Virtually across the board of medicine and psychiatry, doctors will constantly and consistently oversell the benefits of a given treatment, and undersell the risks and side effects of it. This may not be as surprising when you look at some of the key factors into how medical and psychiatric treatment is learned and then conducted on patients.
Why do doctors often oversell the benefits of a given treatment, and minimize the risks and side effects of it?
1. Treatment is rarely experienced first-hand.
While you don’t need to undergo surgery to understand the benefits of surgery or how to do surgery, you will surely have a great appreciation to the patient’s perspective if every surgeon was required to get an appendectomy before being allowed to practice. Surgeons know, in most cases only hypothetically, what it is like to go under the scalpel. I wonder how much differently a surgeon might practice if that were no longer the case.
In the same vein, I wonder how many psychiatrists would continue to prescribe atypical antipsychotics or electroconvulsive therapy (ECT) if they themselves tried it a few times. That’s because we treat fixing human problems the same way we treat fixing a car or dish disposal — it’s just plumbing and organic connections.
Except it’s exactly not that — cars and dish disposals don’t feel emotions and they don’t feel pain. Humans do. And humans should keep that foremost in mind when “fixing” other humans.
The only exception to this rule is, surprisingly, psychotherapy. Virtually every psychotherapist you meet will have undergone some type of psychotherapy themselves. Most know what it’s like to sit on the couch and be on the receiving end of a therapy session. I think that’s part of what makes the psychotherapy experience so unique and unequaled in the treatment world.
2. Risks and side effects are generalized, when only personalized risks are important.
The risks are always placed in a statistical context, none of which allow an individual patient to make any type of informed consent about their specific, particular risk in undergoing a procedure, trying out a treatment, or taking a medication.
Science has provided us with broad painter-like swaths of color to describe risks and side effects. Individuals only care about whether or not any of those apply directly to them. The gap between these two remains impossibly large and unbridged.
Imagine every time you get into your car, a voice greets you, “Hello John. Welcome to your car. How far are you going today?” “About 5 miles” “Well, according to statistics, you have a 1 in 6,500 chance of dying in this car today this year, or, if you’d prefer, you have a 1 in 83 chance of dying in any car you drive during your lifetime. Would you still like to drive today?”
These statistics are absolutely true, but are also absolutely meaningless in helping you make a reasoned, informed decision about whether you should take a trip in your car. Are you more likely to die in that particular trip, in that particular car, due to those particular weather conditions, at that particular time of day? That’s the kind of real information that would help you make a decision. General statistical information about the population as a whole is meaningless for this particular decision.
The same is true in healthcare. Risks are presented in terms of a general population, but say nothing about your specific risks and side effects you personally may experience. Until the information gap between general and personalized information is bridged, any discussion of risks and side effects remains of little value to most people.
3. Doctors and psychiatrists want to heal — they have a pro-treatment bias.
The purpose most doctors believe strongly in is the desire to help and heal those who come to them for a problem. Whether its remission of cancer, setting a broken bone, or prescribing a psychiatric medication, doctors see their life’s mission in helping others. Most get into the profession for just that reason.
So of course the default bias is to want to do something to help the person in front of them — whatever that something is. Sure, they take into account the statistical risks and side effects compared to the patient’s history. But their default bias is to treat, not to not treat.
Need proof? Look no further than the January 5 JAMA study that found 1 in 5 heart defibrillators (known technically as implantable cardioverter-defibrillators or ICDs) are being placed in patients who don’t actually meet the criteria for having one. What makes this finding even worse is that these relatively-healthy patients had a significantly higher risk of in-hospital death. The desire to do something, anything, can be a very bad thing indeed.
Of course we don’t go to see the doctor to be told, “Sorry, there’s nothing I feel comfortable doing to treat you.” In fact, how many times has a doctor told you that?
But maybe they should be saying that a little more often.
4. Or at the very least, be brutally honest about treatment.
When a doctor and patient do make the joint decision to pursue a treatment together, the doctor should be brutally honest about the real side effects the patient is likely to experience. Because nobody likes being lied to or having a treatment’s side effects minimized.
A little while back, I took a bike tour through the hills of Tuscany just outside of Florence. The bike tour operator described the tour as “beginner,” which apparently means something different to Italians, because this bike tour was something like 10 miles up-hill. Every time we would stop for a break, the tour leader would say something like, “There’s just this one small hill left, and that’s pretty much it.” He lied. Over and over again. I guess it was his little joke — one that was not only annoying, but made me lose any trust or confidence I might have had in him.
So when a doctor says, “This may hurt just a little” and then it hurts like hell, how much confidence or trust do you think I’m going to place in that doctor in the future? None. In fact, at the earliest opportunity, I’m going to look to change doctors.
Doctors need to be completely truthful about the likely outcomes, side effects, and real risks a patient is facing. “Sugar coating” it so the patient will “comply” with treatment is no different than outright lying to their face. And while “Gregory House, MD” may be correct in saying that “Everybody lies,” you shouldn’t just naturally expect your doctor to do so (not if you want an actual healing relationship to be there).
5. Nobody would try anything if told the truth.
Perhaps the truth is that more patients would be more reluctant to try an active treatment if given the full truth of its likely negative side effects or risks. Many cancer treatments, for instance, are so painful (and can actually cause future cancers to become more likely), many patients may choose to forgo treatment (or put it off), putting their long-term outcome at greater risk.
If given a choice between a rock and a hard place — like death or this one painful, difficult treatment — perhaps doctors feel like they’re trying to make the treatment choice a little easier to swallow.
6. Medical doctors have it drilled into them that for every problem, there’s a solution — you just need to find it.
Despite our complete lack of knowledge of how the brain actually works, medical students still have it drilled into them during their training that for virtually every medical problem, there’s a solution. Drugs aren’t working? Try different drugs. Try them at higher doses. Try a whole slew of them, despite there being zero scientific evidence to put that particular combination of medications together. Drugs still not working? Let’s apply electricity to the brain and see if that works! (If brains were easily removable, I’m certain enterprising, creative doctors would try soaking it in different chemical solutions, since — after all — the brain is just a bunch of chemical reactions!)
The truth is — not every medical problem has a solution. Not every issue has a treatment. Some people may face an illness or disease that is untreatable. Or treatable only in a very painful manner that may be worse than the disease itself.
I mean, if it weren’t so flying-by-the-seat-of-your-pants ridiculous, you’d have to laugh at it. But then you might start crying when you realize that nearly random trial-and-error practice is what constitutes the basis of modern psychiatry.
And someone you love or care about might be caught in the middle of it.