White Coat Underground

In medicine, theater can go a long way. The seemingly simple acts of laying hands on a patient, leaning in to listen to them, and giving them instructions to follow can be therapeutic. Sometimes this is labelled as part of the so-called placebo effect, but whatever we call it, physicians (and priests) have been doing it for thousands of years. But how far should we push it? As medicine becomes more science-based, relying on actual evidence to guide practice, where does theater fit in?

One argument is that since this difficult-to-quantify intervention can clearly do something, we should use it like any other intervention. But where is the ethical line to be drawn? If a patient of mine is frightened and I lay a particularly firm hand on their shoulder as I listen to their lungs, this may provide them comfort. But what if I hand them a bottle of bitter herb extracts with no proven pharmacologic benefit but tell them it will help? If I play it right, the patient may indeed feel a bit better in some respects, but what of the deception? And what happens when I start to believe in my own magic? What might that lead me to do?

I know of many doctors who advise the use of placebos, sometimes knowing that they are chemically inert, sometimes not. Patients love—love—to be given a bottle of bitter liquid when they have a cold or other self-limited illness because it works—they always get better. And it’s pretty easy as a doctor to convince someone it was my action, rather than the natural course of the illness, that caused them to feel better.

I find this whole approach seductive and dangerous. I regularly tell my patients with colds to drink hot tea with honey, hot soup, and to treat their symptoms with any other soothing technique that works for them. It may seem to be fulfilling part of my ethical obligation of beneficence to hand them a bottle of bitters and tell them that it will help with their cold, but it’s a lie, and if I start to believe my own lies, where does it end? Where will my belief in my own magic take me?

Real medicine based on science and compassion is hard, but we have certain rules and ethical principles in place to protect our patients, and to protect us from ourselves. We are not gods and we shouldn’t behave like gods, even when to do so might make someone feel better. The risk is too great.

Comments

#1 melospiza
November 11, 2009

There’s an big difference between lying and giving sympathetic attention. Touching, listening, and instructing are work for you, and they may feel like acting, but they are part of the job.

When my doctor pays attention to me, I feel I am important, and that she is on my side. I have faith in her, and I’m much more likely be compliant and follow instructions. That’s not placebo effect.
#2 DrA
November 11, 2009

Does this help explain chiropractic care?
#3 Dave the Hospitalist
November 11, 2009

I do not think that having, or at least attempting to have a good bed side manner is the same as pushing snake oil. I am 6’6″, I make a point of sitting next to the beside, when I can, so I do not loom over my patients. This is not the same as being a homeopath or prescribing Obecalp sig 1 tab q8h prn #30 Refill 3.
#4 TGAP Dad
November 11, 2009

First: What’s with “The Great and Powerful…”??? That’s my schtick (hence the pseudonym). Find your own!

Second: My last doctor was a bit of a toad – unpleasant to deal with; no compunction about meting out pain in the process of an exam. I put up with it because I thought he was skilled enough that I could overlook his inner Conan. (This turned out not to be the case, but that’s another story…)

I think there is value in listening to your patients, and treating them with the respect that is due anyone for whom you are the hired hand. When the doctor seems genuinely interested, listens, etc., it changes the dynamic of the relationship, makes the patient more relaxed and open with you.

Richard Dawkins touches on this in his BBC miniseries The Enemies of Reason when he consults a homeopath. This “doctor” listened intently, seemed genuinely concerned, and consulted with the patient for an hour. This makes the patient feel good, which has a great deal of appeal for a patient with no reliable means of assessing a medical treatment or a provider’s competence.

Let me draw an analogy. I am a computer geek. Suppose you had a problem with your computer and you brought it to me for repair. Without making eye contact, I give it a once-over, half-heartedly listening to you, slap a CD-ROM in the drive – hard – roughly tap a few keys and seconds later announce that you will have to take your computer to the hard drive specialist for defrag and directory rebuild. Your appointment is for three months hence. You get the work done and bring it back to me, still not working right. I scratch my head reviewing the diagnostic report, then carelessly pry open the case and announce that you’ll have to take it to the circuit board specialist for a thorough cleaning and electrical check – your appointment is in six weeks. And so on ad infinitum.

