A moral dilemma of placebo in american healthcare

I have been caring for patients for nearly a year and a half now in residency and have come across some of the more subtly haunting realizations in American healthcare. Recently I watched a presentation by Lorimer Moseley on pain psychology which highlighted some of the variables in placebo effect. Early in my training I naively believed in the therapies I was providing. Things needed to be more clear cut and I sought evidence based medicine by tracking down randomized controlled trials or meta-analyses relentlessly. The further along I am the more I have realized that a significant portion of the things we do in medicine are either completely useless or of questionable efficacy. Because of this I realized that largely my patients were having benefit because of natural history of their disease process (aka they were going to get better independent of what I did) or due to placebo.

The impacts of these findings is not insignificant. I think it is fair to say the ambiguity of efficacy of therapies in medicine are not only misunderstood by patients but horrendously understated by medical professionals. The perfect illustration of our inability to provide confident care is a statistical measure called number needed to treat or NNT for short to evaluate how many patients we need to treat for one person to have benefit. To tell a patient, “I would have to treat two of you to obtain this therapeutic benefit,” and to make them aware of potential adverse events would likely turn off several patients to those therapies. To make it transparent that most of our therapies are horrendously worse than an NNT of two would likely create total distrust in the healthcare system, especially when we are talking about unfathomably expensive and invasive things like organ transplant or orthopedic surgery. The reality is that even with a solid diagnosis and a good treatment, the chances of patients having quantifiable benefit is still very low. Add in diagnostic ambiguity and it makes evidence based treatment a total crapshoot.

The reason I bring this up is because I am battling an ethical quandary. Placebo is effective in many cases but very dependent on a whole host of variables. I know that the more I sell my placebo, the more I tell a patient that a therapy is likely effective, the more “doctorly” I am dressed, the neater my hair, likely the better placebo effect I may have for my patient. My patient would by all accounts benefit from those things. The ethical dilemma comes in when I am facing the infinite complexities beyond the quantified therapeutic benefit. For example, is it okay to tell a patient that I believe a therapy will work for them when I am unsure? When placebo works for approximately one out of three patients for many given conditions, is it okay to tout a mild therapy as likely beneficial to increase the chances of benefit even if it may be minimal?

Additionally, what is my obligation to help my patients with my appearance? If you google image search “physician” you’re bound to get countless stock images of doctors of all races, genders, sizes likely wearing a stethoscope and a long white coat. Interestingly there is an appearance of a physician that elicits the greatest placebo response. For example, a female physician was able to provide greater placebo effect than two males colleagues in a trial of 120 people being treated for IBS. The reason this matters is because this appearance actually impacts quality of care delivered. As a younger, frequently clean shaven and youthful appearing physician my judgement is frequently questioned and likely my therapeutic benefit for patients suffers as a consequence. And now I know that, as a male provider, referring to a female colleague for treatment of my patients with IBS would likely promote better outcomes for my patients.

I have dealt with many horribly inappropriate comments on my appearance in the clinical setting by patients and other healthcare professionals. I had a nurse ask me if I had gotten my driver’s license yet, countless obstetric patients decline my care because of my apparent gender, a physician’s assistant tell me I needed to iron my shirt because I looked unprofessional, dozens of patient’s commenting on my age, and a frequent distrust of my credibility as a generalist practitioner. These verbal patients and colleagues are the easy ones to deal with because they state their opinions and I am able to address them. The subtler, less vocal biases are likely the ones that compromise my therapeutic impact. Am I obligated to iron my shirts and wear a white coat to appear more as the classical image of a physician? Should I keep my beard year round to appear older to appeal to the ageism in my older patient panel? How in 2020 are we advocating so hard for dissipation of discrimination based on gender identity and yet so many patients declined my care because I identify as a male? Am I obligated to shape my appearance and refer to differing appearance providers to better help my patients?

To add complexity, our medical system is based on fee for service similar to a car mechanic. In mechanic work the model is that the diagnostician is the same as the interventionist and we know this model creates tension and likely frequently unnecessary interventions and cost to the customer. In medicine I could derive direct financial benefit from a certain treatment and likely I would receive variable compensation for various therapies independent of their indication or efficacy.

