Suggestibility in medicine

My current OB Gyn attending Dr A is probably one of the best physicians I have ever worked with, knowledgeable, professional, efficient, caring, funny. He’s one of those people you see doing something you aspire to do that you wonder if you could ever live up to. However, I observed something very interesting today. Despite the best intentions, physicians are constrained by the rules of economics. The scenario was as follows:

A 50yo patient came in with a few months of perimenopausal bleeding and a family history of cervical cancer which was clearly her first priority. In the process of eliciting a more detailed history of present illness, my attending actually asked several questions about her urination, whether she wets herself, how frequent etc. He then proceeded to perform a physical exam and take a endometrial biopsy (which involves scraping the inside of the uterus for a sample to test for cancer). In his physical exam, he discovered that she had vaginal wall weakness and urethral prolapse (where one’s urethral ligaments are stretched or broken by prior childbirths and cause urinary incontinence). Despite her repeated questions about the biopsy, risk for cancer, etc, he kept redirecting the discussion toward a procedure called apogee/perigee/monarc which is a surgery to repair the walls of the vagina to prevent prolapse. What was interesting was to see my attending talk like a mechanic who examines your car for a routine maintenance and then tells you about the sale they are having on Michelin tires and how you really should think about changing your tires.

My attending was very up front about this saying that “my practice has been built around helping women with these problems” and “most women we do this procedure for say that it changed their lives” and “think about it, if you want I can have to talk to several of my patients who have had the procedure, they will attest to its success”. It was as if he was creating demand for a procedure to treat a symptom that was never the patient’s primary concern.

This brings up the question of suggestibility in medicine. Unlike the mechanic’s customers, most patients trust their physicians to be objective yet from a business model standpoint, physicians make their money similarly to mechanics and are subject to the same financial constraints. The line between mechanic and physician is very fine and easily traversed if one is not careful.