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Dr. Bernard Lown speaks out against overtreatment

Bernard Lown believes less medical treatment can sometimes be more. Convincing you and your doctor has become a mission for the 91-year-old cardiologist.

People often defer toward order, says Newton’s Dr. Bernard Lown. “I don’t function that way.”

Suzanne Kreiter/Globe staff

People often defer toward order, says Newton’s Dr. Bernard Lown. “I don’t function that way.”

CARDIOLOGIST DR. BERNARD LOWN had trouble sleeping. It was the early 1970s, and he and colleagues were trying to prove an idea that had guided their practice: Blockages in the arteries to the heart often were not the ticking bombs people perceived them to be. They could be treated effectively with medications, a healthy diet, and exercise. Yet even when given this more conservative option, patients who had seen the blockages on an imaging test often chose the bypass surgery urged on them by many doctors, with its higher cost and risk of complications. The image of a clogged pipe was a powerful one.

In a move that Dr. Vikas Saini, co-director of the Lown Cardiovascular Center in Brookline, calls “very Lownian,” the practice stopped referring certain patients — those with significant but stable heart disease — for the imaging test. Lown began waking in the middle of the night. He worried about a patient dropping dead. “The family brings a lawsuit,” he recalls thinking. “Now there’s 145 patients who we haven’t referred. We have a class-action suit, millions of dollars. It’s over — my practice, my group, my privileges at the Brigham.”

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But the nightmare scenario did not happen. Instead, Lown and colleagues found that medications were effective. More advanced testing and the surgery that frequently followed were rarely necessary for these patients. They wrote about their results in the New England Journal of Medicine in 1981. That paper and subsequent ones often were dismissed as inconclusive. But, over time, randomized studies have found that medications can do as much to prolong the lives of people with stable disease as more invasive procedures. Lown’s practice was onto something.

There is a movement in medicine today to spotlight overtreatment, in some cases attributable to poorly informed doctors, fear of lawsuits, or financial motives. Nine specialty groups, including the American College of Cardiology, have published lists of tests or treatments doctors should avoid in a campaign called Choosing Wisely, launched in April with support from the American Board of Internal Medicine Foundation. New health care policies instituted nationally and in Massachusetts meant to penalize doctors for unnecessary, costly care have made the effort more popular. While he was not the only early voice on the issue, Lown is considered a grandfather of the movement.

“He speaks with a great deal of wisdom,” says Dr. William Boden, chief of medicine at the Albany VA Medical Center and lead researcher on a trial that has validated some of Lown’s early thinking. Boden says he strives to be like Lown — “brutally honest,” even when his research turns out unpopular results.

In April, the New America Foundation, a Washington, D.C., policy institute, and the Lown Cardiovascular Research Foundation hosted a conference in Cambridge on “avoidable care.” In a keynote address, Lown derided descriptions of modern medicine as “patient-centered” and urged doctors to listen more. “We talk of overtreatment as though it was merely an improper financial transaction,” he said. “Overtreatment does enormous harm to patients, thereby negating the first principle of doctoring, Primum non nocere.” First, do no harm.

***

LOWN, RETIRED SINCE 2007, seems to relish the role of scold. During an interview at the Newton home where he and his wife, Louise, have lived for 53 years and raised three children, Lown delivers sermons on the state of medicine: A focus on hospitals creates a “sickness care system”; medical education fails to teach students about nutrition and community development, issues central to human health; doctors are infatuated with technology, to the detriment of patients.

He spends hours each morning writing essays that are posted to a WordPress blog. He would like to write more. This 91-year-old mounts stairs easily, drives, and has a memory as sharp as someone a third his age but can’t quite keep pace with his passions. “I’ve got a lot of outrage in my old body,” he says.

Suzanne Kreiter/Globe staff

Dr. Bernard Lown in his home.

The sentiment, along with optimism, is a familiar one. In the foyer hangs a framed piece of yellowed paper bearing a line Lown echoed at the April conference: “Only those who see the invisible, can do the impossible.” This page is from a speech he delivered to a gathering of international leaders in Moscow in 1987, urging the Soviets to continue a tenuous moratorium on nuclear weapons testing. Two years earlier, Lown had accepted the Nobel Peace Prize as a founder of the International Physicians for the Prevention of Nuclear War, which united US and Soviet doctors as advocates.

In 1935, at the age of 13, Lown emigrated with his family from Lithuania, ahead of Nazi occupation. He found his identity as a radical physician early on. While a student at Johns Hopkins Medical School, he secretly gave blood from black donors to white patients during shortages, breaking the blood bank’s segregation rules. Found out, he dodged expulsion with the help of other students, by threatening protests. People tend to defer toward order, Lown says. “We all are nice little boys and girls. . . . I don’t function that way.”

Lown had the intelligence to back up the bluster. He joined what was then the Peter Bent Brigham Hospital in 1950, left for military service, then returned in 1957 and established himself as a world expert in sudden cardiac death, developing the defibrillator. He didn’t always get things right. Others point, as an example, to his opposition of the implantable defibrillator, a device that has proved lifesaving for many — a position Lown now acknowledges was wrong. But Lown helped to redesign how hospitals care for cardiac patients. And he became a renowned teacher, focused on bedside manner. “Dr. Lown taught me that your personality is really a medicine,” says Dr. Peter Libby, chief of cardiovascular medicine at Brigham and Women’s Hospital, who interned with Lown. “It can be used for ill or for great good.”

In the early 1970s, Lown established his own cardiology clinic, where doctors are still known for a measured approach and long patient visits.

***

TODAY, LOWN TOILS over another body of work: scrapbooks of his professional and family life. Ninety-seven albums in all. He pastes the front and back covers with images of great thinkers — Darwin, Pavlov, Planck — to inspire his grandchildren. Lown believes society needs a new renaissance, so that “the human being is restored to the centrality of what happens — is not an object, is not a purpose for marketing, is not a steppingstone for others.” Doctors can lead the way, he says. But Lown concedes that change is slow. “The tragedy of life is that you don’t encompass your struggles,” he says. You don’t see the outcomes of your movements. At least not all at once.

A box of Florida oranges arrived on 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. 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.

Chelsea Conaboy is a health reporter for the Globe. E-mail her at cconaboy@boston.com and follow her on Twitter @cconaboy.
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