These questions are not new but I think not as discussed as they ought to be. Placebo effect is infinitely complex and I certainly will wrestle with it for the entirety of my career. More related to the financial incentives of treatment, currently the American healthcare system by nature absolutely prevents me from feeling like I can practice ethical care for my patients. So long as there is a financial incentive for any healthcare providers to deliver care, with well documented greater financial incentives for less evidence based, more invasive care, we will not be able to rest knowing that the career of a physician is a fundamentally altruistic one.

Bikepacking Pisgah

I looked and saw the chance of rain was 0% for the next two days. Today, large raindrops clacked on my windshield and a dense fog surrounded my car. We couldn’t climb because of the weather today but I needed to seize the opportunity for an adventure tomorrow. In my car I have all the tools for an epic adventure: a full trad rack, a sleeping bag and sleeping pad, a hammock and a tarp, and a mountain bike on top. The mountains are open, I just needed to decide what tool I wanted to use to explore them. Continue reading Bikepacking Pisgah

Longs Peak Winter Cables Route Summit

During the summer five years ago, for a last hurrah before starting med school, I opted for a cross-country road trip. From Richmond, Virginia I beelined across the country to Rocky Mountain National Park as my first stop. When I caught my first glimpse of the beautiful craggy summit of Longs Peak, I knew I wanted to hit up the class 3 scramble route to get to the summit. After years of living on the East Coast with mountains no bigger than the foothills at the base of the Rockies, I was hooked at first sight. A few days of acclimatizing got me to the Boulderfield, the campsite at 12,700 feet elevation at the start of the scramble part of the Keyhole Route to the summit of Longs. While eating dinner and chatting with another camper, we saw two guys rappel down another route on an imposing face and come strolling through the campsite. I asked them how they got into that and got the scoop. Step one: join the local gym. Beyond that everything else would fall in place. It seemed like an arduous process for someone who was used to being rapidly self-taught. But as I’ve learned, mountaineering is no joke and definitely takes time to get down. Continue reading Longs Peak Winter Cables Route Summit

Winter 14ers for Beginner Mountaineers: Top 10

With the fall and winter months approaching quickly, Colorado mountaineers are whipping out the crampons and double boots in lieu of the trad rack and trail runners. But if you’re new to the big mountains, the cold and snow can be quite intimidating for good reason. If you’re looking to bag some winter 14ers but don’t want to risk your life to do so, this list list can help steer you to some solid safer climbs. Whether you’re looking for a more intense climb than the summer hikes or love the solitude of the off-season, winter 14ers can be an amazing experience.

However, before even considering attempting any of these winter 14ers, I would recommend that you have experience with climbing 14ers or at least 13ers in the warmer months, or at minimum go with someone who is familiar with the mountain and the cold. For nearly all of these climbs, I recommend having at minimum microspikes and trekking poles. It was a very rare day that these aren’t essential pieces of gear. In addition to that, most of the climbs call for snowshoes, especially after a storm or on the less travelled routes, and many of them necessitate an ice axe and the experience with using one. 10 point crampons are rarely if ever necessary on most of these routes.

This is not meant to be an all inclusive guide to each climb, just merely an introduction to help you decide which climbs to do. Always check weather and route conditions beforehand. I’ve linked to some helpful resources at the bottom.

The short and sweet winter 14ers:

1. Quandary Peak (East ridge)

Quandary peak winter
The route up Quandary follows that ridge and kicks up there in the last third.

Continue reading Winter 14ers for Beginner Mountaineers: Top 10

Bikepacking the Blue Ridge Wrangler

Bikepacking:

verb

  1. a portmanteau of biking and backpacking

  2. combing traits of long distance bicycle touring with the minimalist priorities of backpacking, usually favoring trails and gravel over paved roads

  3. Potential for laughably massive amounts of suffering and hilarity

Day 1, Blue Ridge Wrangler

We set out at 8pm with a sensible goal of getting a few miles into the Blue Ridge Wrangler, a 185 mile bikepacking loop, just to get away from the road for a night of camping. Neither I nor my friend Scott had ever bikepacked before and we were about to ride away from the comfort of our cars. Onto unknown trails. Thirty minutes before sunset. On gravel bikes.

