nope.”

I need to be sure so I ask it another way:

“If there were no doctors, no tests, no scans, would you be aware of any problems?”

“Nope.”

I have been to this place before. Sorry. But the problem–finding disease when there is none–is not getting any better.

It takes a doctor right up to the precipice of failure. The danger, of course, is breaking the first rule of doctoring: if a patient tells you he is well, your first job is to not mess it up. Do no harm. Resist the urge.

Maybe the ECG machine shows something–the heart is out of rhythm. Maybe a shadow from an ultrasound machine is amiss–a valve is leaky. Or perhaps contrast dye seen on an X-ray image shows a partial blockage–the trap of coronary artery disease. Yet, if not for doctors, this human being would have no disease. He would be well. “I exercise 3 days a week. I play golf. I work.”

To be sure, I am no nihilist. I believe in what I am trained to do. I can vanquish aberrant pathways with a catheter. I can place pacing leads into the hearts of people with failed natural pacemakers. These are beautiful procedures. They took years to master. It is intensely gratifying to think a one-time slacker could do these things.

But these fellow humans had complaints. They were sick and I tried to make them better. I am not frightened to work on these patients. The cause is just. The patient informed. Alternatives and risks explained. No inflammation. A clear mind.

What a different story it is with well patients. Like those referred because of “something” found during an annual check-up.

I recently wrote about this precarious scenario on Medscape. I talked about the ultimate medical error.

Taking patients who grade their health as an A and making them a D or F is the ultimate medical error. This is the risk of preventive maintenance: Once in the machine of healthcare, it is hard to get out.

I told a story of a terrible mishap. The disaster began with an annual physical. A blip on an ECG. Perhaps the title of the piece was too provocative: Redefining the Annual Physical: A (Broken) Window Into American Healthcare.

The comments were decidedly mixed. My concern about over-diagnosis and over-treatment did not go over well. I have thick skin but it stings when fellow frontline doctors criticize my words. Maybe I was too hyperbolic. Words are so damn important. I second-guessed myself.

Then I had clinic the day after the essay was published. Three of the four new patients I saw were sent for spurious findings discovered during unnecessary screening tests. Thankfully, I was able to extract them from the machine of healthcare. It was not easy. It is far harder to unscare patients than it is to scare them.

These experiences helped me feel a little better about the criticism.

Then, this weekend, in preparation for two presentations I am giving soon, I came across the work of cardiologist Dr. Bernard Lown, a recipient of the Nobel Peace Prize. Dr. Lown was a self-described maverick. He believed in old-fashioned doctoring. He believed in listening to the patient, that the patient would tell you the diagnosis. He went against the grain of cardiology and its plumbing thesis: coronary artery disease can be a stable disease with a low mortality. Angina was not terrible. Nitroglycerin was underused. He railed against the use of fear:

Patients are led to believe that inaction is likely to have threatening consequences to their very survival. The ensuing fear assures a docile acceptance of the interventionist course of action.

Now I am energized. I am okay. For it seems Dr. Lown’s wheel is a good one to follow.

JMM

Here is a link to Dr Lown’s blog. Therein lies a trove of valuable reading.

Here is a documentary on Dr. Lown.

19 comments

  1. Sadly for patients like me [72 and counting], I have YET to find a single physician who REALLY REALLY [emphasis mine] listens….They all walk in the door with my chart in one hand and their prescription pad in the other.
    And don’t ask about or complain about drug side effects….your comments will be ignored while a new & improved drug is then prescribed.

    1. I respectfully submit Roddy – that you haven’t yet found the right physician … Such physicians (who really listen) may be in short supply – but they ARE out there. I know – because I trained some of them.

  2. So here is my question. What do you do with a 67 yo male trim and fit, regular biking and weights, good diet, feels great. Low BP, low triglycerides, high HDL, OK LDL. BUT, experiences unpredictable 5-10 minute exercise induced afib events once or twice per year causing dizziness and alleviated by lying down and raising legs. No intervening events per implanted monitor. Suffers nose bleeds in winter barely under control with humidity and ointment application. Is worried about anti-coagulants. Are the risk reduction numbers really relevant to this patient making anti-coagulants an important intervention now or soon?