How high is your respect for this computer geek? Do you think he’s competent or not? Would you rather have one who listens intently, and discusses your computer with you for an hour? Suppose this is the only geek in town who will honor your extended warranty. Suppose you have to call for preapproval, and fill out a ream of paperwork every time you take it to a specialist. Are you happy about this?

The difference is that you can scrap your computer, whereas we are all stuck with our bodies, warts and all.

Now, I have no idea what you’re like as a doctor, you seem a decent guy, and so I’m assuming you’re good at what you do and treat your patients well. But your patients have probably seen other doctors before you, and carry the baggage of those encounters – for better or worse. The point is this: once they’re in the exam room, they’ve already had to run a gauntlet of some sort, whether it’s insurance company, scheduling, a long wait time, a s***load of paperwork, payment difficulties (my doctor collects the copay in advance) etc. At this point, a little extra attention can go a long way toward building your patient’s trust and confidence.
#5 Katharine
November 11, 2009

What about pointing them toward good OTC remedies such as a strong decongestant to treat their symptoms until it passes?
#6 becca
November 11, 2009

What if believing in your own magic makes it work better?
Pal, you have an ethical obligation to embrace homeopathy!
#7 Dacks
November 11, 2009

Ha! Seeing the title, my first thought was that this post was about the good doctor Mehmet Oz.;) I wondered what new craziness he was up to!
#8 Tim Kreider
November 11, 2009

Well said. I agree that this is part of the professional code of being a modern physician. By all means, use empathy and communication and a bit of theater. But I think the contract with our patients is that we will not deceive or knowingly treat with nonsense. Yes, that means that mommy’s home remedy, a priest’s blessing, or a shaman’s potion might seem more effective for a self-limiting illness than what the physician offers, but I think that’s a reasonable trade-off for the responsibility of using our specific therapies that are powerful and dangerous.
#9 gaiainc
November 11, 2009

Given that it is cold and flu season, I encourage all my patients to do what is soothing to them. I give them suggestions with the caveat that it may not work, that they may hate the suggestion, but it is unlikely to hurt them. I’ll give them pseudoephedrine if they want (in Oregon, it needs a doctor’s RX). I completely sympathesize with them that their symptoms suck and if my magic wand wasn’t in the repair shop, I’d wave it over them, and make them 100% better right then and there. For kids >1 year for cough, I suggest honey because I don’t have anything better, it may work, it may not (and I tell parents this), but the intervention is unlikely to hurt them (which I also say). Most of time, I get thanks. I also get lots of grumbles, but I can deal with the grumbles.
#10 JustaTech
November 11, 2009

Hey Gaiainc: What is up with that “no decongestants” thing? At least in WA all you have to do is fill out your life story, (provided the pharmacy is open) and you can get some decongestants that actually work. That “PE” stuff they still sell OTC is so worthless it might as well be homeopathic.

It is so frustrating to have a cold and not be allowed to get the drugs that will relieve my symptoms long enough for me to sleep, it just makes me want to punch a meth-head. Which is hardly a productive reaction, I know, but snot makes me grumpy.
#11 daedalus2u
November 11, 2009

Just remember the immortal words of Benjamin Parker

“With great power comes great responsibility”

(Peter Parker’s Uncle Ben to those who didn’t know)
#12 Beth
November 11, 2009

(First, my apologies for length)

I know all too well that doctors may fall prey to this, falling in the trap of setting themselves up as gods. I learned it by misuse of touch, by religion, and by misusing prescriptions. (The pills weren’t inert but I was told the prescription was for something different than what was written on the chart that I wasn’t shown.) I know, too, that once a professional falls in this trap, they can become vengeful gods, blaming a patient for not getting better. Perhaps this is what makes some doctors quacks, I’m not sure.

I’ve learned that, like it or not, it’s my responsibility as a patient to make sure my doctors are not in god-mode around me. (It was in my late teens when most of these things happened, so I didn’t know at first, no one had told me.) I’ve learned to assert myself if something doesn’t feel right. I ask questions if I’m not sure about something, and if I have reason to believe the doctor has gotten something wrong, I’ll bring that up. (There can be misunderstandings and a doctor can be mistaken — and so can I.) Some doctors like me for these things, others think I’m a difficult patient. I don’t mean to be difficult but only to understand and to make sure the doctor understands what I’ve said. I know I have authority over my body and I know that, to maintain that, I need to understand what’s going to (or being done to) my body and why.

