Lown Forum

T HE

2012

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LOWN CARDIOVASCULAR RESEARCH FOUNDATION

Avoiding Avoidable Care Conference

Vikas Saini, MD
On April 24th and 25th, more than 150 physicians, medical educators, policymakers, insurance and hospital executives, and health care journalists put their heads together in Cambridge to grapple with the problem of avoidable care. The Lown Foundation partnered with Shannon Brownlee of the New America Foundation to organize the conference. The meeting addressed the problem of overtreatment in health care from several perspectives. The conferences chief goals Dr. Vikas Saini & Shannon Brownlee were to identify the drivers of avoidable care, and develop solutions to one of the largest sources of wasted money and risks to patients in our country, and increasingly, beyond.

A conference that would focus on the problem of avoidable care was the vehicle we chose to start a dialog about the problem and to propose possible solutions. We invited some of the countrys leading thinkers on health care issues. The result was an intellectually rich, lively, and productive two days.

Why does so much overtreatment exist?

A surprising consensus among participants showed that the principal impetus to overtreat is not, as many had thought, fear of lawsuits. The problem is considerably more complex. It takes more thought and energy not to do things. For example, its easier for a physician to respond to a complaint with a knee-jerk reaction: You need a procedure. As Dr. Lown has stated repeatedly, it takes time to listen to the patient to determine the real issues, and to develop an appropriate approach to the problem, which may involve lifestyle changes in lieu of surgery. Physicians are genuinely motivated to care for patients. And they have a duty to ensure the highest quality care, which Dr. Lown addresses the audience isnt necessarily the most expedient. There is a moral component to doctors decision-making. In his keynote address, Dr. Harvey Fineberg, President of the Institute of Medicine, dened avoidable care as that which oers high risk, high cost, and low benet, while optimal care is that which constitutes low risk, low cost, and high benet what physicians must aim for. Evidence shows that doctors who spend time in conversation with patients are signicantly less likely to be sued, which ies in the face of the conventional wisdom that doctors need to perform more procedures in order to avoid lawsuits. Dr. Fineberg also pointed to an excess of hospital beds as a problem: hospitals create more capacity both as a rationale for fundraising, and to fuel aspirations to be bigger and better. Those beds must be kept full in order to meet hospital budgets, creating a cycle of need for procedures based solely on nancial considerations.
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Why a conference & why the Lown Foundation?

Since its founding in 1973, the Lown Foundation has been a strong proponent of a less invasive style of medical practice. When other doctors say Cut, doctors who practice in the style advocated by Lown Foundation founder Dr. Bernard Lown might say, Hold on. Tell me whats going on. When doctors make the eort to listen to and learn from their patients, they can develop an appropriate treatment plan that may or may not involve an invasive procedure. Our research shows that the Lown approach doing more for the patient while doing less to the patient leads to outcomes as good as those achieved by physicians who are quicker with the knife or the stent. With health care costs skyrocketing, and politicians ghting or shaking their heads in despair, we knew it was time to ratchet up our activity. We had the experience, the philosophy, and the reputation to take a leadership role in conveying that a less is more approach provides part of the cure to what ails health care.

INSIDE

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Lown Award to John Bogle Into the re Lessons learned Development in action 2012 Donor recognition Avoidable Care Conference (cont.)

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Into the re Lessons learned (cont.) Is it true that chocolate is good for me? Patient prole: Being part of the family Statins and the risk of diabetes What not to say to your doctor

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Lown Award to Bogle at Gala dinner

The Mandarin Oriental in Boston was the setting for the Lown Foundations rst annual Straight from the Heart Celebration on May 17th. At the dinner, the Lown Foundation was proud to present its inaugural Bernard Lown Humanitarian Award to John C. Bogle, Founder and Dr. Saini, Mr. Bogle, Dr. Lown, & Shannon Brownlee former CEO of The Vanguard Group, the worlds largest mutual fund manager. Mr. Bogle was honored for his leadership in advancing a strong ethical approach to business and investing, focused on serving the needs of the individual investor, much as the Lown Foundation is committed to advancing a patient-centered style of health care. With the awards creation, the Foundation recognized Dr. Lowns signicant achievements and his profound humanity. A crowd of approximately two hundred fty guests was riveted by two outstanding speakers. Shannon Brownlee, Acting Director of the New America Foundation Health Policy Program, spoke about the ethical and nancial implications of overtreatment Bruce & Donna Leeds, Dr. & Mrs. Blatt, & Tom Grossman in medicine, and the need for a new, more appropriate model of care. Brownlee, the author of Overtreated: How Too Much Medicine is Making

