Утерянное искусство врачевания

by Bernard Lown, Бернард Лаун, Елена Незлобина (Translator)

В настоящее время американская медицина считается одной из лучших в мире. Но все же… В увлекательной и доступной форме автор книги, известный врач — кардиолог, лауреат Нобелевской премии мира, пытается проанализировать "недуги", поразившие американскую систему здравоохранения. Может быть, многие из них имеют место и у нас в стране?

Genres: Medicine, Nonfiction, Medical, Health, Science, Health Care, Psychology

367 pages, Paperback

First published October 1, 1996

Reviews

[Ellie · Rating 1 out of 5]

I began this book with a great deal of interest. The beginning of the preface proved compelling, arguing that a large part of the modern healthcare crisis is caused by doctors relying too much on expensive diagnostic tests and not enough on a thorough history and physical examination. From there, however, the book went downhill fast. Lown goes on to laud his many wonderful achievements in the course of his career, sounding quite proud of himself. His tone throughout the book is self-congratulatory, and he writes from a pedestal, looking down on all patients and seemingly most people who are not himself or one of his beloved mentors. In fact, Lown even uses the word “childish” to describe modern patients’ fascination with technology! Following a number of chapters filled with stories of his miraculous diagnoses and life saves, we reach a chapter called “Words that Maim.” This chapter is filled with stories of doctors scaring patients to death, literally, with words, or saying horrible and manipulative things. All are stories of other doctors, of course; not one story about himself. (There is actually one small anecdote about Lown himself, but no harm comes to the patient he mentions.) In many of the stories, Lown is in fact the one who has to repair the damage done by callous doctors.

This chapter is followed immediately by “Words that Heal,” in which we are again treated to samples of Lown’s perfect clinical skills. He’s so perfect that patients “walk out of [his] office looking stoned, high, floating on air. When they’re from out of town, they ask for the best restaurant in Boston, because they want to celebrate.”Later he dishes out personal advice and reports with pride that a patient “anointed” him “a great guru;” he also lashes out with fury at a patient, yelling at him uncontrollably, but miraculously curing the patient of all of his family problems in the process. Because almost all medical problems are in fact emotional, caused by family tension, according to Lown. He suggests that medicines don’t work well because they are over-prescribed; all most patients need is a smack on the head (metaphorically speaking) to convince them to get their family life in shape, and then they’ll be all better! Magic! Thanks to him, an Indian man is un-dispossessed by his mother; an Orthodox Jewish man learns to love and accept his gay son and his lover, and even march in gay pride parades! Lown truly is a miracle worker!

This book is a complaint about modern doctors for not being more like Lown himself (that is, perfect in every regard). He doesn’t even give consideration to the stresses put on doctors by insurance, malpractice, etc. Modern medical education is soulless and modern doctors are no better. He seems to indicate that he understands the push to do procedures because taking histories doesn’t pay, but he doesn’t consider that doctors (particularly primary care doctors) might actually WANT to do more thorough histories if they weren’t trying to struggle for enough money just to pay their malpractice insurance and make ends meet.

There are interesting portions of this book, and it has some good advice for interacting with patients. Some of the claims about the origin of the healthcare crisis may even be partially correct, though I feel strongly that he ignores the many factors working against physicians in his question to blame it all on the failings of the modern doctor.

(review edited to fit length requirement!)

[Jrohde · Rating 5 out of 5]

One of my favorite books on what medicine can and should be. I have bought copies and given to many who I hope to inspire with Lown's compassion and insight. a fine book for anyone wanting an uplifting reading experience and a refurbishing of faith in the profession.

[Nitrorockets · Rating 5 out of 5]

It was an inspiring read. A reminder to all medical students that knowledge and academic grades are merely one part of their learning experience. Understanding human qualities such as empathy, compassion and the human condition must be reinforced and developed in conjunction with the scientific knowledge of their studies and training.