    1. Surely nobody, even in poor health, can develop a clot sufficient for a cardiothrombic stroke in ten minutes of AFib.

  3. Love, love, love the works and words of Dr. Lown, and have written about/quoted him even more often than I mention you, Dr. John!

    His book ‘The Lost Art of Healing’ should be required reading in med school. And his advice on how patients should take nitroglycerin reminded me that nobody – no doc, no nurse, no hospital janitor – NOBODY ever gave me any instruction on the best way to take nitro before my own CCU discharge. I stumbled upon his nitro advice and share that advice frequently now, as Dr. Lown might summarize: “Nitro is your friend!”

    A born storyteller, he also (rarely, lately) blogs with his granddaughter Melanie at the delightful Lown Conversation – http://thelownconversation.com/

  4. I don’t knock before entering the exam room(should I?) but I do totally agree with you on the importance of listening to the patient and I greatly appreciate your link to Dr. Lown’s online presence.

    I feel compelled to point out that atrial fibrillation is often asymptomatic and the first symptom can be a large stroke. Teaching individuals to check their pulse and report an irregularly irregular pulse may be more beneficial than an annual physical in this respect (http://theskepticalcardiologist.com/2014/09/11/take-your-pulse-and-prevent-a-stroke/)

    1. Anthony… I appreciate the comment. You raise an important point, one I thought about before hitting the publish button.

      I also thought about primary prevention ICD placement. The literature on ICD decision conflict reveals one of the reasons patients decline ICD placement is lack of symptoms. The irony–in patients with LV dysfunction–is that feeling well argues more for doing the ICD than not doing it: more quality years to lose and less competing causes of mortality.

      But let’s think about these two scenarios.

      First let’s set out that these are healthy patients. They are not diabetic or hypertensive or have any other reasons they should be seeing a doctor for regular checkups. In the case of asymptomatic AF in a such a person, the CHADS-VASc score would be either 0 (<65), 1 (65-75) or 2/3 (male > 75; female > 75) I know there is push in the UK to know your rhythm, and I understand the issue of AF being a risk for stroke, but I am not convinced AF screening in truly healthy people would improve outcomes. When monitoring technology improves in the future, my opinion might change. (But you well know the danger of entering the healthcare system with a diagnosis of asymptomatic AF: You need this drug; you need this nuclear stress test; you need this cath; then the cath shows a 75% distal circ; then the stent; then the triple anticoagulant therapy. And so it goes…)

      On primary prevention ICDs, I did not intend this post to address the issue of patients with severe and established heart disease. This is a different category of patient.

      1. Woman over 75 gets with no other issues 3 points on the CHADS2VAS2 system. 5.9% risk of stroke per year. I’ve seen several of these present with TIA or stroke as first symptom.
        Shouldn’t you be tailgating for the Colts game?

        1. You are correct about the score of 3. But the annual risk of stroke is 3.6% on therapy. And 1.2% on warfarin. NNT – 40. Plus…do we really think “healthy” elders should be checking their pulse every few hours?

          1. Hmm. I got the 5.9% off this site (http://www.mdcalc.com/ cha2ds2-vasc-score-for-atrial-fibrillation-stroke-risk/) which claims their calculation comes from the 2012 ESC guidelines. It does seem high.
            My ACC anticoagulation calculator iPhone app lists it as 4.3%.
            My Birmingham CHA2DS2VASc Calculator iphone app yields 4.0%.

            1. Sounds like the decision of whether or not that 75 year old woman should or should not be anti coagulated is one that should be an informed one that the patient should actively help with. There are pros & cons to treatment – and patient values/desires should (in my opinion) figure prominently.

              Otherwise Anthony – I will answer your question regarding, “Should I knock before entering the patient’s room?” by asking what you (and what your loved ones) would want for themselves. Imagine – you are in an office waiting for a good while without any idea of when the physician (who you may or may not know) will walk in. Perhaps you drifted off to sleep – or are adjusting your clothes (or undergarments) – picking at something you shouldn’t be – or who knows what – but I know, I prefer it greatly when someone not only knocks before entering, but in addition waits a magic second to ensure it is ok to enter (rather than reflexively opening the door in the same instant they knock). There is MAGIC in the respect the simple courtesy of what a knock before entering can do. Thanks for your openess to feedback on this question – 🙂

      2. Non-cardiologist here — why would asymptomatic a-fib warrant a nuclear stress test and/or catheterization? Is it that patients with asymptomatic AF commonly have “soft” symptoms that lead to this overtesting?