Dinner co-chairs: James Joslin, Patricia Aslanis, & Jeremy Grantham

Into the re Lessons learned

Brian Bilchik, MD
Over the last several years, I have had the privilege of taking care of a few reghters. I most frequently get to see these incredible people after retirement. They exude dedication and bravery, and I feel a tremendous responsibility to help to take care of those who have put their lives on the line for others. The life of a reman is a dicult one: You need to be extremely strong, you need to be conditioned, and you need to be at the constant ready for sudden bursts of energy. There is a need to eat well muscles need to be fueled. They are constantly exposed to inhaled toxins, not only increasing their chronic risk but also risk for acute cardiopulmonary issues.

What can we learn from the challenge of managing high-risk individuals?

Sudden intermittent strenuous activity puts the cardiovascular system at risk. Shear/mechanical stresses on blood vessels and sudden emotional stress can cause a cascade of physiologic, biochemical reexes, and inammatory processes. There can be a surge in blood pressure and heart rate. The combination of all of these processes can cause vulnerable plaque in a blood vessel to rupture. This can lead to a blood clot forming in the vessel, and ultimately a heart attack or stroke.
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DEVELOPMENT

Lown Foundation takes center stage

The Lown Foundation has become a leading voice on avoidable care, which includes unnecessary tests and procedures. And we have been able to extend our vital message because of you. We are absolutely delighted to thank those donors, listed below, who contributed $500 or more during our last scal year ending August 31st, 2012. Dr. Vikas Saini, President of the Lown Foundation, has been widely quoted on the issue of overtreatment in connection with our conference, Avoiding Avoidable Care, in media outlets including the New York Times, Chicago Tribune, Boston Globe, and Radio Boston. We are extremely proud of our ability to make a signicant dierence for patients, their families, and in the medical profession overall. We intend to continue to speak powerfully about the issues that have long been a hallmark of the Foundation: Unnecessary tests are not good medicine and they often waste money. We look forward to our generous friends continuing to join us as we work eectively and energetically to change how health care is delivered in this country and around the world. Thank you for your support!
Lown Society Mr. & Mrs. John C. Bogle Dr. Fredrick A. Stare Graboys Society Mr. & Mrs. John Brennan, Jr. Mr. Herbert I. Corkin Dr. Joan Glass Morgan Dr. & Mrs. Thomas B. Graboys Mr. John J. Granahan, CFA Mr. & Mrs. Jeremy Grantham Mrs. Judith B. Hale Mr. & Mrs. John G. Hayes Mr. James L. Joslin Estate of Alvin H. Shwartz Mr. & Mrs. Robert F. Weis Sponsors Ms. Patricia Aslanis Dr. Joseph D. Brain Mr. James Carney, II Mr. & Mrs. Oswaldo Castillo Mr. & Mrs. Nassib Chamoun Mrs. Josephine Coppola Mr. & Mrs. Andre Danesh Mr. & Mrs. Breck Eagle Mr. & Mrs. Norton Foxman Dr. Renee L. Gelman Mrs. Glenyce Kaplan Mrs. Shirley F. Levy Mr. C. Bruce Metzler Dr. Vikas Saini Mr. David W. Scudder Ms. Deborah A. Stone Mrs. Jean Vinios Benefactors Mr. & Mrs. Donald R. Adams Mr. & Mrs. Christopher Barker Mr. Kevin Beatty Mrs. Dorothy Bent Mr. Lawrence C. Best Mr. & Mrs. John C. Bogle, Jr. Mr. & Mrs. William Y. Bogle, IV Dr. & Mrs. Anthony A. Caputi Mr. & Mrs. Alan M. Cobb Mr. & Mrs. Enrique Collazo Mr. William T. Connolly, Jr. Dr. & Mrs. Edward Crispin Mr. Peter DeRoetth Mrs. Myra S. Dunn Mr. & Mrs. Harry Ellenzweig Mr. Dan L. Fahey Ms. Ann T. Ferguson Mr. & Mrs. William H. Floyd, III Mr. & Mrs. Donald C. Fraser Mr. Stephen Friedlaender Mr. Martin Gantshar