[Lygia Marina · Rating 5 out of 5]

This was the kind of book that I bought on some level of impulse and it turned out to be one of the best books I've ever read. It is an old title, but the way Bernard Lown wrote about medicine and his experiences seems, somehow, very accurate even today. If you're looking for a scientific book that debates around scientific matters, like life-saving measures, this is not what you're looking for. Although you can, indeed, learn some things about heart diseases and about defibrillator history, what you absorb from this book is way to deeper than that. It is more of a philosophical and psychological growth than any other thing.

What I liked the most was that the author doesn't hesitate in telling us, readers, about the mistakes he made or about how he sometimes underestimated the role of compassion in the healing process. He also cites other books and authors as he introduces ideas about life, death, illness etc. His patients are his source of learning and being able to visualize this doctor-patient relationship so closely is what makes the reading way more addictive.

[Sarah · Rating 4 out of 5]

Offers insight of a world-renowned cardiologist towards the doctor-patient relationship. In real life, I wouldn't imagine this man to be as humble/raw-in-thought as he presents in this book. Enjoyed it, (thanks Linda! thanks Dr Keith! for the rec)

[Douglass Morrison · Rating 5 out of 5]

The Lost Art of Healing Practicing Compassion in Medicine (1996) is cardiologist, Dr. Bernard Lown’s impassioned plea for patient-centered care, and against the corporatization of medical practice by the profit motive or fee-for-service. It is his manifesto of compassionate cardiac care:
• “Boston physician Francis Peabody counseled that the secret of care of the patient is caring for the patient.”
• “... Health care, instead of being an accountable system, has grown into a hodgepodge of corporate fiefdoms whose central aim is to maximize profitability for venture capital investors. To achieve this objective, time-honored clinical decision making by doctors is being curtailed. Arbitrary regulations, supervised by a burgeoning bureaucracy of technocrats, has now invaded every precinct of clinical judgment, whether involving drug prescription, the need for specialist referral, the propriety of an emergency room visit, or the advisability of hospitalization…”
• “In market-driven medicine the primacy of the patient yields to the perverse accountability of investors, bureaucrats, insurers, and employers. For-profit health care demands the doctor to perform as a gatekeeper to ration or deny health care… the doctor-patient relationship is undermined by the suspicion that any advice is determined by the corporate bottom line. For-profit healthcare is essentially an oxymoron…”
• “Patients crave a partnership with their physicians who are as sensitive to their aching souls as to their malfunctioning anatomy. They yearn not for a tautly drafted business contract but for a covenant of trust between equals earned by the doctor while exercising the art of caring… modern health care with a human face,”
The Lost Art of Healing emphasizes the importance of the initial History and Physical as both the keystone of the physician’s diagnostic armamentarium and also as the foundation for the doctor-patient relationship.
• “One must be an active listener to hear an unspoken problem.”
• “Attentive history-taking does more than add details. It is the most important aspect of doctoring. While obtaining a history takes time, no time is more productively spent. Ultimately it lays the foundation for human relationship between patient and doctor based on mutual respect…”
• “Lewis Thomas in The Youngest Science, comments wisely that touching (as in the physical examination) is the oldest and most effective tool in doctoring… Touching is a means for gaining significant insights… The remoteness dissipates… The ear riveted to the chest wall (through a stethoscope) was a display of human affinity.”
Lown carefully distinguishes the content and style of a doctor’s discussions with his/ her patient. The doctor’s intention to help is crucial. He tells care providers that ‘Words That Maim’ include, such classics as:
• “You have a time bomb in your chest’
• ‘You are a ticking time bomb’
• ‘You have a widow-maker coronary artery blockage’
In contrast ‘Words That Heal’ convey honesty without denying hope. The doctor must avoid overstatement and understatement while communicating both potential benefits and risks:
• “Acknowledged mistakes provide potent learning experiences. Admitting them helps ensure that they will not be repeated. The humbling avowal of error prevents doctors from confusing their mission with a divine one. We possess no omniscient powers, only intuition, experience, and a patina of knowledge…”
• “My aim in relating these stories is not only to emphasize the value of optimism and of communicating certainty, but the fact that medicine still requires navigating through largely uncharted waters. Many think that since we are living in the age of science, much of the guesswork is taken out of the practice of medicine… Effective patient management requires appreciation of the art of healing, in which one is guided by experience, by the recall of a similar case, and by the exercise of common sense. A sense of humility is also an asset… for any advice has a substantial amount of conjecture… There is never any certainty as to where an individual fits on the normal statistical distribution curve. Statistics may present probabilistic truth but they shred souls and individuality… When confronting uncertainty, the physician must be an ombudsman for the patient. But advocacy requires caring…”
Dr. Lown’s discussion on medical malpractice is balanced:
• “One cannot outlaw human error, and even the best doctors make mistakes.”
• “As every patient is unique, medical work is essentially experimental, uncertain, and prone to error.”
• “It is the insurance companies more than the victims of malpractice who are collecting the loot.’
• “The fear of malpractice has grown as a rationalization for lucrative procedures, especially invasive ones.”
• “Our health care system is breaking down because the medical profession has been shifting its focus from healing, which begins with listening to the patient. The reasons for this shift include a romance with mindless technology which is embraced in large measure as a means for maximizing income. Since it is uneconomic to spend time with patients, diagnosis is performed by exclusion, which opens floodgates for endless tests and procedures. Malpractice suits should be viewed a mere pustules on the physiognomy of a sick healthcare system. They are not what ails medicine in the United States, they are the consequence. The medical system will not be cured until the patient once again becomes central to the doctor’s agenda.”
The contributions made by the sections of The Lost Art of Healing on aging and death deserve to be studied by everyone who cares for the elderly, the critically ill, and dying patients. Among my favorite takeaways:
• “For many people, growing old is a passage to be dreaded, marked by abandonment and loneliness. But for those adequately prepared, it can be embraced with the ardor of youth and an insight that young people rarely possess. I see quite a few elderly, who in their tenth decade are still creative and dreaming…”
• “The elderly do not fear death as much as the long act of dying, the bumpy road to final dissolution.”
• “I am persuaded that loneliness incubates hypochondriasis. Furthermore, our culture medicalizes age, as though growing old were a disease… Many elderly are willingly entrapped in the burgeoning medical-industrial complex. Visits to doctors, like shopping, combat loneliness.”
• “The depression I encounter in the elderly comes not ‘as a howling tempest in the brain’ (William Styron, Darkness Visible)… It is a form of ennui with living that is so subtle that at times it defeats recognition. The smile of sociability has not vanished. The mask all wear is not turned down at the mouth. Conversation is briskly engaged. No change in attitude is admitted. It is when the doctor knows the patient well that one senses attenuation. The boast is gone. The bravado isn’t there. A sense of indifference or even defeat reigns around the eyes. The presence of a spouse is enormously helpful in confirming such observations… ‘Yes, Charly is depressed.’ Then details a wealth of somatic and behavioral changes.”
• “With the passage of time, I share my uncertainties with my patients. Contrary to expectation, this increases confidence and trust. The arrogance that doctors convey is a transparent coverup for enormous uncertainty! Humility is not granted to the young, but gifted to the old… It takes a doctor nearly a lifetime to clear from his or her system the tendency ingrained during medical education, to focus on rare and remote oddities; to think of zebras when hearing hoofbeats; to cease being on an ego trip; and to stop dreading being wrong.”
