Lown Forum

Charles M. Blatt, MD The good physician treats the disease; the great physician treats the patient with the disease. Sir William Osler

T HE

2009

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LOWN CARDIOVASCULAR RESEARCH FOUNDATION

Stable coronary artery disease: a benign condition

for invasive diagnostic or therapeutic interventions. Indeed, a careful history and a simple exercise test, in most patients, can determine the right clinical approach.

Successful management of CAD is key

Stable, well-managed CAD is a benign condition. Patients can enjoy long and healthy lives, enhanced by physical activity and full involvement in activities at home and at work. Lown Center cardiologists communicate this optimism--which is based on solid medical research and decades of experience--to both the patient and family, and especially to the worried spouse. We also include spouses whenever possible in our patients CAD management. We utilize invasive procedures only when they are clearly warranted and when the benet of intervening far outweighs the potential harm.
Read the Lown Center patient guide to managing coronary artery disease on page 4.

Because the Lown Cardiovascular Group treats patients as people, not diseases, we have had extraordinary success in the management of patients with coronary artery disease (CAD). Our approach is based on a wealth of clinical experience beginning in the 1950s with Dr. Samuel Levine, Dr. Lowns mentor in cardiology. Throughout their renowned careers, both Dr. Levine and Dr. Lown emphasized the importance of a meticulous medical history and physical examination in all patients. Today, this approach enables our group to lead the cardiology community in recognizing that the vast majority of patients with CAD--and particularly elderly patients--can be managed successfully without the need

PATIENT PERSPECTIVE
In March 1994, I was on track for quadruple bypass: two of my main arteries were 100% blocked, and a third was blocked 50%. My primary care physician and others I consulted all recommended surgery. But my wife was persistent in looking for an alternative and she learned about the Lown Center. My rst meeting with Dr. Blatt is very vivid in my mind. Id talked to so many people, I assumed I would be told the same thing--that with my kind of blockage, bypass was the only option. I was scheduled to crossmatch blood for the surgery that day and was in a hurry to get through the appointment. Despite my impatience, Dr. Blatt spent a lot of time listening to me. That surprised me--I was used to quick visits. He said that my CAD could be controlled with medication, exercise, and diet. I left his oce walking on air--I felt terric! I always enjoyed swimming but had gotten o-track with it. Now Ive been swimming 4-5 times a week for 15 years. Dr. Blatt prescribed medication and emphasized that I need to maintain a healthy weight and stay away from certain foods. I was cooperative and it worked ne until September 2006, when I experienced my rst chest pain ever and Dr. Blatt recommended a catheterization. He was with me during the procedure and suggested that they put stents in. Ive had no symptoms since. I think its important to have condence in, and listen to, your cardiologist. Its also important to listen to your wife--Im grateful that mine never gave up and I want to give her the credit she deserves. Stephen Price, PhD

INSIDE

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Presidents message: Annual appeal New care-at-home project Patient question: H1N1 ProCor: Global CVD training summit Guide to managing coronary artery disease

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Second opinions LCRF board member promotes womens health Lown Center News b eat Principles for a comprehensive health system

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Presidents message
Vikas Saini, MD
Putting people rstthe core principle of the Lown Center---makes us more than a medical practice. Rather, we are a community of physicians, nurses, patients, and families working together to build healthier lives. We see every man or woman who comes through our door as a human being--someones parent or child, husband or wife, brother or sister, neighbor or friend, living a busy life in a complex world. Our eorts touch people locally and around the world-from Brookline to Botswana and beyond. Through the Lown Foundations research activities, we continue to deepen our understanding of cardiovascular disease and the most eective, cost-eective ways of treating it. One of our current projects compares the eectiveness of our care to other models, seeking to quantify what we have seen for decadesthat our patients do substantially better than those who receive care that is driven by available technologies. An exciting new home care project soon will begin exploring the use of laptop computers and the internet so patients at home and clinical sta in the oce can see and talk directly to each other. (Read more at right.) Nowhere is the message about cost-eective prevention of heart disease more urgently needed than in the worlds poorest countries. Through ProCor, our global outreach program, we share the latest groundbreaking research with health professionals in more than 200 countries. Now in its third year, the Louise Lown Heart Hero Award brings international visiblity to grassroots health eorts in low-resource settings. This years winning program, in Uganda, promotes heart health from childhood through old age with innovative strategies that can inspire communities around the world and here at home. We need your help to keep the Lown community strong and vibrant. I hope you will consider a charitable gift to the Lown Foundation so we can continue our research, training, and global outreach. Your tax-deductible contribution is a gift to everyone in our community, from friends weve known for years to friends well never meet in distant countries. Your support makes a big dierence. On behalf of everyone at the Lown Center, I thank you.