Mr. & Mrs. Gary Hatton Mr. & Mrs. William C.S. Hicks Mrs. Carol A. Jarvis Mrs. Janet Johnson Bullard Mr. & Mrs. Edwin M. Kania, Jr. Mr. & Mrs. Bruce Leeds Dr. & Mrs. Bernard Lown Mr. & Mrs. Milton Lown Dr. & Mrs. Charles Magraw Mr. & Mrs. James Mahoney, Jr. Mr. & Mrs. Jay Marvin Mr. & Mrs. John R. Monsky, Jr. Mr. Albert F. Nagel Mr. John J. O'Connor Dr. & Mrs. John O. Pastore Mr. Morris Raker Prof. & Mrs. V. Kasturi Rangan Mr. & Mrs. Ira J. Rosenberg Dr. Arno A. Schneberger Mr. & Mrs. Milton Schwartzberg Mr. & Mrs. Joseph L. Serani Mr. & Mrs. Ronald M. Shaich Mr. & Mrs. Jerey M. Shaw Mr. & Mrs. John Simon Mr. & Mrs. W. Mason Smith, III Mr. & Mrs. Luke T. Sotir Mr. John D. Spooner Mr. & Mrs. Kenneth L. Sullivan Mr. & Mrs. Bernard Taradash Mr. Charles Thomas Tenney, Jr. Mr. W. Nicholas Thorndike Mrs. Elizabeth P. Vining Patrons Anonymous Mr. & Mrs. Christopher Arnold Mr. John J. Barry Mr. & Mrs. Joerg Braun Dr. & Mrs. Norman M. Bress Mr. Robert Bullard Mr. & Mrs. James E. Clawson Mr. Joel M. Cohen Mr. Christopher H. Covington Mr. & Mrs. Philip Devlin Ms. Michelle Duarte-Anderson Mr. Michael A. Esposito Mr. & Mrs. Louis L. Farber Mr. & Mrs. David I. Feingold Mr. Richard S. Forte Mr. & Mrs. Lawrence Fruman Mr. Eric Geller Mr. & Mrs. George Graboys Dr. & Mrs. David S. Greer Mr. & Mrs. Jay I. Grossman Mr. & Mrs. Thomas S. Grossman Dr. David M. Hodges Mr. Harold G. Jacklin, Jr. Mr. & Mrs. Ted King Mr. & Mrs. Yoseph L. Linde

Dr. & Mrs. Robert M. Lurie Mr. William D. Mahoney Mr. Vincent Megna Mr. David G. Mugar Dr. & Mrs. Silvio J. Onesti Dr. & Mrs. Rolf F. Poser Mr. Samuel S. Pratt Mr. James Rakowski Mr. Eugene E. Record, Jr. Mrs. Susan Rocca Mr. & Mrs. Mark A. Ross Mr. Louis Rudolph Mr. & Mrs. Nathaniel Saltonstall Mr. John Schneider Dr. Michael Sheehy Mr. & Mrs. Chester F. Sidell Mr. & Mrs. Francis Spellman, Jr. Mrs. Irene M. Stare Mr. & Mrs. Jerey I. Sussman Corporations & Foundations Daniel Neidich/Brooke Garber Fdn Enable Hope Foundation Foley Hoag, LLP The Glaser Family Charitable Fdn Grimshaw-Gudewicz Foundation The Haenreer Family Fund The Krauss Charitable Foundation The Lunder Foundation Max Kagan Family Foundation Nissie & Ethel Grossman Fdn PERSONAL MDS, LLC The Print House Reuben & Lizzie Grossman Fdn The Rhode Island Foundation Saracen Properties, LLC Temple Emanuel TFC Financial Management The Tilles Family Foundation Wellington Management Co., LLP Workable Alternatives Foundation

Special Thanks to our 2012 Conference Funders Agency for Healthcare Research and Quality California HealthCare Foundation Fannie E. Rippel Foundation Kaiser Permanente The Mattina R. Proctor Foundation Robert Wood Johnson Foundation

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Avoiding Avoidable Care Conference