There was a point in the past when I hardly asked questions or raised objections (only when I was prescribed a drug combo that contained one that gave me terrible side-effects). During that, there were doctors who played they were gods over me. That messed me up medical, hurt psychologically (who can I trust if not doctors?), and their works may well be on my medical records forever. Now I hold my hand much closer. I ask about nearly everything and I am not slow to challenge, to ask hard questions if something seems amiss. But I also thank doctors for explaining things to me and for helping resolve a disagreement or misunderstanding and thank them even more if they admit they’re not sure of some point and will check about it. I know doctors have specialized knowledge that I don’t. I also know I need to know what’s going on with my body, my medicines, my health… and I know I decide whether or not to use a treatment, that that’s my job… so the doctor and I must come to some understanding. I do my best to assure I understand what’s going on and that I am truthfully informed so that I can properly make a decision. I wish it wasn’t so hard.

I wish doctors didn’t fall into the trap of godhood, of lying to their patients to make them better, but physicians are people first: it happens and it probably will always happen some. And so I do my best to play my part by acting in a way incompatible with being under a doctor-god. It’s a pity, yes, but we’re all people. I don’t think this will go away, though I do wonder if there’s a way the problem might be reduced.
#13 catgirl
November 12, 2009

I don’t think that doctors should prescribe placebos just because they think the patient wants or expects that. Instead, you can try giving them brochures or even print-outs with advice to treat the symptoms. This is helpful in two ways. First, it provides “closure” or an end to the session, and it can be comforting to just have something. Second, it’s better to give the advice on paper after talking about it, because people simply won’t remember everything that they hear, especially if they’re feeling sick when they hear it. I’ve had several doctors do this, and can be really helpful.
#14 gaiainc
November 12, 2009

Justatech, you’ll have to ask the Oregon legislature about the whole pseudoephedrine needs a doctor RX thing. Personally, I think it’s stupid, it’s a pain in the butt, it increases work and health care costs, and did I mention that I think it’s stupid.

The theory is that this will decrease the meth production and use in the state. The reality seems to be that most meth producers were getting their pseudoephedrine from local convenience stores in amounts that should have made anyone raise an eyebrow (you don’t need 10 boxes of the the 12 hour formulation for a cold). Instead, any time a patient of mine wants some pseudopephedrine, I either have to write a prescription or have someone in my clinic all it in. I can’t send the prescription electronically. As for meth use, yeah… making me write a prescription is really going to keep my patients from using meth.

I think I said “I don’t know” to my patients about a dozen times yesterday. I know I told one patient that I was unlikely to figure out precisely why he has the symptoms he has and that unlikely anyone was going to and that’s OK. We know he doesn’t have the really bad stuff. I’m doing better with his symptom relief which he appreciates. Not all doctors play god.
#15 KristinMH
November 12, 2009

gaiainc, that sounds like a remarkably stupid law. It seems designed to spread infectious disease, by making sick people go to their doctors and sneeze all over other sick people. Way to go, Oregon!

Here in Ontario you can’t buy pseudo ephedrine by itself anymore – it’s always in a formula with acetaminophen or something, which is kind of a pain if you don’t want to overdo the Tylenol, but at least it’s available OTC and you don’t have to fill out any forms. At least if you only buy more than one package at a time.
#16 Dave
November 12, 2009

Is it just me, or do others see a day when the whole psycho-neuro-immunological landscape is more elucidated? That has to rank right up there with patient-specific genetic therapies for revolutionizing medical science.
#17 becca
November 12, 2009

What happens if we test a drug administered with and without significant medical theater, and can show that there’s a significant effect for the theater?
Further, let’s say we can figure out not only the brain region that is activated differently, but also identify the endocrine molecular mechanisms by which the brain signals to the immune cells which are key for responding to the infection.
At what point would the mind/body dualism break down sufficiently to consider theater valid medicine?
#18 k8
November 12, 2009

This made me laugh and think of my last appointment. I have what amounts to chronic sinus infections and I’ve been instructed by my MD that I am to come in or at least call in for antibiotics if I’ve been sick for more than a week. And when he confims my newest case of what I call the Monkey Plague, he says, “Well, I can give you some cough syrup with codeine for the…whoops! Nope. You’re allergic to codeine. Guess you’ll just have to suffer.” And then we both laugh. I think it’s the acknowledgement that I’m going to have to wait that part out that makes me feel good when I leave there.