If you would prefer to receive the Lown Forum by email, send your full name and preferred email address to info@lownfoundation.org.

RESEARCH UPDATE

Using communication technology to enhance patient-focused care

The Lown Cardiovascular Centers application process for our exciting new research project, Virtual Home Visits for Elderly Cardiology Patients: A Pilot Study, is underway. Approval by Partners Healthcares Institutional Review Board is required for all research involving human subjects to protect patients and ensure that their rights are being upheld. As soon as the application process is completed, the Lown Center will recruit a small number of patients to participate. The project will utilize internet videoconferencing to enhance communication with patients about their medical care. Participants will be randomly assigned to one of two groups. Members of one group will receive a small laptop computer that will be used to videoconference with their doctor and other sta at the Lown Cardiovascular Center. During a videoconference, patients will be able to see and hear their doctor on the laptop, and the doctor will be able to see and hear the patient on his computer. These e-Visits will be scheduled every two weeks and will be in addition to patients regularly scheduled oce visits. Patients will also be able to initiate a videoconference visit if and when they want. Members of the other group will continue with their regular care, which will not change in how it is delivered. We look forward to bringing you future updates about this exciting new venture.

A patient at home (left) can see and speak with Lown Center physicians and sta during e-Visits that are conducted over the internet using a laptop computer. In the photo on the right, medical assistant Elena Popkova, Dr. Shmuel Ravid, and Padraig Carolan, research assistant, speak with a patient. For more information, contact Padraig Carolan, research assistant at 617-732-1318 x3349 or pcarolan@partners.org.

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Question from a patient

Fred Mamuya, MD, MPH Constantly in the news, swine u (H1N1) can be confusing and frightening.
Question: What is swine u? Answer: The World Health Organization (WHO) has designated the 2009 pandemic inuenza (H1N1) as the Swine u. Question: If I am a cardiac patient, what should I do? Answer: You should receive the regular annual inuenza vaccine and the newly approved swine u vaccine. If you are over 65 years of age, you should also make sure that you are up to date with your pneumonia vaccination. Question: What symptoms should I be concerned about? Answer: Shortness of breath with activity or at rest, high fever that persists more than 3 days, rapid or shallow

breathing, turning blue, bloody or colored phlegm, chest pain, low blood pressure, decreased activity, lightheadedness, decreased urination, lethargy, drowsiness, diculty awakening, confusion, severe weakness, or paralysis are some common concerning symptoms. However, if you do not feel well, please call your physician before more serious symptoms develop. Question: What is the recommended treatment for swine-u (H1N1)? Answer: Oseltamivir (Tamiu) started within 48 hours of onset of symptoms is the recommended treatment. If Tamiu is unavailable, treatment with Relanza (zanamivir) should be considered. Treatment should be started as early as possible, and laboratory conrmation of inuenza virus infection is not necessary prior to initiation of treatment. Thus, please remember to call your primary care physician with any concerning symptoms.
Updates on H1N1 are available at the US Department of Health and Human Services website: www.u.gov.