Vikas Saini, MD
As Dr. Don Berwick, former Administrator of the Centers for Medicare and Medicaid Services, elaborated, It would be better if hospitals were empty instead of full. And we must make health care a human right. A panel on What Makes Us Do It presented a host of impulses behind physicians providing unnecessary care, including humiliation avoidance and conformity, as well as market inuences, such as drug and device companies. Sadly, this has led to a conict of interest, in which Dr. Don Berwick physicians actions could be inuenced by their own interests as much as or more than those of their patients. In sum, doctors' professionalism is at stake in the search for solutions to unnecessary tests and treatments. Whats called for is a change in cultural norms, much as smoking and drunk driving became unacceptable behaviors. Physicians need to change their habits of thought in order to change their impulses to overtreat, or never start them in the rst place, which is where the medical education establishment plays a signicant role. Peer comparison, in which doctors are ranked based on the number of procedures they do, can also be a powerful motivator.

Staying positive
In remarks on Day Two of the conference, Shannon Brownlee reminded everyone of the power of ideas. We need to recapture the soul of medicine, she said. Dr. Lown pointed out that overtreatment had been a trickle at the start of his career, but now its a ood. Yet the more time the doctor invests, the more cost eective the encounter and the more satised the patient. If time is given short shrift, the doctor treats only the chief complaint, not the person. "And medicine is a calling, Dr. Lown said. At its core, it's a moral enterprise, grounded in trust. We have a challenge before us. And any challenge is doable. Those who see the invisible can do the impossible.

Exporting unnecessary care

Sadly, avoidable care is becoming a global issue. Dr. Julio Frenk, Dean of the Harvard School of Public Health, said that the old conceptions of infectious disease as the principal health issue in poor countries are outdated. Heart disease and other ailments of the developed world are on the rise, and with that, the adoption of the "hightech, low touch" American model is leading to an epidemic of avoidable care.

What next?
In conversations after the event, it has become clear that many are looking to the Lown Foundation to continue to engage the national medical community on this issue. The growing national focus on cost needs to be leavened with a genuine concern for patients. We bring enormous credibility to such an eort and have an opportunity to have the kind of impact that matters. We have recently received a planning grant from the Markle Foundation of New York City to develop a strategy for building a coalition of organizations and individuals dedicated to changing the health care system to one that provides the Right Care. The Lown Foundation looks forward to leading the charge on right-sizing health care, creating a system in which costs are reasonable, physicians spend time communicating, and patients come rst. For more information visit: www.avoidablecare.org.

Some Solutions
Payment reform is clearly one answer to the overtreatment problem. The volume imperative do more

Conference makes a media splash

Dr. Saini was quoted in the New York Times on the "less is more" approach to health care on April 4th. The Boston Globe reported on the Conference in its White Coat Notes on April 30th, and the Conference was also featured on NPR's The Diane Rehm Show and in the Chicago Tribune. The conference achieved international recognition, with an article in The British Medical Journal.

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Into the re Lessons learned

Brian Bilchik, MD
Mr. M is now 68, and has been retired from reghting for over 10 years. He has an abdominal aortic aneurysm, chronic lung disease, and coronary disease. He described life in the rehouse: They were a close band of brothers, each took turns cooking, they all smoked at least a pack a day, exercise was sporadic, they ate well (too well, actually), they worked 24 hour shifts, they took risks, and they did not wear their masks as recommended. A new guy joined them he was a health nut and he catalyzed change. They ran daily, most of them quit smoking. Mr. M feels his life would have ended much sooner without this change maker. Mr. M has since been humbled by his multiple vascular conditions and signicant limitations.

He described the machismo that pervaded the rehouse, the denial if only we had made changes sooner.
Cardiovascular disease is largely preventable it requires knowledge and action, and importantly, consistency in lifestyle modication. The Lown physicians have embraced a model of prevention, a model of a proactive, inclusive approach to wellness. We encourage evaluations before trouble nds our patients. We are convinced that longevity is possible if chronic disease and risk factors are well managed in a motivated individual. We are hopeful that we will help foster change in our local rehouses, working collaboratively with the re chiefs, reghters, the unions, and our towns, we are proposing wellness and prevention programs helping to protect those who protect us.

