RUTHFULLY YOURS

In writing about Dr. Braunwald, Thomas Lee, a professor of medicine at Harvard, attempts to capture both the life of this remarkable man, now 84, and the explosive scientific progress that fundamentally altered medicine in the second half of the 20th century. “Evidence from research began to matter to doctors and to patients. . . ,” Dr. Lee writes. “In 1950, heart attacks were ‘bolts from the blue’—unpredictable, unpreventable, and untreatable—but in the decades that followed, mortality from myocardial infarction fell from 30-40 percent to 5-8 percent. Throughout cardiology and the rest of medicine, unbeatable diseases became treatable, and some even became curable. Progress helped to drive fatalism out of medicine.”

Dr. Braunwald’s life is emblematic of this change: “Over six decades, he was repeatedly in the right place at the right time with the right people. He became interested in and worked on cardiovascular hemodynamics when he was a medical student in 1951, just as modern cardiac catheterization was being developed. He went to the National Heart Institute in 1955, when it was small enough for someone in his mid-twenties to be a creative force,” Dr. Lee observes.

He grew into a skilled manager, helping to build a new department of medicine at the University of California, San Diego, and rebuilding an old one at the Peter Bent Brigham Hospital in Boston. He became a leader in medicine’s cultural shift toward relying less on experience and more on rigorous science. “After starting his career in intimate laboratories with just a few colleagues, he saw that many big questions in medicine could be addressed only through big studies—often randomized trials involving tens of thousands of patients in multiple countries.”

Born in 1929, Dr. Braunwald grew up in Vienna and can remember the crowds when he was 8 cheering the arrival of Adolf Hitler. One night he watched his father, a prominent businessman, being forced onto a truck with other Jewish men. His family, fortunately, was able to save him by persuading the SS that he was indispensable for the process of liquidating his company. The family fled Vienna soon thereafter, leaving all their possessions behind—the children were told they were going on a picnic—and eventually making their way to Brooklyn.

While in medical school at NYU, Dr. Braunwald, like many physicians-to-be of that era, was influenced by Sinclair Lewis’s Pulitzer Prize-winning novel, “Arrowsmith” (1925), which “described the rigors of medical training and the discipline of scientific research, and . . . romanticized the selflessness of the people who pursued this work.” After NYU, Dr. Braunwald worked for a period at the National Institutes of Health, where his seminal work in cardiology took shape. “I realized that when you are young, bright, motivated, willing to work upwards of a hundred hours a week, and you get the right conditions, you can grow simultaneously as a researcher and clinician,” he would comment later about that fruitful time. “You can multitask. It’s one plus one equals three—or at least 2.5.”

He completed his residency at Johns Hopkins and then returned to the NIH in 1958, during what is referred to as the NIH’s “Golden Years.” The NIH was responsible for creating a new breed of doctors across the country: the physician-researcher. In Dr. Braunwald’s words: “There was a brand-new culture. Scientific and even social networks of these physician-researchers developed that had not existed before, and those networks soon became the most important relationships in their professional lives.” Among his many contributions while at the NIH was his work identifying a condition called hypertrophic cardiomyopathy, in which thickened sections of the heart’s own tissue can restrict blood flow and which we now realize is far from rare.

After a decade at the NIH, Dr. Braunwald was restless, ready for another challenge. He moved to the new medical school in San Diego, to chair the Department of Internal Medicine. It was a big move. “The clinical enterprise was as chaotic as any other startup business,” Dr. Lee writes, “but the research environment was as vibrant as Braunwald had promised those recruits it would be.” Although the move was largely good for him, it was harder for his wife, Nina, a thoracic surgeon. “The chairman of surgery viewed Eugene Braunwald as his rival for power, and was far from welcoming to the first woman cardiac surgeon in his department. The environment for her was hostile from the start, and Nina became progressively more unhappy. Eugene felt guilty that he had dragged his wife away from the NIH, where her career had been on a brilliant trajectory, to UCSD, where she had become a pawn in a medical political battle.”

His next move was to Boston, where Dr. Braunwald transformed the Peter Bent Brigham Hospital in Boston into the premier internal-medicine department in the country. He replaced a lot of the old guard, made radical changes and pushed forth a vision of excellence at every level. In 1978, Dr. Lee notes, when most chief residents were white and male, the Brigham’s Chinese-born chief resident, Victor Dzau, told an Asian-American applicant “that there were no perfect meritocracies, but the Brigham came close—and that Braunwald set the tone. ‘You don’t get ahead here by playing golf with the chairman, because the chairman doesn’t play golf,’ Dzau said. ‘Dr. Braunwald doesn’t care what color you are—he wouldn’t care if you were purple. What he cares about is whether you’re smart and work hard. If you are, and if you have any kind of luck at all, things tend to work out well here.’ ”

All the while, Dr. Braunwald continued his work on interventions for treatment of heart attacks, focusing particularly on the new “clot-busting” drugs. There was a desperate need for rigorous clinical experimentation to define their appropriate use. Dr. Braunwald led the Thrombolysis in Myocardial Infarction trial, which became known as TIMI. In a series of landmark tests beginning in 1984, Dr. Braunwald established the superiority of one clot buster over another and the effectiveness of a number of other medications after a heart attack. He proved a master at coordinating these multicenter studies, enrolling thousands of patients and negotiating contracts with industry that were win-win, such that there was money not only to prove the worth of one drug or another but also to test blood for biomarkers that were of more academic and experimental interest.

Keeping the many participating hospitals and the central TIMI research group intact, Dr. Braunwald followed up with several more studies. “TIMI became an actual research ‘brand’: when a study had the TIMI name in it, journal editors and readers knew that this paper was going to be rigorously done by well-respected researchers . . . ,” Dr. Lee writes. “With Braunwald as chairman, TIMI became an academic and business success. It placed Braunwald in the middle of a network of many outstanding cardiovascular researchers. Hundreds of young cardiology researchers around the world realized that if they worked on TIMI trials, they would have funding and the chance to be an author or coauthor on research papers, some of which would document important advances.”

Dr. Lee’s book is thoroughly researched and well-written. If it has faults, they may well reflect the reticence of his subject. Dr. Braunwald’s wife, Nina, came of age in medicine with Dr. Braunwald and chose a difficult path as a surgeon. As a reader I was curious to learn more about her—what it was like to be the trailblazer she must have been and be married to another trailblazer. Her struggle with and death from metastatic breast cancer in 1992 is mentioned in a sentence or two. One is left feeling that Dr. Braunwald, who seems to have been most cooperative with his biographer, shut the door on the more personal aspects of his life. Still, what is there is most satisfying.

Dr. Braunwald, looking back on his career, says that it was “not very hard to write papers that get published in good journals, but it’s immensely difficult to develop treatments that will help people and change medical practice. To think that somewhere, thousands of miles away, somebody whom I’ve never met and never will meet is living longer and better because he is receiving an ACE inhibitor following a myocardial infarction—now that’s gratifying.”

—Dr. Verghese is Professor for the Theory and Practice of Medicine
at Stanford University and the author of “Cutting for Stone.”

Eugene Braunwald and the Rise of Modern Medicine by Thomas H. Lee (Aug 5, 2013)