The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.



Rethinking Placebos

Placebo. I love the word; it comes from the Latin verb placere: to please, and in the first person future indicative –placebo– translates as ‘I will please’. Wonderful.

I’ve been thinking about it a lot lately, probably since rereading a Dec. 31/14 article in Medscape entitled ‘Should Doctors Use More Placebos?’ The answer, of course, is ambiguous –no one seems to want to commit to the use of a technique favoured in the days when there were few other options; times when there were no antibiotics, no condition-specific medications –no detailed knowledge of the physiology of the body, let alone diseases. Those were times when naming the problem and being able to give a likely prognosis was an important part of Medicine. I suppose it still is. But the other, equally important component nowadays, of course, is solving the problem so named –solving, as well as hopefully curing it with specifically targeted medications or therapies.

Placebos have usually been construed as inert, essentially harmless substances with little or no known properties that might otherwise be helpful in restoring bodily health. No pharmacological effect… So why would anyone wish to use them anymore? Or do we?

In this informed era of medical ethics –and of course, social media- would it even be possible to use placebo treatment, except, maybe, in a study where a treatment is being compared to no -or likely ineffective- treatment (placebo treatment) and where the participants are unaware which substance they are receiving (so as not to bias the results) and have understood and accepted this? Not something likely to occur in the average visit to a doctor’s office for an illness.

And the ethics that need to be considered? Well, amongst others, the concept of autonomy –the right of an individual to make both their own treatment decision and an informed choice. And then, of course, there is the ethical requirement for Informed Consent. How can you give someone a treatment without telling her that you may well end up using something that is pharmacologically inert? A non-medication, as it were.

A placebo is usually a trick –you think you have been given something specifically designed to help; you take it on trust; you have faith in the doctor… If you found out that what you had been given –lied to about, in fact- was inert, wouldn’t that undermine your confidence, and especially your trust, in that doctor? Even if it worked? Or maybe especially if it worked –it would mean he thought your condition was more psychological than physiological –i.e. ‘all in your head’. Not very likely to foster a continuing relationship.

But what if the doctor told you he was going to use a placebo for your condition? Would it work if you knew? Well, here’s where it can get interesting; there is a difference between using a placebo and using the placebo effect: the approach to the patient matters as well as what is given to attack the problem. Such things as actually hearing the patient –listening to what they have to say- rather than immediately reaching for the prescription pad; being reassuring and sympathetic. Friendly. Understanding. The demeanour and hope with which any treatment is administered has been shown to effect the results –the art of Medicine.

But nowadays, we all know about this. The fact that there is some theatre to medicine, and a play of characters is not a secret –although I suspect that most of us prefer not to think about it when we ourselves have an illness. The play within the play…

It got me thinking about placebos in my specialty, though. Are there any placebos in gynaecology, for instance, and do we ever use them? We certainly use the placebo effect in obstetrics –we are constantly reassuring our patients about the never-ending and always-changing symptoms occasioned by their growing bodies. Most of them don’t need investigations or tests- nor do they need any specific medication -just an acknowledgment by the doctor that whatever the patient has noticed is not something to be worried about. It is not something malevolent, nor likely to affect the baby, but merely something that happens in pregnancy –part of the spectrum. Something to be expected. It’s a trust issue. That’s why they came to you after all.

And what about gynaecology? All medicine involves placebo effects –we’ve just discussed that- but what about placebos? Are we kidding ourselves to think that gyaecology is exempt from their use? I suppose it depends on how you define a placebo. As we’ve already seen, a placebo is classically defined as a substance that is not likely to have any measurable pharmacological effects and so is considered inert. But what about a substance that is not yet proven by scientists to have an effect –for example by well-designed studies that compare various treatments? Of course, it may simply be that no one has actually studied the substance so far; there are many complementary and alternative medicines that Western Medicine has not subjected to analysis. So their use by the doctor would not necessarily be as a therapy, but maybe as an acquiescence to a patient’s request, in the absence, perhaps, of any other recognized treatment options.

How about a substance that has some effects, and yet likely not enough, nor sufficiently consistently to be considered a mainstay treatment, but which might be sold, say, in a health food store? Some of the phytoestrogens found in materials like clover or soy have estrogenic effects, but may attach weakly or ineffectively to certain estrogen receptors -and in some organs but not others…

And then there are medications that are useful for other conditions –perhaps related, but not necessarily so- but are re-packaged for a new life. The use of ovulation inducers in infertility treatment, even when the patient is known to be ovulating –a just-in-case therapy. Or an antibiotic for a new-onset, ultrasound negative –but as yet undiagnosed- pelvic pain in a woman when she shows up in a busy emergency department. Maybe it’s an infection… Or vitamin pill use for the busy woman who doesn’t have time for a healthy diet every day. It can’t hurt and it may help… Surely these are placebos.

Or substances that have switched their roles over the years –were they inadvertent placebos that have been since promoted? Acetylsalicylic acid (ASA) was once only considered a pain reliever and was used for menstrual cramps. It seemed to help patients cope with the period but this was assumed to be only because of the pain relief. So it was a placebo for coping, a therapy for pain. Then, because it was later discovered to be an anti-prostaglandin –which is a chemical mediator of inflammation and has a direct effect on the flow through blood vessels (and hence one cause for increased bleeding and cramping with periods because of dilated blood vessels in the area)- ASA, or at least more modern analogues of antiprostaglandins such as ibuprofen, was reassigned to a new function. A new, non-placebo job, as it were. So, although it did one job at first, was it an unsuspecting placebo that actually did two jobs? Is that a temporal placebo? An interesting philosophical conundrum –but I suspect I am stretching the concept beyond any useful application.

Maybe we’re looking at the whole idea of placebos the wrong way. In our data-glutted age where information is conflated with knowledge perhaps we need a concept that defies mere illumination and transcends erudition. Something that is so embedded in the weft of context that it disappears in the very act of searching for it –an unsolvable Where’s Waldo. Sometimes our need for elucidation of every aspect of the world we live in is self-defeating. Maybe –just maybe- we don’t need to know where the geese go when they disappear through clouds that gird the mountain tops. Just that they come back every year. ..Somehow.

The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”