ProCor plays leading role in international CVD training summit

"Am health worker, I need your help, I need free Oxford handbook on medicine. I hope you help me in this way. My address in Algeria...." Message from visitor to ProCor's website, Oct. 2009
Access to the global knowledge-base is fundamental to recruiting, educating, developing, and retaining people who can play a role in cardiovascular disease prevention --from village health workers to cardiologists. ProCor recently helped organize a two-day international summit focused on developing new strategies for training a global workforce to prevent CVD. Seventy people from 20 countries attended the Global Summit on Education and Training in Heart Disease and Stroke Prevention at the US Centers for Disease Control and Prevention in Atlanta on October 14-16, 2009. Dr. Brian Bilchik, ProCors Director, is Co-chair of the Regional and Global Collaboration Implementation Group of the National Forum for Heart and Stroke Prevention, which sponsored the summit. Catherine Coleman, Editor in Chief, ProCor, and Dr. Vikas Saini, Foundation President, also participated. To guide the planning of the Summit, a survey of global CVD training needs was emailed to ProCors 1300member network and to members of the National Forum. Based on survey results, plenary sessions explored diverse training formats, such as short courses, fellowships, and continuing education. Dr. Bilchik and Catherine Coleman delivered presentations on Online Learning that highlighted Dr. Brian Bilchik presented a ProCor and other programs session on Online Learning at that use technology to support the Global Summit on CVD training and education. Small-group brainstorming sessions explored potential ways of meeting the training needs of clinicians, health professionals, researchers, and policymakers. Dr. Saini moderated a session on the training and education needs of clinicians.

Education and Training in Heart Disease and Stroke Prevention.

In the nal plenary session, participants were asked to collectively describe an ideal long-term strategy to develop and sustain a national CVD prevention workforce, after which Dr. Billy Bosu, Director of Noncommunicable Diseases, Ministry of Health, Ghana, was asked to provide a reality check. Other things will be required as well---like political will and funding for chronic disease prevention, he observed. We need to be aware of the challenges, but not daunted. Read more about global heart health at www.procor.org.

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Lown Center patient guide: Managing coronary artery disease

Charles M. Blatt, MD
Stable, well-managed coronary artery disease (CAD) is a benign condition, and most patients can enjoy long, healthy lives. The Lown Center emphasizes management of CAD without unnecessary invasive interventions. The doctors willingness to listen to the patient and individualize the medical program is a powerful element in the successful management of CAD.
frequent use of a simple nitro tablet (under the tongue) at the onset of an episode of angina or, ideally, before the angina even starts (for example, anticipating onset from walking up a hill) can provide comfort and freedom from prolonged symptoms. The ability to exercise without angina also encourages physical activity and the ultimate proliferation of collateral blood vessels, the small but numerous vessels that travel with and alongside larger coronary arteries that are prone to blockage. These collateral vessels account for the frequent observation that angina disappears over time . Statins: Many large studies around the world have shown consistent benets among CAD patients who take statins. It now appears that lowering cholesterol is only a part of the picture; statins also reduce inammation within the lining of the blood vessel and may stall or even reverse atherosclerosis (hardening of the arteries). Ace-inhibitors such as lisinopril (Zestril) are useful for CAD patients who can tolerate further lowering of blood pressure. Ace-inhibitors relax blood vessels in the heart and throughout the body, and have been shown to improve outcomes of patients with all forms of vascular disease, preventing heart attacks, stroke, and kidney failure.

Diagnosis
In the vast majority of patients, critical narrowing of the coronary arteries can be ruled out with simple and inexpensive measures. The absence of chest discomfort at rest, a solid performance on the treadmill, and normal blood pressure response to exercise can dispense with the need for cardiac catheterization. Modest medication can further benet the large percentage of patients who in all likelihood will never require invasive and potentially risky interventions.

Ongoing follow-up
Close, regular follow-up of patients to monitor for changes, sometimes subtle, in symptoms and exercise response is essential for successful CAD management. This allows doctor and patient to learn the nature of symptoms that may suggest an important change in condition; assess tolerance to medication; and guide meticulous adjustment of medication doses and schedules. Regular follow-up also helps dispel a patients fear of imminent catastrophe and builds condence in the medical program recommended by the cardiologist. The willingness of the doctor to listen to the patient and to individualize the medical program is a powerful element in the successful management of CAD.