As far as the theater part? This same MD is the one that rounded every single day I was in the hospital with meningitis. He didn’t have to say a thing for that to be comforting to me. His mere presence made me feel just that much more safe. And the tiny bit of drama that ensued when I was crying one morning because I detested the nurse that was assigned to me that day? He got her reassigned. That’s like gold to a person completely dependent on their daily staff to care for them.
#19 Dave
November 12, 2009

Becca, love your thinking on this! If we can discern the correct endocrine pathways and neural mechanisms, it seems that we could directly stimulate/suppress them and skip the theater completely, thus keeping the patient/doctor relationship honest. That’s a big ‘if’ there, but I think we’ll get there, and as a bonus drive a large chunk of the woo industry out of business.
#20 daedalus2u
November 12, 2009

becca and Dave, many of those pathways are known, they are triggered through nitric oxide.

And yes, by increasing nitric oxide you could drive a large chunk of the woo industry out of business because placebos won’t do anything once the pathways are triggered pharmacologically by increased nitric oxide.
#21 PalMD
November 12, 2009

In fact many of them are known and react rather positively to heroin.
#22 becca
November 12, 2009

Oh come now, do be serious. You don’t really think your theater is as good as heroin, do you? Morphine, maybe.
#23 PalMD
November 12, 2009

Exactly my point. Placebo, such as it is, is several orders of magnitude smaller than real meds.
#24 daedalus2u
November 13, 2009

Placebo by theater; yes. Placebo by more nitric oxide; not so much.
#25 Dave
November 13, 2009

Clearly I’ve spent too much time doing the brain-in-a-vat philosophical thought experiments.

But if you can prime the immune system so that it works in concert with meds to the greatest effect, can that priming be brought out by manipulating conscious mental states (as opposed to whacking them with heroin)? Can it be done in a way that is not deceptive or nonsensical? Can that be incorporated into medical practice, or does it just boil down to the particualr doctors character or bedside manner? Or is it a matter of patient education or lack thereof, which makes them either more or less susceptible to the theatrics of doctors or salesmen?

It still seems to me that there are more potential tools in the psycho-neuro side that western medicine has not explored fully, but I could be wrong. It makes me wonder if, instead of a jolt of heroin, if you could potentiate macrophages for example by using a cognitive/psych approach instead.

Daedalus, it seems if you could trigger a more narrowly focused aspect of NO signaling it could be used, but that would require triggering the specific pathways for immunologic function as opposed to the multitude of other things that NO affects. Is this possible? If they can come up with a drug that makes your dick hard, shouldn’t pharmy cos be able to create a NO product that only affects the neuro-immunological pathway? I would on principle favor such a pharmaceutical approach over some smoke and mirrors manipulation of the patient through ‘theater’.

I admit, it’s my day off and I’ve had two baileys and coffee already, and prone to fanciful ideas.
#26 Dave
November 13, 2009

“The physician must invent and devise some spiritual pageant to fortify and help the imaginative faculty, which is corrupted and depraved; yea, he must endeavor to deceive and imprint another conceit, whether it be wise or foolish, in the patient’s braine, thereby to put out all former phantasies.”

from Approved Definitions of Health, 1612. Thought it was interesting and germane.
#27 becca
November 13, 2009

But Pal, I’m sure *some* theater is heroin quality. Hugh Laurie’s, perhaps. Just not YOURS.

Actually, your point depends on the drug. Placebos are orders of magnitude poorer than penicillin for syphilis, I’ll grant. However, they are definitely on the same order of magnitude as prozac for depression.

If you insist on a rigid mind-body duality, then all psychologists do with cognitive behavioral therapy is medical theater style placebo.

