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The Point - August 8, 2013

In this edition of The Point:

Article #1

Excerpted from "Doctors Badmouthing Other Doctors," The New York Times. July 11, 2013 -- A physician friend recently disclosed that she was named in a malpractice lawsuit. Her revelation was rattling not only because there were no discernible errors in the care she provided, but also because another doctor had provoked the patient to hire a lawyer. "I'm shocked that nothing was done sooner," the other doctor had said when the patient went for a second opinion. "You could have died."

Surely, the doctor who had trashed his colleague was out of line. Throughout training and regularly at work, we are reminded of the importance of professionalism and respect. Shifting blame demoralizes other clinicians, undermines patient trust and compromises patient outcomes.

But it didn't take long for me to recall instances when friends and I had been equally critical about other doctors' work. Are we all capable of talking like that in front of patients? The answer, according to a recent study in The Journal of General Internal Medicine, is an unqualified and disturbing, "Yes." "Doctors will throw each other under the bus," said Susan H. McDaniel, lead author of the study and a professor of psychiatry and family medicine at the University of Rochester Medical Center. "I don't think they even realize the extent to which they do that or how it can affect patients."

"There is probably something reassuring in saying, 'Boy, your doctor didn't do a good job and now I'm going to take care of you,'" Dr. McDaniel noted. "But those kinds of comments are bad for the patient." To help remedy this problem, Dr. McDaniel began a physician coaching program at the University of Rochester Medical Center a year and a half ago. "There's a lot of attention focused on the patient experience, but I think we need to work on improving the clinician experience as well," Dr. McDaniel said.

Commentary #1

CMDA Vice President and National Director of Campus & Community Ministries J. Scott Ries, MD -- "When I first read the title of this article, my initial reaction was, 'I don't do that.' Then the rubber met the road. Just last week, a 7-year-old girl accompanied by her grandmother came to my clinic with the same abdominal pain that had been plaguing her for four days. Initially evaluated by her grandmother's family physician, she had been diagnosed with a urinary tract infection and treated with antibiotics. Three days later, when the pain had not improved, she returned to that doctor. A repeat urinalysis was normal and they were sent home with instructions on how to treat constipation.

"Later that day, they came to me. I had the advantage of both urinalysis results (neither remarkable) as I evaluated the healthy appearing child in front of me. But something didn't seem quite right. A couple hours later, I whisked her off to meet the surgeon at the OR to intervene for her ruptured appendix. But before they left the clinic, the question came: 'Should the other doctor have diagnosed this on Monday?' Two things hit at me at once, freezing any potential response. The first was the reaction, 'I'm just glad you brought her to me. She could have died.' The second was the article adducing that very phrase.

"How should we respond when we encounter and disagree with the work of a colleague? Try answering these three questions before responding:

  • Will my response benefit my patient?
  • Will my response attempt to inflate trust in me, by diminishing that in another?
  • Am I representing well with my words the Physician I desire to emulate?

"If we are honest, our pejorative off-the-cuff responses are often (if not subconsciously) geared at building our own ego. Confident in our abilities, we want to make sure our patient shares our confidence in our prowess. But is this how the Great Physician treated His colleagues? Is this the grace with which the Great Physician has treated me? Ephesians 4:29 offers the answer that we need at this precise moment, 'Do not let any unwholesome talk come out of your mouths, but only what is helpful for building others up according to their needs, that it may benefit those who listen' (NIV 2011)."

Article #2

Excerpted from "Patients' attitudes about the use of placebo treatments: telephone survey," British Medical Journal. July 2, 2013 -- Several recent surveys of physicians have documented their use of placebo treatments in clinical practice. In a recent U.S. survey of internists and rheumatologists, half reported that they have prescribed placebo treatments, defined as treatments "whose benefits derive from positive patient expectations rather than from the physiologic or pharmacologic mechanism of the treatment itself." These placebo treatments included active agents such as vitamins or analgesics that a physician prescribed to promote positive placebo effects rather than specific pharmacologic or physiologic effects.

The prescription of placebo treatments as part of medical care is ethically controversial. Their use has been criticized because the practice is thought to involve deception, thereby violating patient autonomy, because of concerns about the compatibility of placebo treatments with evidence-based medicine, and because the risks introduced by some placebo treatments outweigh the possible benefits of their use, as in the case of prescribing antibiotics for viral infection. U.S. clinical practice guidelines prohibit the use of placebo treatments without a patient's knowledge, citing concerns about undermining trust and compromising the patient-physician relationship. Despite these concerns, some have argued that use of placebo treatments can be justified when they are effective, at least in certain cases.

The perspectives of U.S. patients have been missing in the debate over the use of placebo treatments in clinical practice. To probe the attitudes of U.S. patients regarding placebo treatments, a survey was conducted of adult members of a large Northern California health plan. The survey utilized a carefully constructed definition of "placebo treatments," used a combination of general questions and detailed scenarios, and included a large and demographically diverse sample of patients. The data shows that patients are open to the idea of placebo treatments. Most (50 to 84 percent) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to the doctor's level of certainty about the benefits of the treatment, the purpose of the treatment (for example, to address a patient's need to receive a treatment) and the transparency with which the treatment was described to patients. Fewer than a quarter stated that it was never acceptable for doctors to recommend placebo treatments. In addition, many respondents indicated a willingness to try placebo treatments in different scenarios. This is generally compatible with trends reported in previous patient surveys in other countries regarding willingness to try placebo treatments.

Commentary #2

CMDA Member and Ethics Lecturer at Dublin City University, Ireland Dónal P. O'Mathúna, PhD: "The placebo effect is often viewed negatively, as something to be eliminated in medical research or as a way to explain how 'inert' interventions have effects. More recently, placebos have been declared unethical, a deceptive violation of patient autonomy. The American Medical Association holds that placebos should be prescribed only if patients agree to their use.

"The BMJ study defined the placebo effect as patients getting better after a treatment because they expected improvement, not because of the treatment itself. It found that most patients are open to placebos, but concerned about the deceptive element. The findings highlight the importance of honesty and trust in medical practice.

"Many believe placebos only work if patients do not know they are taking them. In the BMJ survey, two-thirds would try a placebo for moderate stomach pain or chronic abdominal pain, if told they were given a placebo. A recent randomized controlled trial found that irritable bowel syndrome patients, fully informed about being given an inert placebo, had significantly better outcomes than those given no treatment (Kaptchuk et al. PLoS ONE 2010;5(12):e15591). The placebo included a supportive interaction with patients given a clear rationale for how placebos might be beneficial.

"Research into the placebo effect provides evidence that ethics matter, and that patients want open and honest interactions with their physicians. These studies support the non-deceptive use of placebos. Our mind, body and spirit are intricately interwoven. How we relate to others makes a difference."

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