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YOU might have heard about the American illusionist, James Randi, who is famous for exposing spoon-bender Uri Geller. Randi never calls himself a “magician” – his mission is to expose “magic” as clever illusion. It’s worth hearing what he has to say.
Thoughts about magic, illusion and exposure have led me to speculate about similar ideas in health care. My conclusion is: transparency destroys magic.
The rapid development of medical science and technology in health care in the 20th and 21st centuries has transformed modern life. Not only have we eradicated many infectious diseases, but we can now cure childhood cancers, transplant organs and re-implant limbs. It’s tempting to see this as miraculous and the medical professionals as magicians.
Like the illusionist, however, the trick only appears to be “magic” if you don’t understand how it’s done, and if you never see the magician fail. If you’re shown how they did the trick, or if they get it wrong, the illusion is destroyed. Transparency destroys magic.
Over half a century, clinical medicine has evolved from doctor-as-magician to a therapeutic partnership. Medical training now emphasises ethics, communication skills and patient autonomy. The quality and safety movements have meant that error and adverse events are not only measured, but also openly declared and publicised. At the same time, many patients are better informed, with both television and the internet providing an astronomical amount of information about medical science, technology and treatment.
So far, so good. This model of therapeutic partnership between professional and client suits our societal values. But what can happen when the magic is destroyed? Doctors can then be seen as failed magicians, exposed as imperfect beings who make so many mistakes and express so much doubt that they are not to be trusted. It’s only a short step, then, to demonise us as greedy, arrogant, “Big Pharma” shills. The fallen angel, if I can mix my metaphors.
Meanwhile, health care still has its magicians. They are those “alternative” providers who sell simple messages and false hope through supplements, “remedies” and scam treatments. They make claims about “miracle cures”. And, importantly, they resist the scrutiny that would destroy the magic. No audit of outcomes, no transparency about mechanisms, no publication of error rates. By keeping customers in the dark, they can preserve the magic.
It’s important, then, that all health care providers and all therapeutic modalities are held to the same standards. No therapy is “beyond scientific testing” – it either works under controlled conditions, or it doesn’t. Providers must be held accountable for making false claims, and purveyors must be prosecuted for selling useless products.
The Review of the Australian Government rebate on natural therapies for private health insurance shines a light on many of these modalities. James Randi would be proud.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.
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Magic still happens in quality GP care due to an intimate understanding of the patient and their relationship with their doctor. Show me the the DBRCT proving that magic? You can’t and that is part of the reason why our healthcare regulators are prepared to reduce the involvement of doctors in patient care on a cost basis.
Doctors “cost” more than other healthcare providers, especially those whose services fall outside public health funding. Over time our magic is being eroded by poor rebates and bulk billing that encourage revolving door medicine and loss of that intimate relationship in the interest of economic survival. When added to the push for nurse practitioners, community care models (are they really cost effective?) and patients wandering off to spend their heard earned on practitioners who retain some magic, it’s liking watching a candle expiring without the help of the wind.
Can we really blame dodgy miracle-makers when our own healthcare system and the way we now practice as a glorified referral writers devalue us in our patients’ eyes? The evidence is we are looking for the wrong evidence in primary care outcomes. Being patient is not part of the healthcare regulator’s psyche and it overlooks the true magic of a long term and meaningful primary care relationship.
There is an obvious set of problems with the claims and low-level of proof required for supposed “efficacy”of complementary medicines. Purveyers of these products indeed make it seem like magic!
Too bad and so sad,when patients start using magical “jungle juice” for conditions that progress towards severe disease outcome because of neglect of conventional care eg. symptoms of prostate disease-even worse where potential life-threatening infant and childhood diseases are involved!
Medicine still needs magic it’s just a matter of how it is applied We can admit we don’t know if a therapy will work but it can, as with a placebo, still have a benefit. Even telling a patient that this is a placebo can relieve symptoms that’s transparent magic!
Dr Ieraci as usual hits the nail firmly on the head. Ethics, evidence based practice, scientific are terms easily used. The charlatans within health, both scientifically trained and non-scientifically trained quacks, have picked up on this terminology and use it freely in their blog posts and advertising material. Reform needs to be aimed at every person who makes specific health claims and this is best done through regulation, which in the age of “anybody with a keyboard can publish” has to happen via “proof of positive” principles rather than “proof of negative”. Currently the TGA has no teeth, AHPRA register woo practitioners to give them a legitimacy they do not deserve, and unethical and bogus practice is ubiquitous. It is not enough for medicine to push forward with the reform agenda and sanction and re-educate our own. The “alternative” practitioners and products need to prove themselves efficacious or be sent back to the fortune telling tents from where they emerged.
There is of course another side to Dr. Ieraci’s beautifully summarized “over half a century, clinical medicine has evolved from doctor-as-magician to a therapeutic partnership”. That is from doctor-as-paternalist-purveyor-of-hubris with the dominating narrative “do as I command because I know what is best”….to what on earth does person centered care look like? The power balance between physician and those persons ministered to was in some quarters fiercely protected.
Whatever happened to “I know that I have communicated well with the family when I have brought them to the same level of uncertainty over the problem as I have”.
The practice of medicine is and always has been a “wicked problem”.
But, isn’t it the invariable mark of wisdom to see the miraculous in common (Emerson). To me transparency itself is a miracle! Isn’t it miraculous to be able to expose magic as an illusion?
spot on