• “Experience with death does not lend wisdom to physicians any more than to undertakers… Doctors, however, are experienced in observing the process of dying, and indeed, they frequently shape the traverse of the final denouement, either as chief perpetrators of a technologic obscenity or as orchestrators of a serene passage.”
• “Sudden death does not prepare those who are left for the totality of the loss… The sudden death of a spouse, parent, sibling, or friend is an unanticipated destination undertaken without the preparatory journey. Such deaths leave an unfinished life, a lingering ghost long remaining unexorcised to haunt the living. I am not convinced that sudden death is a fair deal for everyone.”
• “The mere show of concern and affection is beginning of absolution, lessening the burden of pressing guilt. A last goodbye is emblematic of communion, a terminal reconnection that has enduring meaning for the living.”
• “The dying person struggles… to cling to a human identity, but the struggle is a losing one. Even the best of hospitals is an environment organized to depersonalize, infantilize, and disempower. The patient is detached from all that is intimate, familiar, and kind. Adding to the disintegrating image of self is the usurpation by anonymous others of decisions about life’s fundamentals.”
• “American culture has approached death not in a sensible manner but with a schizophrenic mix of denial and preoccupation. A French woman told me, ‘Americans are the only people who think death is an option’. This stems in part from the American glorification of youth…. But the paramount factor is hospitalization of the dying with the pervasive idea that death is somehow indecent and to be avoided at all cost.”
There are a number of humble acknowledgements of some of Dr. Lown’s extraordinary contributions to cardiology practice that make The Lost Art of Healing a first-rate, medical memoir:
• Identification of sympathetic and parasympathetic triggers for cardiac arrythmia
• The invention of the cardioverter – defibrillator and its clinical application
• The premature ventricular contraction (PVC) hypothesis in the etiology of sudden cardiac death (SCD).
• Description of Levine’s sign (Samual A Levine): “Levine emphasized the art of misdirection, for example, asking the patient to ‘point with a finger’ where ‘the pain’ is located. Angina is not (typically) sensed as a pain, nor can one point to it with a finger. If the patient nonetheless followed the instruction and pointed to a spot on the chest wall, one could forthwith dismiss the diagnosis of angina pectoris. If, however, instead of pointing, the patient clenched a fist or laid the flat of his hand on the midsternal area, angina generally was present. This was further confirmed if the patient, in describing the sensation used such words as ‘I find it hard to describe, it’s really not a pain, it’s more of a tightness, or a heaviness, or a squeezing’. Then the diagnosis was secure.”
Dr. Lown finishes his book by expressing gratitude for his career as a Doctor:
“I feel extraordinarily privileged to be a physician. A doctor, after all, has a front-row seat for an unmatched theatrical performance. While art may imitate life, it never quite measures up… rarely is one permitted to gain such intimate insight (into the life of another human). No pleasure is quite akin to the joy of helping other human beings secure their hold on life. This book (The Lost Art of Healing Practicing Compassion in Medicine) is a small recompense to my patients, ultimately my greatest teachers, who helped me become a doctor.”
I strongly recommend The Lost Art of Healing to doctors and patients alike. It has taken its place on my bookshelf, next to: Counsels and Ideals from the Writings of William Osler; James Forrester’s The Heart Healers The Misfits, Mavericks, and Rebels Who Created the Greatest Medical Breakthrough of Our Lives; Sherwin Nuland’s The Art of Aging; Atul Gawande’s Being Mortal; Abraham Verghese’s A Country of My Own and The Tennis Partner; Stephen Westaby’s Open Heart A Cardiac Surgeon’s Stories of Life and Death on the Operating Table; and Paul Kalanithi’s When Breath Becomes Air. None of these doctor’s books are perfect (any more than the doctors themselves), but all are that good.