Bikepacking Blue Ridge Wrangler
My trusty steed

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Rock climbing Buzzard Rocks near accident

This past weekend I went climbing with a few friends at Elizabeth Furnace up in Northern Virginia. On Saturday we hit up a small roadside crag called Talking Headwall where we cranked over some pretty fun well protected roofs. We wore ourselves out and then the next day went to go climb Buzzard Rocks on some classic slab routes, a nice two mile hike up the mountain from Talking Headwall. It was a great weekend with some super fun climbing ranging from crimpy face climbs to juggy overhangs to featureless slab but you may deduce from me writing about it that in classic Grayson adventure fashion, things didn’t quite go as well as intended. Continue reading Rock climbing Buzzard Rocks near accident

Balancing adulting vs adventuring

Nearly constantly people are trying to talk me out of doing the things I love. My mom cringes when she hears plans for the next adventure. My aunts and family friends comment on facebook pictures demanding that I come home right this instant. Park rangers warn me of the dangers up above, ski patrol reminds me they won’t rescue me, hikers exclaim how dangerous rock climbing is and how many people die doing it. They’re not wrong to have those thoughts and I’ll admit that to reconcile those sentiments and my own fears with my cravings and love for adventures in the backcountry is a constant struggle. It’s the mountaineers dilemma to balance life at home and family with our own very selfish need to explore. Continue reading Balancing adulting vs adventuring

Climbing Looking Glass Rock

We were dilly dallying, procrastinating on packing, wanting to be there but not wanting to do the 6.5 hour drive to actually get there. So we farted around, took dogs for a walk, got some dinner, took dogs for another walk, and finally around 6pm we were ready to go. We were headed to Looking Glass Rock in southwest North Carolina, closer to Birmingham, Alabama than to Richmond, Virginia. We had deliberated for a while on where to climb. We knew we wanted something the trees, something south facing, some place warm-ish for late December, and ideally some place for trad climbing. Stone Mountain in NC had been our original goal but highs in the low 30s thwarted our desire compared to highs in the low 40s at Looking Glass Rock. So we committed to a longer drive for warmer temperatures and cruised southwest. Continue reading Climbing Looking Glass Rock

11 of the best climbing videos ever

1. James Pearson on “The Walk of Life”

James Pearson making the first ascent of The Walk of Life with runout poorly protected featureless slab with a HUGE whipper. Doesn’t get any better than this. “You start off and you climb almost 10 meters with no gear and then you get a really, very bad nut which is, maybe you’d hang your coat of it.”

Continue reading 11 of the best climbing videos ever

Why your hands swell while hiking: the real reason

The myths of why hands swell while hiking

You’re five miles into a hike with a group of friends. You’ve never been hiking before and it sounded adventurous and fun and a great way to to get out and have fun with friends, enjoy being outside, and relax for a bit. And you’re having a great time with the exception of a weird feeling in your hands. Your wedding ring and watch are getting tight and your skin feels taut. Your arms feel bloated and you look down and sure enough you’ve got big old sausage fingers. Are you dying? Do you need to turn around and race to the hospital? Maybe you have cell service and after you post a quick pic to insta you do a quick WebMD search. It says you have heart failure or this weird thing called thrombosis. Now you’re worried and want to go back so you can do more internet searching before you head to the ER. When you get home you dig deeper in your internet searching and get more specific. Instead of just searching hand swelling, you search had hands swell while hiking and find an Outside Magazine article, where you may learn that you’re suffering from hyponatremia. You find a facebook thread of loads of confident expert internet commenters recommending the cure-all tip of hydration or electrolytes.

But nearly all this information you’ll find is absolutely, jarringly, painfully wrong, so I hope this article becomes the one to top out on the google searches so maybe some people will learn the real answer, and learn a real solution. You don’t have heart failure, you’re not alone, and you don’t need to hydrate. Continue reading Why your hands swell while hiking: the real reason

Adventures of a medical student