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.