“If they can come up with a drug that makes your dick hard, shouldn’t pharmy cos be able to create a NO product that only affects the neuro-immunological pathway?”
Dave, this reveals a woeful ignorance of the history of viagra, which started as a drug for cardiac conditions.
Sadly, drugs that are 100% organ system specific are mostly in the realm of the fanciful as well, at least currently. If we do some hard core revamping of the drug discovery process and *start* by identifying a target based on it’s cell specificity, maybe that’ll change.
Also, I’m not even sure if we know for which diseases potentiating macrophages is a wise therapeutic strategy. It sounds good- until you remember that (assuming a pathogen is self-limiting) most of the problem is actually caused by the immune response. You make the cytokine production stronger, you increase the symptoms and may not even clear the bug all that much faster.
#28 gaiainc
November 13, 2009

KristinMH, you are preaching to the choir. I no longer make my patients come to see if they want pseudoephedrine for a cold. If I’ve given it to them before and I’m sure they aren’t a meth manufacturer, they can have a script. The caveat is that if they are not getting better, they better get their butts into my clinic.

Anytime anyone wants to fully elucidate how the brain affects pain perception and how I can harnass that to help my patients, go for it.
#29 daedalus2u
November 14, 2009

Dave, the reason that drugs have side effects and don’t have the kind of specificity that we would like them to have is for basically two reasons. First there is lots of “cross-talk”, that is most physiological pathways are used multiple times in multiple tissue compartments to do multiple different things, as in the Viagra example, to make your dick hard (actually all erectile tissue which women have too, that is why nipples get hard), and second because there is “feedback control”.

Virtually all physiological pathways have automatic gain control. That is important so that the setpoints can be modified easily as you age, as you need to do different things, as your physiology responds to myriad different things.

That automatic gain happens inside a feedback loop. For example one way that blood pressure is regulated is by the velocity of blood flow across the endothelium causes shear, that shear activates nitric oxide synthase, nitric oxide synthase makes NO, than NO activates guanylyl cyclase in the smooth muscle, guanylyl cyclase makes cGMP and the cGMP causes the smooth muscle to relax, expanding the blood vessel, increasing the cross section for flow, so the blood velocity goes down, the shear goes down and nitric oxide synthase makes less NO. If you add more NO, you can make the vessel expand so much that blood pressure drops to zero and the patient dies. That is what happens in sepsis, NO is made from iNOS under open loop control because gigantic amounts are needed for immune system function. You can always control blood pressure with NO, what is used is a NO donor, sodium nitroprusside. It will always cause smooth muscle to relax. You can never develop “resistance” or “tolerance” to NO causing relaxation of your blood vessels because that is the primary control mechanism.

There is feedback control, and if blood pressure is dropped with SNP, then the shear on the vessel is less, and less NO (or even none) is generated by the endothelium. If you do that for a long time, then the endothelium “thinks” it doesn’t need so much nitric oxide synthase (because it doesn’t), so the control system that regulates nitric oxide synthase levels stops making it, and then when you try and take the person off the SNP, their normal control system is screwed up and you have to “wean” them off it, allow time for the normal control system to reestablish itself and take over.

The exact same thing happens with all the control systems that are regulating the immune system. Many of them have a NO component precisely so that they can be regulated as part of a NO loop. Low NO increases the sensitivity of mast cells, so that it takes less of a stimulus to trigger them. Mast cells release cytokines and proteases which activate other things and trigger inflammation, which lowers NO levels. Anything that lowers NO levels will make mast cells more sensitive and easy to trigger. If they get sensitive enough, they will trigger spontaneously. High NO inhibits that process.

Opiates trigger the release of NO too, but the opiates are outside the feedback control loop, which is why people develop tolerance for opiates. The signal from the opiates regulates the number of opiate receptors (in some tissue compartments) which changes the effect that opiates have in those tissue compartments, causing tolerance. The control systems in the different tissue compartments doing different things are different, which is why opiate tolerance affects sensitivity to pain more than it does breathing suppression; this is why the dose that relieves pain without tolerance is safe, but with enough tolerance is not.