[Rachel · Rating 3 out of 5]

In times of unrest and turbulence in the United States health care system, it can be difficult to assign the problem to any one party. As patients, a lot of us look toward insurance companies and the government. However, The Lost Art of Healing: Practicing Compassion in Medicine shows that patients and doctors have a hand in the problem as well.

Dr. Lown gives a number of anecdotes from his practicing where listening was almost paramount to helping the patient. As technology advances, he notes that doctors are more keen to listen to their test results rather than the patient themselves. In the words of Dr. House, "everyone lies." While that may be true, the best lies are the ones that base themselves in truth.

As an aspiring biomedical engineer, this book shed new light on the practical impact my designs might have. I really enjoyed the first look into a doctor's mindset, but also the humbleness in Dr. Lown's stories. Although the medical jargon is thick in this book, he makes it understandable for anyone to understand. While over 10 years old, the book is still relevant today, or even more so, and I highly recommend to people who may be interested in the larger issues of the healthcare system today.

[Sara · Rating 3 out of 5]

I think what I enjoyed most about this book was getting to hear the words of the most influential people in cardiac medicine within the last 100 years. Dr. Bernard Lown is the inventor of the defillibulator and radically changed medicines ability to go farther in caring for its patients. His mentor was Dr. Samuel A. Levine, whose contributions to caring for cardiac arrest patients and using EKG to monitor the conduction system in the heart were revolutionary. It was a privilege to get to hear the stories that inspired these changes and the doctors that dared to make them. It is hard to believe that these advancements at one time didn't exist because they are now the standard of care that occurs at every hospital around the world (eh give or take a few).

That being said... inspiration and medical advancements and all... it was a pretty dry read. Three stars.

[Juka Kim · Rating 5 out of 5]

Absolutely the best book I have read in regards to medicine. While many championed "premed" books address the issue of humility and humbleness in treating patients, Dr. Bernard Lown distinguishes his book by describing how to employ the art of healing. His numerous anecdotes on clinical vignettes as well as his experiences in clinical research (and in some cases contradicting his own mentor) are memorable. Those interested in the field of cardiology would likely find this book most enjoyable, with descriptions of HF management with digitalis, DC cardioversion in A fib, vulnerable VF period during T wave, etc. Still extremely relevant despite being written in 1996!

[Don Kent · Rating 5 out of 5]

If you want to understand how and why the physician-patient relationship has deteriorated and lacks compassion or why hospitals are operated the way they are now or how to try to manage end-of-life decisions you should read this book. While the middle of the book is a bit heavy on the history and developement of modern Cardiology the over-all content is well presented and very valuable. All physicians and every patient should understand and embrace the principles presented by this exceptional author.

[Beverly Kent · Rating 4 out of 5]

l have had doctors who would have benefited from reading this book and I have had doctors who could have written the book. The author is a noted cardiologist with long experience and many good observations and patient stories. Several chapters were beyond my understanding; his many examples were interesting and clearly showed his method of compassion. It is worth a look by anyone who trying to navigate the health system for himself (herself) or for a loved one.

[David Martin · Rating 3 out of 5]

Bernard Lown is in many ways a great example to emulate as a doctor: he was patient-focused, resisted the commercialization of medicine and showed a radical interest the individuality of each of his patients.
I guess I wasn’t really in love with this book because I was hoping for essays and principled arguments, and found anecdotes instead.

[Jonathan Weinkle · Rating 5 out of 5]

This book set the course for my entire career. A must read for anyone in the healing professions, especially if you're beginning to question why you're there. Lown was the rare confluence of brilliant research, top-notch clincal acumen, and genuine compassion.

[Thomas Fratkin · Rating 5 out of 5]

“Science is constantly providing new and ever more powerful tools. Current imaging techniques leave no part of the body unexposed. None of these, however, can reveal the basis of an aching heart. This is left to the art of medicine, which has remained largely unchanged over millennia. Its most powerful tool is listening to a patient’s words.”

Very touching and heartfelt. Gives me hope for humanity.

[Sara Kaufman · Rating 5 out of 5]

One of the most moving books I've ever read.

[Claire Quinlan · Rating 5 out of 5]

Sometimes conceited and sometimes wise, all the time I felt proud to be entering this profession

[Johnathan Yao · Rating 5 out of 5]

Dr. Lown comments on how doctors do more than just treat disease, but heal a human being. That art, which has extended back millennia, is now being lost in the advent of technology and 'efficiency'. Through his many years of experience, he has developed many tricks and tools to build rapport and genuine connection with his patients. He has also observed profound insights into human nature and the human condition that only the most astute philosophers and literary giants have reached. I needed to read this book to remind myself why I wanted to be a doctor. The road is long, arduous and difficult, with many sacrifices.