QUESTION FROM A PATIENT

Is it true that chocolate is good for me? Or is it all just white noise?
Fred Mamuya, MD, PhD
Dark chocolate has been in the news lately everywhere I turn, yet another benet is ascribed to this delicacy. Dark chocolate may help reduce high blood pressure is the headline in a prestigious medical journal. Dark chocolate has also been reported to substantially reduce the risk of coronary disease and strokes, lower bad cholesterol (LDL), and lower markers of inammation due to its powerful anti-oxidant eects. It turns out that it is even good for your teeth when compared to uoride according to researchers from Tulane University. I could go on and on, but a headline from this spring really took the cake Chocolate: melts in your mouth and melts o your waistline! The New York Times actually headlined the same story The chocolate diet?. Never mind that the title of the scientic paper published in the Archives of Internal Medicine actually read Association between more frequent chocolate consumption and lower body mass index, and that the ne print went on to say, Causality in the observed association cannot be presumed. The problem usually lies with the supercial approach of how health information is presented to the public. Titillating

headlines sell and the caveats are usually mentioned casually and usually buried deep in the article or ne print.

It is unclear if dark chocolate consumed regularly can indeed deliver on all of its touted benets.
Almost all of the studies cited have looked at an association between people who regularly indulge in dark chocolate, and health outcomes. However, an association does not imply causality since the people who regularly consume dark chocolate may indeed have other qualities and attributes that promote a healthier lifestyle, with subsequent better outcomes. A 2010 review of all published studies looking at the association of chocolate and high blood pressure reduction noted that other factors such as local dietary habits or genetic/ethnic disparities may have been responsible for the results. A subsequent 2011 review, which concluded that chocolate consumption is associated with a substantial reduction in the risk of cardiometabolic disorders, admitted that none of the studies cited was a randomized trial! It should also be noted that many of the short-term trials, and some of the review articles have been funded by the chocolate industry. If you were to believe the headlines and consumed 40 grams of dark chocolate daily (~ 4 squares), you would be consuming about 227 extra-calories; and may gain about a pound of weight per week. At the next social gathering when someone comes up to you and begins to regale you with the latest news headline touting the health benets of substance X smile its probably just white noise.

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PATIENT PROFILE

Being part of the family

A patient/doctor relationship should be personal and profound
Over the past 30 years Arthur Barnsteins health has been a roller coaster ride with its ups and downs. However, one thing remained constant he has been a patient at the Lown Center for all that time. After a couple of minor heart attacks in his early 40s, Mr. Barnstein found himself a new patient at the Lown Center. I was referred to the Lown Center through a family friend, and I saw Dr. Lown on that rst visit...His attitude was very comfortable, it was like coming to see family. Fast forward several years Mr. Barnstein had a major heart attack in 1995 and required bypass surgery. He recovered, led as normal a life as he could, but his heart condition eventually deteriorated and in 2007, necessitated an implantable debrillator. His condition progressed, his heart was failing, and in September 2011, Mr. Barnstein had a left ventricular assist device (LVAD) installed a bridge until they can nd a transplant for him. (The LVAD is a battery-operated mechanical pump, placed inside the body, helping the heart to circulate blood.) Its a lot of work with the LVAD its a life support system. I didnt have a choice, it was get the LVAD or die. Its been a slow recovery to get my strength back, but Im now driving again, Im able to go out, Im able to get on with my life again. But we still have a long way to go.

Statins and the risk of diabetes: Putting facts into perspective

Shmuel Ravid, MD, MPH
The benets of statin drugs such as Lipitor (atorvastatin), Zocor (simvastatin), and Crestor (rosuvastatin), in prevention of cardiovascular events in those with proven heart disease were demonstrated in numerous large, randomized, and unbiased clinical trials. Nevertheless, statins use, like any other drug, is associated with potential side eects.

Food and Drug Administration warning

Recently, the Food and Drug Administration issued a warning regarding a documented association between statins and glucose intolerance and diabetes. In order to put these concerns in context, several aspects of this association deserve further consideration: 1. The risk for developing diabetes was higher in patients already prone to the condition, such as prediabetics and patients with metabolic syndrome (obesity, high blood pressure, abnormal lipids, and glucose intolerance). 2. Only one additional case of diabetes developed in 255 patients treated with statins for 4 years, while 5.4 serious cardiovascular events were prevented in this group. (Five times more patients need to be treated to cause one case of diabetes vs. the number that need to be treated to prevent one cardiovascular event.) 3. Those who developed diabetes and diabetic patients in general derive a similar cardiovascular protective benet from statins as non-diabetics. 4. The risk was higher with higher doses as compared to moderate dose statins. Any drug has potential side eects and their use is determined by balancing the potential benet with the potential risk. The risk of developing diabetes from statins is modest and is signicantly outweighed by the proven benets of statins in reducing cardiovascular disease and death. Statin therapy is a safe and eective intervention for prevention and management in those with cardiovascular disease. However, it has potential side eects and should be used judiciously. Nonpharmacological interventions and lifestyle adjustments such as optimal weight, healthy diet, and regular exercise remain the corner stone of eective risk reduction and prevention of both diabetes and cardiovascular disease.