        If I had asymptomatic a-fib I would obviously pursue lifestyle management but, depending on my age, would consider beta blocker for rate control, warfarin for anticoagulation, and/or ablation. I would vastly prefer to take no medications and thus far have avoided them, but a stroke would be too devastating for my family and me.

        However, I’ve taken your recommendations to heart and aim for an AF-preventive lifestyle including healthy diet, healthy weight, moderate exercise, excellent blood pressure, no alcohol (don’t like it), and stress reduction/management strategies. My father, who is in a similar boat, has had 2-3 episodes of AF resolved with acute medical management, so I’m aware that I’m not immune.

    2. I think knocking signifies my respect for patients. During medical school I watched a doctor walk in (without knocking) on my mother while changing. She was standing in the middle of the exam room wearing nothing but underpants.

      I thought it odd that the doctor would want my mother to change into a gown before meeting her in her clothes (ah, time pressures we all know well), but the moment she entered the room was very awkward and the visit never recovered. My mother gave her a negative review in the follow-up telephone survey.

      I think she would have been kinder in her review had the doctor made a better connection with her, which she more easily could have done had she knocked.

  5. John, I am with you. For many reasons, Doctors increasingly rely on screening tests to “catch” illness in the patient with no complaints. — Fear of litigation. Patient expectations. Patient’s family’s exoectations. Keeping up with the Dr. Joneses. Unfounded beliefs. Silo practice. Increasing billing to keep business afloat amidst inadequate reimbursement. Loss of physical exam skills. Time-saving maneuver to send patient on their way during a typical overbooked day. Angling for good on-line patient reviews. Pleasing the hospital/practice. Getting a salary bonus. — And yet so often these screening tests only yield anxiety, more tests, more doc visits, more procedures, and fail to improve health or quality of life. It is time consuming to undo the damage of screening tests with their often ambiguous results. It can be almost impossible to derail the fear-fueled train, once it departs. Only through (non-reimbursed) extended discussions, educational picture-drawing, and trust-building can the momentum sometimes be slowed or stopped. And only a fraction of the minority who recognize that brakes need to be applied will take the time to do so, or even care. The dictum holds true now more than ever that the most difficult thing in medicine is NOT to do something. Especially in this era of prodigious publication of soft outcomes, patient lumping, and excessive accolades for all things in print, irrespective of true quality/relevance. Restraint could be the biggest step forward in health care. But it is not being taught, it doesn’t pay the bills, and it is antithetical to all that our country seems to value and believe.

  6. In the early 70’s my grandmother, who had had a previous heart attack, went to visit her cardiologist for a routine visit. She was feeling fine and looking forward to leaving on vacation the next day. On her way to the bus after that visit she suffered a massive heart attack, collapsed and died. I know that CVD is not your thing, but there can be serious health issues that the patient does not feel until it is the last thing they feel. In such cases a little intervention would be nice – a patient must rely on a physician to evaluate their condition and determine the necessity of treatment.

    1. Sorry about your grandmother David. What happened to her is exactly why routine cardiac screening does not work. Your grandmother likely suffered cardiac arrest from abrupt closure of a blood vessel. But here is the rub: the blockage that led to that event was likely a minor undetectable obstruction, an immature plaque. The heart muscle supplied to that area was not conditioned for an acute closure.

      This is why treadmill exercise tests–and even cardiac caths–do not predict heart attacks. I always tell people who pass treadmill tests that they are now in a lower-risk category but heart attacks can still happen.

      Maybe some day in the future there will be a way to detect the so-called vulnerable plaque. Today there is not. IMHO, we are not that close.

      1. Thanks very much for the response. I had always thought that she could have had another decade or so if stents and the technology to detect calcification, etc. had been around in the 70’s. I hope somebody is working to develop the diagnostic technology that will allow detection and diagnosis of such immature plaques in the future!

  7. I wish you could have seen the look on my new pt’s ( think high level business exec)face today when I told him he not only didn’t require his yearly treadmill but that I didn’t think he would benefit from his yearly PSA…
    It doesn’t help my cause that I still look 18 but hopefully patients (and I really think this pt did) appreciate you spending a few minutes explaining the pros and cons of screening.

Comments are closed.