What patients really want
By Aidan O’Donnell
Picture this scenario. In a brightly-lit room, young women in spotless white tunics apply high-tech treatments to a group of people lying on beds. At first glance, you might think this is a hospital or clinic, but in fact, it is a beauty salon.
We are becoming increasingly familiar with the paradigm that beauty treatments are good for us. Companies use evocative phrases such as “beauty therapy” to associate cosmetic treatments with medical ones. Beauticians wear white smocks suggestive of lab coats. Advertisements for skin and hair products often feature pseudo-technical jargon and complex diagrams, to suggest to consumers that their particular favourites have been lovingly created (or at least formulated and controlled) by white-coated scientists in a high-tech laboratory, rather than churned out of a chemical factory which also produces industrial lubricants and agricultural pesticides. Remember when every shampoo ad had the science part?
The association between cosmetics and pharmaceuticals has created a neologism, cosmeceuticals, which refers to cosmetic products which imply some additional medical or pharmaceutical action.
The cosmetic industry uses these strategies because they are effective in selling products to consumers. By appropriating the trappings of medicine and science, it adds to its products an air of medically-endorsed respectability they might otherwise lack.
Do these initiatives actually make your hair silkier, your skin more lustrous, your wrinkles less noticeable, your eyes more captivating? No! But they make you feel like they do, and that counts: it adds value, which can be expressed in economic terms.
From my point of view as a doctor, this is a deliberate use of the placebo effect. There is a lot of nonsense spoken about the placebo effect, so to avoid confusion, let me specify that I consider the placebo effect to be the added satisfaction patients derive from a treatment, over and above its actual benefit. It is neither quackery nor witchcraft; nor is it closed to the orthodox tools of scientific inquiry. The crux of it is this: the placebo effect makes you feel better, even if it doesn’t make you get better.
The placebo effect is associated with perceived expertise, hence the beauticians in the white coats. It is associated with dramatic treatments, and expensive ones. Most importantly, the placebo effect is associated with the attention of a warm and caring practitioner.
Most types of complementary and alternative medicine are proven to be no better than placebo, yet they are extremely popular and increasingly mainstream. High-street pharmacies stock herbal and homeopathic remedies alongside more traditional preparations.
Marcia Angell and Jerome Kassirer famously stated in the New England Journal of Medicine (1998) that “There cannot be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.”
Angell and Kassirer’s editorial is powerful, forthright and unambiguous. I applaud its clarity, but I can’t help wondering if it misses something very important: patients want the placebo effect. In fact, some of them are prepared to shun orthodox medicine and pay money to practitioners who can provide them with only the placebo effect.Worldwide, people spend over US$100 billion on complementary or alternative medicine. It seems that people are voting with their wallets, for treatments which don’t “work”.
To be clear, I do not consider such people to be credulous fools. Instead, I think they are looking for something which orthodox medicine doesn’t quite recognise the value of.
In New Zealand, the UK, and other countries, doctors are no longer permitted to wear white coats. This is because it has been shown that white coats are a vector of infection which can be transmitted from patient to patient via the doctors’ sleeves. Similarly, neckties have been banned in most hospitals. As a result, doctors turn up to work wearing short-sleeved shirts with no tie: they don’t really look like doctors any more.
This impacts not one whit on the quality of care such doctors provide. But it diminishes doctors’ status in the eyes of some patients, makes it hard for patients to figure out who the doctor is, and creates the irony that just about the only people these days who dress like doctors are actually beauticians.
What can doctors do about all this? The first thing is to oppose erosion of the status of the medical profession in the eyes of the public. We are still trusted, we are still valued, and I believe being a doctor is still something meritorious and honourable.
The second thing is to reclaim the placebo effect, and learn how to use it to our own advantage. The placebo effect isn’t something to be used in place of orthodox medicine, but something which can be added to it. The placebo effect lies in the solid relationship between the doctor and the patient. We can harness the placebo effect to our orthodox treatments, and provide therapies which both make our patients get better and feel better.
Because they’re worth it.
Aidan O’Donnell is a consultant anaesthetist who works in New Zealand. He is a Fellow of the Royal College of Anaesthetists and a Fellow of the Australian and New Zealand College of Anaesthetists. He is the assistant editor of the current edition of the Oxford Handbook of Anaesthesia, and author of Anaesthesia: A Very Short Introduction. You can also see his previous post on Propofol and the Death of Michael Jackson.
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Image credit: Blond woman with white coat is writing on a clipboard via iStock photo