[Pamela Fernandes · Rating 5 out of 5]

Every doctor must read this book. It talks about the subtle art of practicing medicine. Dr Lown is a renowned cardiologist and his mentor Dr Samuel Levine appears in many of his experiences throughout the book. Dr Lown tries to simplify the book for non medical people reading it. But the book describes the finer details of medical practice, the reason for doctor's insecurities, their battles with malpractice and the plight of patients. As a catholic doctor, this is fantastic, because healing trumps curing, but for the more robust, money centric medical world it may make one take a step back and wonder.
The book with its humor, real life experiences and brilliant quotes from literature leaves you feeling inspired to take on the world with renewed vigor. At the very end Dr Lown does talk about how patients can help their physician and what their behaviour should entail, but few would find that happening.
The book is great if for doctor's who've forgotten about the sensitivities to patients. I would gladly recommend medicos to read this book.

[Bill · Rating 4 out of 5]

An interesting and readable book by a preeminent physician. The author emphasized that good doctors come to many of their diagnoses by physical examination and by knowing their patients through good conversation. He further notes that both of these methods are falling by the wayside in then-present-day American (the book is copyrighted as of 1996). My time was well-spent in reading this book -- it gave me a good deal of insight about what being a physician is like. To add icing to the cake, as I got further into the book it because apparent (though a low-level mention) that the author was winner of the Nobel Peace Prize! Sure enough, I looked at the front cover and there in small print under the author's name was "Winner of the Nobel Peace Prize."

[Ryan Manns · Rating 4 out of 5]

I read this book in 2 days. Couldn't put it down actually. I epecially enjoyed the first 200 pages and felt like I gained some great insights into whats really important in medicine. The recurring theme of the book is basically that despite all the advancements in science and medicine the strongest means of diagnosing and helping a patient is getting to know them, taking a good history and physical, and being supportive of their problems. My only real criticism is the Dr. Lown didn't really write about his failures as a doctor. He focused a lot on all the good things he had done and basically came across as "I'm the best doctor ever and I know it." While he did do some remarkable work I feel readers could learn a lot from failures as well as successes.

[Dawn Davies · Rating 5 out of 5]

This book is a must-read for people interested in autopathography, narrative medicine, and how doctors and patients develop and maintain relationships. Dr. Lown seemed to be a gifted doctor who bridged the distance between old-school medicine (doing a complete history, anyone?) and modern technological medicine, which so often leaves the doctor scanning through a computer chart while the patient gulps on the paper-covered table.

Is there some old-school stuff in there that we shouldn't do today? Yes. But that doesn't make it less of an important read, especially if you are interested in relationships, healing, and see the patient's experience as something more than a medical product.

I recommend this book.

[Jay Nair · Rating 4 out of 5]

A must read for all healthcare stakeholders. Very well written with lots of examples of the challenges faced both by the doctor as well as the patient.

Very relevant to the present context of patient becoming much more empowered and wanting to be more in the know of his or her treatment, both medically and as an individual.

[Becca · Rating 4 out of 5]

Sometimes cynical, sometimes self-aggrandizing and often self-contradictory the read is very uneven, but overall an enlightening and occasionally even instructional presentation of the best tools that we can bring to the bedside to approach our patients.

[Valentina Chiriac · Rating 4 out of 5]

O adevarată valoare care merită citită de toți cei din domeniul medical și nu numai. Mă bucură mereu să citesc carți non-medicale scrise de medici. Îmi place viziunea doctorului Lown asupra profesiei de medic, care trebuie sa fie mai întai de toate uman!
Merita 4,5*!

[Barbara]

Wise words from a true healer

[Marie · Rating 5 out of 5]

incredible.

[Veronica Fernandes · Rating 4 out of 5]

Dr. Lown is the Yoda of cardiology. This book contains precious lessons for practice. May he rest in peace.

[Benjamin · Rating 5 out of 5]

Awesome! Great book for anyone who is interested in health care. An immediate favorite.