Jan 11 2008

Changing Attitudes

In response to my blog entry from yesterday, When Quacks Were Quacks, nfpendleton wrote: “When will we see the advertisement with the doctor who recommends Charlestons because they’re a ‘cleaner, healthier’ smoke?” While this question is a non sequitur, having nothing to do with the original post (I specifically distanced myself from any nostalgia for my colleagues of the past), it did inspire me to delve deeper into the changing attitudes over health care and doctors in the last half century.

It is true that up through the 1950 doctors were not generally warning against smoking, and some doctors were even shills for the tobacco industry. Orac has already collected a number of videos from the 1940’s and 1950’s showing how much attitudes toward smoking has changed. Included is one in which a physician is asked, “what brand of cigarrettes do you smoke, doctor?” Of course I cringe at all these advertisements, but especially the scene of a doctor smoking and recommending his favorite brand.

Here is an interesting anecdote – my grandmother told me that she started smoking in the 1930’s on the advice of her physician, who told her it would calm her nerves (she had just lost a her one year old daughter to pneumonia).

To what can we attribute these changes in attitudes? Of course, the biggest factor is the recognition that cigarette smoking is a health hazard and has been linked to certain kinds of lung and other cancers, heart disease, emphysema, and stroke. The year 1950 was the turning point, when three important epidemiological studies linking smoking to cancer were published in high profile journals. Prior to 1950 you could excuse any ignorance about the risks of smoking, after 1950 you cannot. The video linked to in Orac’s blog is from 1952. To put this in perspective, the 1950 studies raised for the first time public awareness about the potential health risks of smoking. The tobacco industry began a campaign to vigorously defend the safety of smoking, which meant denying the growing scientific evidence revealing links between smoking and disease. Enlisting doctors to promote smoking was part of this campaign, which makes the ad all the more despicable.

One thing that has apparently not changed with time is that wealthy companies can find someone with an MD after their name to shill for their products. Just look at the supplement industry advertisements and you will see this practice is alive and well.

I think, however, there are other cultural factors at play here. Specifically, in the 1950’s the dominant paradigm of the doctor-patient relationship was what is now called paternalism. Physicians were the authority and they would tell patients what they had and what to do. Patients, generally, did not question the wisdom and experience of their physicians.

There are positives and negatives of such a relationship. The positives are that acquiescing to the authority of an expert may lead to greater compliance with treatment. Also, in general, experts are more likely to have an informed and experienced opinion than a lay person. The negatives are that patients may acquiesce too easily, not ask the right questions, and not even give the physician all the information he needs to make the best decision. This hampers clinical decision-making, and also makes patients vulnerable to incompetent or fraudulent practitioners.

Over the last 50 years, in general the public has become more self-empowered and also better informed. The internet has greatly accelerated this process. Often now patients will come into my office very well informed on their condition, they ask many relevant and pointed questions, and are much more aware of their options.

The current model of the doctor-patient relationship is one of cooperation. Patients not only demand that they be a full partner in their own healthcare, it is expected of them. The strengths of this system is that patients are better informed, and I think doctors are better informed also. Treatments can be better tailored to all the needs of the patient, because the patient feels more empowered to make their needs known and to explore their options. Also, patients are more likely to question bad advice.

The negatives of this system is that patients are also subject to a host of misinformation. Some of this misinformation may be very appealing and may lure them into bad health choices. Being empowered to make your own health decisions also means being responsible to make your own health decisions and to be as well informed as possible. Obviously, different people have different ability and inclination toward understanding complex health information and may feel overwhelmed by the burden of having to take so much responsibility for their own health decisions.

In practice I find I have to gauge with each patient how much of a role they want to play in their own healthcare decisions. Some patient happily submit to my opinion and advice, others will grill me relentlessly about their condition and options, and still others will simply disagree with my opinion in favor of their own. This means that, generally, doctors have to dedicate more time to educating their patients – a process I actually enjoy. But it can be frustrating to see your own patient seduced into a terrible decision by a compelling fraud.

This relates back to what I said in my entry yesterday – the genie healthcare freedom is out of the bottle, and there is no putting it back. This means that as a society we have to educate the public better about science in general, and health science in particular. As physicians we have to educate our patients not just about mainstream medicine, but the dangers of pseudoscience and fraud that lurk on the internet and elsewhere.

The very positive aspect of all this is that the entire system is much more transparent. Doctors, other health professionals, and in fact all experts, are kept much more honest than in the past. It is more difficult (although by no means impossible) to hide behind the cloak of degrees or position.

Also, gurus and con artists have their own cloaks – they try to reassure the public with pleasing but ultimately meaningless words such as “natural,” they confuse with post-modernist legerdemain, and they hide behind conspiracy theories and populism. One of the goals of this blog (any my new Science-Based Medicine blog) is to strip away these veils of deception, to better inform the public and to keep all practitioners honest – not just those wearing white coats.

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