Exercise
Regular physical activity--ideally, 30 minutes per day for 5 days each week--is essential to manage CAD. Patients should exercise on an empty stomach--at least 90 minutes after a large meal. This is important because it allows digestion to take place before diverting blood ow away from the digestive tract to the exercising limbs, a process that puts unhelpful strain on the heart. The form of exercise--walking, swimming, bicycling, or jogging--is less important than the consistency of engaging in the activity. We suggest that patients schedule a convenient and regular time to exercise, and and then stick to their schedule. Exercising should be a high-priority item in your life, and shouldnt be crowded out of your schedule by a meeting or a haircut. Its important to enjoy whatever physical activity you choose, rather than engage in something that feels like a boring obligation. The psychological uplift provided by regular exercise can be profound. And exercise, of course, helps maintain a healthy body weight.

Medication
A range of medications, some recent and others in longstanding use, are a key component of the medical treatment of patients with CAD. Beta-blocker medications such as atenolol or metoprolol buer and blunt the eect of adrenaline on the heart, and limit the rise in heart rate and blood pressure that occurs with exertion and emotional stress, in order to maintain regular and stable heart rhythm. Occasionally, beta-blockers cannot be used due to an asthmatic condition or side eects such as fatigue or depression. Aspirin reduces likelihood that an unwanted clot will form along the irregular inner surface of a coronary artery and suddenly obstruct blood ow. Nitroglycerin is an old and inexpensive but eective remedy to manage angina or heart pain. Prompt and

Diet
Patients with CAD should consume modest portions of food with a focus on fresh vegetables, fruits, sh, chicken, and low-fat meats. Live well by following the adage: Less is more.

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Second opinion cardiovascular center

A national medical consumer advocacy group recently wrote, The Lown Cardiovascular Center in Brookline, MA is the place to go if you want a second opinion about the necessity of angioplasty or coronary bypass surgery.1 The Lown Centers reputation as a source of expert second opinions began with research published by Dr. Thomas Graboys and other Lown physicians in the 1980s and '90s. Our research concluded that angioplasty and bypass surgery can often be safely Dr. Thomas Graboys deferred in patients who have previously been told that a procedure is urgently needed. When published, it attracted a lot of attention, and people began coming to the Lown Center from other states and even abroad, Dr. Thomas Graboys recalls. These and other studies also led us to recommend a second opinion when cardiac catheterization is advised, because its often the rst step toward unnecessary angioplasty or bypass surgery. As a result of the attention his research attracted, Dr. Graboys practice became the heart of the Lown Centers second opinion work, which remains integral to the practice of every Lown physician today, observes Dr. Vikas Saini. Tom was sensitive to the psychosocial needs of patients, and aware that many dimensions besides the biological have a favorable impact on outcomes.
Obtaining a second opinion is a time-honored tradition in medicine, and most physicians agree that any signicant surgical procedure warrants one. If your doctor really cares for you, he or she will welcome it. If a physician suggests its not necessary, a patient can arrange for one directly.
1 Second opinion cardiovascular center www.medicalconsumers.org

