In memory of Bernard Lown [PODCAST]

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“Ever the teacher, the Dr. Lown we knew modeled ‘The Lost Art of Healing’ (the title of one of his books) in the clinic, the laboratory, and the halls of power. As health professionals, we watched him listen carefully to his patients; as citizens, we saw him listen deeply to our neighbors. We heard him importune our health care enterprise to do what is best for democracy with an eye on the future, instead of what helps today’s bottom line. And he entreated us to bear witness to the harms and risks of our social choices, to shine a light on the possible, and to lead toward a future that is better than the past. ‘If you can see the invisible,’ Dr. Lown said, ‘you can do the impossible.’

Dr. Bernard Lown was the best of his generation. Kind and wise. A listener, a thinker, a doer. A teacher and prodder. A challenger and inspirer. Impossible to equal. And impossible to ignore.”

Michael Fine is a family physician.

He shares his story and discusses the KevinMD article, “In memory of Bernard Lown.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Michael Fine. He’s a family physician, and he co-wrote the KevinMD article “In memory of Bernard Lown.” Michael, welcome to the show.

Michael Fine: Thank you very much for having me. It’s great to be here.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and journey to where you are today?

Michael Fine: I’m a community organizer turned family physician. I got to start the largest family practice in the little state of Rhode Island. That practice helped found the DPC movement many years ago, in about 2000. I then became the director of the Rhode Island Department of Health, a position I served in for about four years, till 2015.

Along the way, I got to write a couple of books, one called The Nature of Health, one called Health Care Revolt, a novel, and a book of short stories, and I became convinced that the only way to fix the incredible mess that we call health care is by organizing health care workers and physicians. As part of that, I got to become part of the board of the Lown Foundation, the Lown Institute, and then I got to meet Dr. Bernard Lown himself, who was a real giant in medicine and in my personal life.

Kevin Pho: In your position as a public health official during the pandemic, what would you say were some of the biggest challenges that you faced?

Michael Fine: Well, the biggest challenge was that we don’t have a health care system in the United States. We have a market, not a system, and that means we have no way to reach every single person. In the community in which I worked, about 50 percent of the population has no primary care and no access to care, and that made things incredibly challenging.

In addition, we had to look at the great social discrimination that exists, so that people who are at greatest risk had to go out to work regardless, and they picked up disease at work and brought it home and spread it at home. And that’s why our densely populated cities and communities got so badly impacted.

Kevin Pho: I’m a primary care physician myself; I’m an internist, and I’m certainly interested in hearing your thoughts on the future of primary care. I’m certainly aware of the issues as you describe them, but in terms of big-picture ideas that you have to save primary care going forward, what would some of them be?

Michael Fine: Well, the biggest one is that it’s going to take a movement. This is not something that’s going to happen because someone passed an act in Congress or in a state legislature. It’s not going to happen through reimbursement reform; reimbursement reform is 30 years late. It’s going to happen when we all get together, stand up together, and make it change. We have incredible power as primary care clinicians, if we just would finally use it.

You take something like the home health certification and plan of care. That’s a form we all have to fill out. We all hate it. It is totally meaningless. It comes from CMS, and it will change if we force it to change, if we band together and stop doing it. Stuff like that. I sometimes say we need to occupy CMS in order to change this. But it’s not going to come from somebody else. It’s got to come from us and our resolve, focus, and organization.

Kevin Pho: I think one of the issues when it comes to organizing physicians is that we’re very siloed, even among primary care. We have internists, we have family physicians, and we don’t have a unified voice speaking for all primary care physicians in the United States. So when you say that there needs to be a movement, and we in primary care need to act as one, how do we go about doing that?

Michael Fine: Well, that’s going to take years of movement building. There are plenty of examples in American history where the United States has been made better, more democratic, and more interesting by social movements, from the abolitionist movement, to the movement for women’s suffrage, to the civil rights movement, to the anti-war movement, to the movement for marriage equality. All of those fundamentally changed American society, and that’s what it’s going to take to fundamentally change health care in the United States.

We are the people who are best suited to build and run this movement, but it’s going to take work and sacrifice. It’s not fair. It’s too much to ask of busy primary care clinicians who are slammed left and right every day, from their EMR to CMS requirements to this and that. The problem is, there’s no one else to do it.

Kevin Pho: So let’s transition now into the KevinMD article that you co-wrote. It’s titled “In memory of Bernard Lown.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to co-write it?

Michael Fine: Well, Dr. Lown was a major influence in my life. He died in February at age 99. He had an incredible life story and was incredibly dedicated to medicine and to listening to patients. As some people may know, he invented the defibrillator. He described the contemporary treatment of myocardial infarction, post-myocardial infarction. He described an aberrant conduction pathway, the second most common after WPW, et cetera, et cetera.

And then, in his 60s, he worked to create an organization called International Physicians to Prevent Nuclear War, which did exactly as I said: It brought together hundreds of thousands of physicians from around the world, and they worked together and forced the nuclear disarmament of the late ’70s and early ’80s, a body of work for which he received the Nobel Peace Prize.