When I had my LVAD put in, I spent 78 days in the hospital, and someone from the Lown Center came and sat with me almost every day.
Mr. Barnstein has worked hard to keep up his general health, and he gives much of the credit to the Lown Center. The practice exemplies not only caring for their patients, but also their personal lives. Its not Arthur, his wife, Dr. Bilchik, Lown sta just about the symptoms, but how are things going at home? They care for you as a person, not a sick organ. Its a cardiology oce, but the doctors are also like psychologists. They deal with all the issues in our life, and they give us time to talk about all our issues. You dont have to go in and say your piece quickly and then get out of there. That feeling of family that I rst had with Dr. Lown continues to this day. Even our own psychologist was enthralled by the Lown Center, Mr. Barnstein chuckled.

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NewsBeat
Dr. Charles M. Blatt was interviewed by Reuters Health on February 28th regarding a recent study on statin use and depression risk. Dr. Blatt and colleagues at the LCRF had published one of the earliest reports on this novel nding. On March 26th, Dr. Vikas Saini presented the Lown Foundations research Long-Term All-Cause Mortality in Second Opinion Coronary Patients Managed with Optimal Medical Therapy at the 61st Annual Scientic Sessions of the American College of Cardiology held in Chicago, IL. The research abstract was co-authored by Dr. Deepa Aggarwal, Padraig Carolan, Dr. Fred Mamuya, Dr. Brian Bilchik, Dr. Shmuel Ravid, and Dr. Charles M. Blatt. Dr. Fred Mamuya presented on the topic of End of Life Care on April 3rd at the Brookline Council on Aging. Dr. Vikas Saini attended the National Press Club event: U.S. Medical Specialty Societies to Identify Overused or Unnecessary Tests, Procedures on April 4th. On April 5th, Dr. Brian Bilchik addressed the Brookline Rotary Club on the topic of heart disease, family involvement, and decision making. Dr. Vikas Saini and Padraig Carolan presented the Lown Foundations research abstract Long Term Outcomes with Optimal Medical Therapy in Patients Seeking a Second Opinion Regarding Invasive Coronary Angiography at the American Heart Associations Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke: 2012 Scientic Sessions in Atlanta, GA on May 9th. The abstract was co-authored by Dr. Deepa Aggarwal, Padraig Carolan, Dr. Fred Mamuya, Dr. Brian Bilchik, Dr. Shmuel Ravid, and Dr. Charles M. Blatt. Dr. Selwyn O. Rogers, Jr. and Dr. Bruce B. Feinberg were awarded the 2012 Bernard Lown Award for Excellence in Teaching at Brigham and Women's Hospital. Dr. Rogers serves as the Division Chief of Trauma, Burn, and Surgical Critical Care for the Department of Surgery. Dr. Feinberg is the Research Director of the Complement Research Unit in the Division of Maternal Fetal Medicine. Dr. Bernard Lown was the recipient of the 2012 British Medical Journal Group Lifetime Achievement Award in recognition of his exceptional contribution to international health and healthcare. The Lifetime Achievement Award is the journals top annual award and was awarded last year to Sir Richard Peto. On June 12th, LCRF Board Member Dr. Barbara Roberts was a guest commentator on NPRs Diane Rehm Show, joining other national gures in a discussion on the use of statins for prevention. Dr. Roberts was invited in part because of her new book, The Truth About Statins, which has received favorable notice in the media, including a recent Q&A, How to Lower Your Cholesterol in Womens Day magazine.