Once the control system gets out of whack, you can end up with a state where you can’t give enough opiate to control the pain without killing the patient. This can happen in many other control systems too. Many drugs work for a while and then either stop working or start to cause unacceptable side effects. That is physiology remodeling the control systems to match what it evolved to do, not what you “want” it to do. This is why finding actual drugs that have actual therapeutic effects over the long term is so difficult. Depending where in the feedback loop you try to insert external control, you may be unsuccessful.

In terms of NO and the placebo effect, NO is the natural signal to end the “fight or flight” state. The only “tolerance” is that it is slightly more difficult to enter the “fight or flight” state when you are in a high NO state. The difference is small.

Similarly, when in a low NO state, the trigger to activate the immune system is also smaller. I think that is the reason for the decline in some infectious diseases before the onset of vaccination. With a hypersensitive immune system, an infectious disease would have a shorter and milder course. But with a hypersensitive immune system there are more autoimmune disorder, allergies, GBS, rheumatoid arthritis, systemic inflammation and so on. That chronic inflammation ends up causing more cancer, more heart disease, more neurodegeneration. Deaths from infections are down, but deaths from heart disease, obesity, cancer, kidney failure, etc. are up.

Restoring a normal basal NO level will improve the operation of every control loop and every feedback pathway that utilizes NO. They all still “work” with a perturbed NO level, they are just regulating at the wrong level.
#30 James Sweet
November 16, 2009

It may seem to be fulfilling part of my ethical obligation of beneficence to hand them a bottle of bitters and tell them that it will help with their cold, but it’s a lie, and if I start to believe my own lies, where does it end?

Tell them to do a shot glass full of vinegar. It ought to have the same effect as the bottle of bitters, it is something readily available in most homes, and one could even argue that it might maybe kinda sorta work. (Though the effects are almost certainly trivial, the highly acidic nature of it ought to be disinfecting; and it would not be completely crazy to imagine that the unpasteurized type of vinegar could have a mildly antibiotic effect on par with yogurt).

I eat a clove of garlic and take a shot of vinegar when I am feeling run-down. It’s almost certainly pure woo but a) I already have garlic and vinegar in my house, so I’m not paying some fraudster to provide it to me; and b) it will perk you up. Trust me.
#31 James Sweet
November 16, 2009

Re: Pseudoephedrine… Yeah, that Phenylephrine crap is total bullshit. I probably shouldn’t confess this, but one time when it was all I had, in desperation I tried taking like a double or triple dose. It made me jittery as hell, but still didn’t relieve my congestion. Nice.

Here in NYS, I’m not sure if they ever made it an official law or not, but every place gets your driver’s license number when you buy real pseudo. Problem is, when I’m sick enough to want it, I really don’t feel like standing in line to talk to a pharmacist and present my license and sign my name and such. The solution I’ve come up with is that I always go out and buy a box of pseudo right when I recover from a cold. That way I always have it when I get sick, and don’t have to go through the whole rigamarole.
#32 Lab Rat
November 18, 2009

“If a patient of mine is frightened and I lay a particularly firm hand on their shoulder as I listen to their lungs, this may provide them comfort. But what if I hand them a bottle of bitter herb extracts with no proven pharmacologic benefit but tell them it will help?”

There is a HUGE WIDE GULF between those two actions…and where you’ve ‘gone too far’ is by jumping over it.

Consider, in the first case you are doing an action that makes them feel better. In the second case you are *actively* lying to them.

There is a big difference there.

Being sympathetic and human is very different to selling snake oil. You can be as empathetic as you want without having to lie, or having to do something you know is medically unsound. The idea that doing *anything* to a patient without it being proven scientificly is one end of a slipperly slope to placebos is just…wrong.

The last time I had an operation I was real shaky afterwards, so the doctor sat me down and got me a cup of tea. The scientific/clinical benefits of tea after surgery have not even been looked into yet! However this doesn’t mean he was a small step away from giving me yellow water instead of codine.
#33 WMDKitty
December 2, 2009

Hey, PAL, would you advocate the “wait a few days and see if it goes away” approach?
#34 WMDKitty
December 2, 2009

becca (#25)

“Actually, your point depends on the drug. Placebos are orders of magnitude poorer than penicillin for syphilis, I’ll grant. However, they are definitely on the same order of magnitude as prozac for depression.”

Except that antidepressants actually work.