Two Lown Center patients share their opinions about second opinions
"I was literally being wheeled into the operating room for urgent coronary bypass surgery in September 1991 when I heard a voice say, 'Take him back, we have an emergency.' The next morning, a nurse told me to pack up and go home because my surgeon was on vacation and my surgery would be rescheduled. "My son had own in from the Philippines to be with me during my surgery, and I was upset. I was a physician, and I knew the Lown Group used a less invasive approach in their cardiac care. I told the nurse that I wouldnt be back and my son drove me to the Lown Center to make an appointment. When I walked in and told them my story, the nurse said, 'I think you ought to be seen right away.' Dr Ravid was willing to see me. He reviewed my records, which my son retrieved from the hospital Id just left. After a long examination and conversation, Dr. Ravid said, 'Your condition is very stable and we can try medications to control your symptoms.' After adjusting my medications, I didnt have any more pain. I walk regularly and stay away from sodium and fatty foods. Im 88 years old and havent had any pain for 18 years. I underwent aortic aneurysm operation and pacemaker implant without diculties. I work two days a week conducting medical examinations for military recruits. Ive been a physician for the past 60 years and I like to keep busy. B. H. After my wife died three years ago, I started getting sick. Wed been married for 50 years, and I took care of her for quite a long time so I thought I was just considerably run down. But when my doctor tested my heart, he said I was going to need surgery--three bypasses and a stent. My son said, Dad, why dont you get a second opinion? He got on the computer and found Dr. Brian Bilchik. I got a second opinion from Dr. Bilchik, who said surgery would not be necessary. What a relief that was! Dr. Bilchik told me, Exercise will do more for you than medication, so I started walking on my treadmill for 30 minutes every day. He followed me closely for several months, but now I only need to see him once a year! I walk on the treadmill around 7:30 every morning. I play the radio or a CD, listening to old songs--Tommy Dorsey, some Latin numbers in there too. I watch my diet and take care of myself, eat plenty of fruits and vegetables, and try to get 7-8 hours of sleep every night. On Saturday evenings, I go to Manchester, New Hampshire and visit two nursing homes. When the Lawrence Welk program comes on television, I dance for the residents, which they really enjoy. My wife and I were ballroom dancers, we danced twice a week for almost 20 years. Once in a while, one of the nursing home residents will come up and say, May I have a dance? That makes them so happy. Im lucky Im able to do that. George Sophos

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LCRF board member promotes womens heart health--and fun

This summer, an unusual party of golfers was spotted at a local golf course. In fact, it was impossible not to spot them-how could fellow golfers, dressed in traditional golng outts, miss the little black dresses and long strings of pearls? Or the red feathered boas, tie-died shirts, polka dot visors, and orange golf balls? To encourage other women Board member Pat Aslanis (center) onto the golf course for a fun and friends organized summer-long and social gamein contrast to themed golf outings. Shown here: Little Black Dress. the competitive atmosphere often found among golfers--a Lown Foundation board member, Pat Aslanis, founded the the Divine Divas. Six of us organized monthly golf parties for each other over the summer. Each month, a dierent person selected a theme and provided everyone with their accessories. Pat launched the series with The Little Black Dress. Everyone received strands of thirtycent pearls and 100-calorie snack packages of coee roll treats. We played golf, had a good time, then went to lunch together, relaxed, and laughed. The next months theme was Red Hot Mamas, with the golfers wearing feathered boas, little feathery things in our hair, and munching on red hot candies. One-upsmanship began to take overnot for golf scores, but for the creativity and elaborateness of game themes. We did the Summer of Love because of the Woodstock anniversary. The woman who organized it gave us little round granny glasses, mood rings, and brownies baked with a special ingredient which she kept secret from us. (Pat is certain the ingredient was legal). We rolled up little cigarettes for hermade of dried oregano. Then there were the polka dots...(We all wore polkadotted clothing. We had polka-dotted visors, a polka dot rule book, and polka-dotted golf balls)...followed by Bling (We put on all our gold and silver jewelry and were presented with jewels to adorn our outts and martini glasses lled with gold and silver Hersheys kisses). The nal outing, Tee Time, hit the top, according to Pat, with watches on a chain, silver tees for our orange golf balls, socks with tees, and after lunch we had tea with special mini-desserts. But it was not over until we were all presented with a beautiful package of tea. To ocially end the season, one of the Divine Divas invited the rest to her home for dinner with instructions to wear something from each event. It The Summer of Love! was a great evening with great friends. We are looking forward to next season, Pat reports. Gender is a common barrier preventing women from engaging in heart-healthy physical activities. I think women often are intimidated about getting out on a golf course, Pat observed. When theyre playing with a group and are not sure of the rules or do not feel they play well enoughthey feel intimidated. I like to go out and have a good time. Many golfers thrive on competition, but to me golf is a wonderful social event. Im outside, its gorgeous on the golf course--its good physical activity and a great way to manage stress. Dr. Barbara Roberts, LCRF Board member; Director of the Womens Cardiac Center at Miriam Hospital in Providence, RI; and ProCors Womens Heart Health Editor, agrees. Pat is on to something important: exercise needs to be fun for people to stick with it, and for women that often means exercising with friends. This provides another benet since social interaction can lower stress. Pat is to be applauded for this wonderful initiative! Pat became a member of the Lown Foundations Board of Directors in 2001. It was shortly after my husband, Gus, died. He was a patient of Dr. Graboys and they had become friends. Tom took me to a restaurant and talked me into joining the board. I had a business background, which he thought would be helpful to the Foundation. Im pleased to support the Foundation in this way because I believe in its mission. The way health care is approached today, it feels like youre on a conveyer belt. Most doctors dont listen to their patients any more, they dont have the time. Sometimes just by listening, you can tell that symptoms are not from a physical ailment but from depression, or something is wrong at home. Im also involved with a wellness community that oers support, classes, other things at no cost for people with cancer. Its similar to the Lown Foundations missionjust because you have cancer doesnt mean you cant live, and just because you have something wrong with your heart doesnt mean you need to stop your life.
Learn more in the Womens Heart Health section of ProCors website: www.procor.org/issues/.