Celebrating 100 years

Josephine Worrell, one of Dr. Brian Bilchiks patients, celebrated her 100th birthday this year. Ms. Worrell holds a special place in our hearts here at the Lown Center. In addition to being a wonderful patient, she was previously featured in the Forum (Summer 2007) at age 94 when she was the only patient to make it into the oce during the treacherous Valentines Day storm in 2007. Ms. Worrell, a retired nurse, spent 28 years as a volunteer caregiver at Childrens Hospital in Boston, and only retired two years ago. Happy Birthday Ms. Worrell!

Thank you for your support

Your financial support allows us to continue our work and carry our health message to local, national, and global audiences. We greatly appreciate any donation you are able to make. You can donate online at www.lownfoundation.org or mail your donation to 21 Longwood Avenue, Brookline, MA 02446. Please make checks payable to the Lown Cardiovascular Research Foundation. For more information, please contact Andi Brown, Director of Development at andrea.brown@lownfoundation.org or 617-732-1318 (x3350).
Board of Directors
Nassib Chamoun Chairman of the Board Vikas Saini, MD President Bernard Lown, MD Chairman Emeritus Thomas B. Graboys, MD President Emeritus Patricia Aslanis Charles M. Blatt, MD Joseph Brain, SD Janet Johnson Bullard J. Breckenridge Eagle Carole Anne McLeod C. Bruce Metzler Barbara H. Roberts, MD Ronald Shaich Robert F. Weis

CONTACT US
Lown Cardiovascular Research Foundation
21 Longwood Avenue Brookline, MA 02446 USA (617) 732-1318 info@lownfoundation.org www.lownfoundation.org www.lowncenter.org www.procor.org

Lown Cardiovascular Group

Brian Z. Bilchik, MD Charles M. Blatt, MD Wilfred Mamuya, MD, PhD Shmuel Ravid, MD, MPH Vikas Saini, MD

Lown Forum Editorial Sta

Andi Brown Jessica Gottsegen Claudia Kenney With special thanks to Benn Grover for his editorial assistance

Advisory Board
Martha Crowninshield Herbert Engelhardt Edward Finkelstein William E. Ford Renee Gelman, MD Barbara Greenberg Milton Lown John R. Monsky Jerey I. Sussman David L. Weltman

2012 Lown Foundation Printed on recycled paper with soy-based ink.

Lown Cardiovascular Research Foundation 21 Longwood Avenue Brookline, Massachusetts 02446-5239

Nonprofit Org. US Postage PAID Boston, MA Permit No. 53936

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not forget issues of importance and nd yourself calling the oce later to relay other details. This list should include: 1. All current medications and doses 2. A summary of past major medical events by relevance to current visit or listed chronologically 3. An outline of the current complaint (What is the exact complaint? When did it start? How often does it occur? Is it ongoing?) 4. Any other issues of importance

What not to say to your doctor

Charles M. Blatt, MD
The oce encounter with a doctor can be a turning point in a persons life. At 1pm you consider yourself a healthy person concerned about children, mortgage, or your golf game but by 2pm, a new diagnosis, disease, or novel problem requires your attention. What happened between 1pm and 2pm? An appointment with your doctor took place. During an oce visit, you often have several important discussions with your doctor and other health sta. A visit can be a life-changing event, but patients and doctors can do several things to ensure a visit goes smoothly.

What to avoid
It is important to come prepared for your discussion with your doctor, but at the same time, it is also important to avoid certain statements. For example, it is a mistake to begin the oce visit by telling the doctor that you need a dierent medication to treat angina. This lets the doctor o the hook and presents the busy physician with the opportunity to simply take your word for it, prescribe a new antianginal medication, and be done with the visit. The patient should aim to describe the symptom or complaint in his own words without attaching a medical label or diagnosis. Let the doctor do his own work and gure this out by asking more questions and probing the history for clues. The patient must also avoid perpetuating possible errors of past doctors. This is especially important when meeting a new doctor for a consultation. A new symptom and/or consultation requires an open mind. With this approach, you engage the doctor to evaluate your unique complaints and circumstances and thereby help assure that you will receive better medical care.

Preparing in advance
For both patient and doctor, it is important to come to the meeting prepared in advance. For the doctor, this means reading the past medical record and becoming familiar with information that may have been forwarded from other physicians. For the patient being prepared means coming to the appointment with a clear understanding of the following: 1. Purpose of the visit 2. What information you want to convey 3. What you want to learn For the oce visit to achieve your goals, preparing an organized written list in advance is useful. An organized, written account helps the doctor (and you) so that you do