Medicine often finds itself in a quandary as a profession. Like any profession, it offers an important service. In a sense, patients are customers and consumers. Physicians do compete to some extent with naturopaths, homeopaths, nutritionists, acupuncturists and all who hawk their latest miracle cure or millennia old natural remedy on late night television infomercials. We try to separate ourselves out from these with science, evidence base, and therefore increased credibility. While this credibility is very important to patients, the truth is they just want to feel better. The conflict is this, as a scientists, doctors are trained to be skeptical of all medical claims so they can be rigorously evaluated. Yet, as healers, it is critically important to believe that what you are doing is, in fact, best for the patient, as the patient needs to believe in the treatment for it to have any effect as well. In a very important sense, we have to sell what our recommendation is to the patient.
People don’t have the highest opinion of salesmen, and probably for good reason. In a pure capitalist economy, Caveat Emptor, or “Let the Buyer Beware” will always apply.
The problem comes on those occasions when accepted medical practice is not backed up by grade A evidence, (This will happen quite frequently in real life, part of why it’s called medical practice.) Doctors, because of their scientific training will tend to emphasize the warning that this may not work, precisely the opposite of what the classic snake oil salesman would do. We have it hammered into our heads to ignore the experience of one patient here or one patient there (anecdotal evidence) and instead rely on double blind placebo controlled studies before we can have any kind of confidence that any treatment works. As a result, we often subtly or forcefully communicate the lack of confidence to the patient. Anecdotal evidence is the staple of the snake oil salesman, on the other hand.
We tend to be very concerned that if a particular treatment does not work, the patient will then write off anything we say, again, we depend on credibility. Therefore, we pre-emptively give the caveats ourselves. Furthermore, because of the value we put on informed consent, we run over all the bad things that might happen due to our prescribed treatment. Again, the classic miracle cure seller never follows this approach.
As much as the placebo effect works to heal maladies, it also can create side effects. Placebo controlled studies are riddled with headache, nausea, etc. caused by the placebo as well as actual drug. I wonder how often we shoot ourselves in the foot with warnings of possible side effects. Are we undercutting the power of the placebo effect to work for us rather than against us?
The placebo effect is a powerful force, requiring us to always measure against it to know if any drug or treatment works. While any new drug must be tested by giving the patients medicine that may or may not be the real thing, what you will never, ever see any drug company do is give the real drug to a patient with the impression that it is a placebo. The antiplacebo, or nocebo effect would very likely erase the benefit of the drug in study. If you really want to impress a skeptic, this would be the model to use. By our inherent use of disclaimers and side effect warnings I believe we physicians are often doing this to our own patients. To do otherwise feels as slimy as selling the patient a one-legged chair.
So how do we tap into the power of the mind to aid in the healing of the body without bending the truth and dipping into the slime ourselves? I don’t know the perfect answer and certainly no answer will apply to all patients in all situations. I do believe that it takes more than science to become a good physician. We cannot compromise or skimp on the science and research, but we must realize that medicine is also an art.
In my experience patients respond much better regardless of outcome when they are convinced that we really do care about them and want the best for them. To borrow a phrase from Steven Covey, it turns out that they really don’t care how much we know, until they know how much we care. In medical training, I have not uncommonly heard this kind of thinking derided as too touchy-feely. Whenever it is inserted into medical curriculums, a large portion of the class inevitably feels their time is being wasted. Allow me to disagree. Touchy-feely may be derogative to a scientist, but it is central to being a healer.
The time, effort, and general mindset pounded into the medical student is science, science, science, and consequently skepticism, skepticism, skepticism. I cannot blame my fellow physicians who have come to feel this way. Skepticism has its place, but it can really create distance between ourselves and those we are sworn to help. Our job depends on the human connection we make with our patients.
So here’s to those educators who insist we take classes like literature in medicine classes, or death and dying, or patient communication. To me, this is the single most important part of what an effective physician must learn. In the past many have assumed that this stuff was intuitive and you either had it, or you did not. The truth is we can learn it. Just as some intuitively pick up math or pharmacology, some may intuitively know how to connect with patients, but that does not mean it cannot be learned. Too often, I fear it is our own skeptical souls that stifle our ability to be taught.