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LOWN CARDIOVASCULAR CENTER

NewsBeat
Dr. Shmuel Ravid presented an abstract on Medical Management of Coronary Artery Disease: 12 year Outcomes Stratied by Exercise Duration at the American Heart Association meeting in November 2009 in Orlando, Florida. The presentation explored exercise endurance during a stress test as a highly signicant predictor of outcomes in CAD patients that may reduce the need for invasive and costly revascularization procedures, as well as improve risk stratication and treatment selection. Dr. Bernard Lown spoke at the 25th Anniversary of the rst IPPNW Concert by the Berlin Philharmonic in Berlin, Germany on September 19, 2009. (Dr. Lown also was the speaker at the rst IPPNW Concert in 1984.) The event was organized by International Physicians for the Prevention of Nuclear War-Germany as part of the launch of the German edition of Dr. Lown's book, Prescription for Survival. The German title, Ein Leben fr das Leben, means A Life for Lives. Dr. Lown gave book readings in Berlin, Nuremberg, and Frankfurt. Dr. Vikas Saini participated in an Expert Group Meeting on "Chronic Disease Management in India: A Health Systems Agenda" in New Delhi, India from October 26-28, 2009. The meeting was organized by the Public Health Foundation of India to share European, American, and Indian perspectives on chronic disease management....Dr. Saini was a featured speaker at the World Hypertension Congress 2009, which took place October 29-November 1, 2009 in Beijing, China. More than 3000 cardiologists participated in the conference, which marked the 25th anniversary of the World Hypertension League and the 20th anniversary of the Chinese Hypertension League. Dr. Sainis presentation focused on ProCors online resources and electronic network. Dr. Fred Mamuya presented Imaging the Woman with Chest Pain and Normal Coronary Arteries at Heart Disease and Women: 2009 Update, which took place at Harvard Medical School on October 6, 2009....Dr. Mamuya also presented A clinicians perspective: What is the clinical role of coronary CT, if any? at the 8th Annual Clinical Cardiac Imaging Conference in Boston on September 11, 2009.