So that’s the objective evidence. The subject evidence was, when you spent time with Bernie, he was the smartest man I ever met. He knew more medicine than I can imagine. He started by testing people’s ability to know how much medicine you actually knew, and then he would tell stories about his organizing work, about his work around the world, and encourage everyone he talked to to get involved, to get active, to listen to patients, and to really build on the beauty of the patient-physician relationship. He was just an amazing guy. And he brought to medicine something that I fear sometimes we lose, and that is an aware social conscience and a deep commitment to the relationship between physician and patient.

Kevin Pho: I talk to a lot of physicians on this podcast, and of course, a lot of physicians write on KevinMD, and there is almost a sense of demoralization, of burnout, of moral injury among clinicians today. What would Dr. Lown say to these physicians who are maybe burnt out and thinking of leaving medicine?

Michael Fine: He would say exactly what I hinted at, which is, “Don’t mourn, organize.” He and I had a conversation a week or two before he died. We would talk with some frequency, because he was my mentor and teacher, almost kind of a father figure for me. And I was dispirited. Things were bad in the country, and things were bad in health care. I feel terribly about how we performed with COVID. From my perspective, we lost 500,000 lives unnecessarily. And Bernie, at 99, said, “I’m hopeful.” I mean, people have no choice but to organize themselves and fix this mess.

And that’s what I think he’d say to our dispirited colleagues. We’ve been beaten up by the insurance process, we’ve been beaten up by CMS, we’ve been beaten up by pharmaceutical companies, et cetera, et cetera. We can either stay beaten up, or we can join together and fix this mess. And we are the best-suited people in the nation to lead the nation to a health care system that’s for people, not for profit.

Kevin Pho: Now, if I’m in the exam room talking to a patient, examining a patient, what would some of Dr. Lown’s lessons be, specifically in the exam room?

Michael Fine: I think they would start by asking clinicians to listen, to have paid, to do what you’re doing with me: to ask people to tell their story and to elicit from people what they think is important for themselves, so that the clinicians involved can meet them where they are and help them get what they want, not just what the guidelines say. I think his real focus was making sure he knew the human being and valued the human being and his relationship with that person.

Kevin Pho: We’re talking to Michael Fine. He’s a family physician, and he co-wrote the KevinMD article “In memory of Bernard Lown.” Michael, you mentioned that in a past life, you had spearheaded the DPC movement, the direct primary care movement. Going forward, what role does direct primary care play in the future of primary care?

Michael Fine: Well, I think direct primary care is really important and a really valuable idea. I think it gives physicians a shot at having a reasonable life, and it basically throws all the checkboxes away. It won’t help us provide primary, I mean, it will help us, but it won’t be able to, totally by itself, provide primary care to all Americans, which is what I think we should be focused on. We need to do that in partnership with others, DPC plus others. But it’s a critical piece of that, and it provides real competition to employed physicians, so that employed physicians have a place to go if they get beaten up, as they keep getting beaten up, so that we can model what an ideal relationship between a patient and a physician is. And I think that ideal relationship is: You work for the patient and provide unself-interested advocacy. The DPC movement provides the opportunity for people to do exactly that.

Kevin Pho: And when you talk about starting a movement, what are some actionable things individuals can do to help grow and nurture that movement?

Michael Fine: Well, thank you for the opportunity. It’s actually laid out a little bit in this book called Health Care Revolt. But what I think people need to do is start in the exam room and start listening to people when they themselves run into the chaos of what purports to be a health care system but is really a market in the United States. So when a CT scan gets denied, or when somebody’s medications, pharmacy benefits, get played with and they have to get all redone, or there’s trouble getting a referral to a specialist, as there is in the lives of primary care physicians many, many times each day, I think we should be talking to our patients and say, “Look, we have a mess. We have a market that’s there for profit, not a health care system that’s there for people. Do some talking to your friends and neighbors.” That’s one thing we can do.

I think we can start inviting people to come into our waiting rooms and having group conversations. I think we can do some things organizing in our own communities, little health care systems. So in the little town I live in, which is called Scituate, Rhode Island, we’ve had something called the Scituate Health Alliance going for 20 years. And we’re the only community in the United States I know of that guarantees everyone access. Every single person in Scituate is guaranteed access to primary care, and we purchase that for people without insurance in a capitated way.

There are a zillion things people can do. People can run vaccination programs. Many physician colleagues are out right today; I’m going this afternoon to volunteer in a vaccination clinic. We shouldn’t be waiting for other people to do that. We should be leading that and modeling how communities can build health care systems for themselves. And once we model those, that helps each community start a movement. And then we bring those communities together and begin to build a national movement over time.

Kevin Pho: And my final question: What’s your take-home message for the KevinMD audience? And perhaps you could end with a final memory that you want my audience to remember Dr. Lown by.

Michael Fine: Well, my take-home message is, as you might think, “Don’t mourn, organize.” That is to say, don’t get upset about the craziness of the market. The market is doing what we ask markets to do, which is make money. Instead, assert the ethical prerogatives of our profession, which means we need to be about unself-interested advocacy.

And from Dr. Lown, the quote that most of us remember most is when Dr. Lown said, “If you see the invisible, you can do the impossible.” And I think for those of us in the United States, the invisible is the existence of a health care system that’s for people, not for profit. And the impossible has always been to build it, build it. But it’s not impossible if we do it together.

Kevin Pho: Michael, thank you so much for sharing your time and insight, and thanks again for being on the show.

Michael Fine: Thanks for the opportunity again, and thanks for the work you do bringing us together.

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