Like everyone else, I get requests from many charities, but supporting
the Lown Center is at the top of my list. Other places practice hard-core medicine, but the physicians at the Lown Center have a special amount of caring and understanding for their patients. Theres a lot of heart there. And theyre training young doctors the Lown waytaking care of the patient, caring for the patient. I feel lucky to have the Lown Center in my life. Thats why I try to help the Center as much as I can. Ira Rosenberg
The Lown Cardiovascular Research Foundation promotes cardiac care that advocates prevention over costly, invasive treatments and restores the relationship between doctor and patient.
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 Carole Anne McLeod C. Bruce Metzler Barbara H. Roberts, MD Ronald Shaich Robert F. Weis Advisory Board Martha Crowninshield Herbert Engelhardt Edward Finkelstein William E. Ford Renee Gelman, MD George Graboys Barbara Greenberg Milton Lown John R. Monsky Jeffrey I. Sussman David L. Weltman CONTACT US

Lown Cardiovascular Research Foundation

21 Longwood Avenue Brookline MA 02446 (617) 732-1318 info@lownfoundation.org www.lownfoundation.org www.procor.org Lown Cardiovascular Center Brian Z. Bilchik, MD Charles M. Blatt, MD Wilfred Mamuya, MD, PhD Shmuel Ravid, MD, MPH Vikas Saini, MD Craig S. Vinch, MD Lown Forum Editor Catherine Coleman Editorial support Claudia Kenney Jessica Gottsegen
c2009 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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Principles for a comprehensive health care system

Bernard Lown, MD
Our health care system is dysfunctional. According to the World Health Organization, the US ranks 37th among 191 countries in health outcomes. This is not merely a statistic. Embedded in the number are despair, grief, tears, and shortened lives. The Swiss, with a far lower gross domestic product, have half our infant mortality and live nearly four years longer. Our poor health outcomes are not due to national stinginess. On the contrary, we spend nearly twice as much as the Swiss and other industrialized countries. Despite investing a kings ransom--an astronomic $2.4 trillion annually--one-third of Americans are inadequately or totally uninsured against illness. This accounts for 45,000 annual preventable deaths. During my lifetime, more Americans died because of such deprivation than from all the wars fought in the 20th century. These sobering facts are a moral wake-up call to change national priorities. We are now in the midst of a bitter health care debate. After 50 years in clinical practice, I am convinced of the need for drastic change. Adhering to the following key principles would shape an equitable, comprehensive and cost-contained universal health care system. Foremost is the need to arm health care as an inalienable human right for everyone, not just for the privileged few. We recognize that a democratic government requires an educated citizenry. A population secure in its health is no less a bastion for a democratic society. Market-driven health care drives an unsustainable cost ination. In our present system, prot takes precedence over patient needs. As physicians prescribe tests and procedures as well as hospitalizations, a fee-for-service arrangement maximizes unnecessary interventions. To curtail the inationary cost spiral, health care providers need to be salaried. Primary care physicians are the appropriate rst waystation for patients. We need to upgrade their numbers and increase their compensation. Gate keepers would diminish the ood tide of costly emergency services and the shuttling of patients to multiple specialists. Funding for comprehensive care should be based on a single payer provided by a progressive national health insurance tax. A Medicare-like system should, over time, cover all age groups. The present sickness care system needs to be replaced with a health care system. This would entail a signicant allocation of resources for community-based public health programs to promote healthy living. Delivery of care should be based on multidisciplinary teams incorporating primary care physicians and specialized services. Increasingly, technical services would be the domain of paraprofessionals. A national center of health excellence should assess the comparative eectiveness of outcomes and sponsor programs to appraise novel technologies and the benets and hazards of various pharmaceuticals. The growing elderly population, accounting for a disproportionate cost of health care, should be provided with an electronic bridge for instantaneous access to their primary provider. Such a homecare program would shortcircuit Internet surng and emergency ward visits. The philosophy of doctoring must shift to a biopsychosocial model, wherein the patient is treated as a human being rather than an amalgam of potentially dysfunctional organs. Lastly, health care providers mustas is the mantra of the Lown Centerlisten to the patient. This facilitates a proper diagnosis with minimal resort to costly tests. Additionally, it promotes mutual respect and forges a relationship of trust. This listening requires far more time spent with patients by physicians better trained in the art of communication.