Clicking the Placebo Button

Every physician who has ever consulted with a patient knows that there’s a subtle game that needs to be played. Taking an accurate history in order to formulate the most appropriate treatment plan requires honesty and full disclosure from the patient – and there are a myriad of reasons why they might be hiding something. Medical students are therefore taught early on to ask the right questions, in the right way, to get the answers they need; to listen carefully to their patients’ replies, and to look at their facial expressions and body language for ‘tells’ that might suggest further (verbal) probing is necessary. Essentially, to get good histories, a physician has to practice psychological jiu jitsu with their patients.

But if you move away from general medicine, and towards specialties like ophthalmology where highly trained specialist doctors offer a range of elective, and often expensive and customized procedures, there’s an additional psychological art that’s required. It’s not sales, but it is customer service. Take the example of cataract surgery using premium IOLs. The first psychological jitsu is still crucially important: understanding how patients actually read, work, and drive (rather than how they say they do). You need this information to choose the right IOL for them. But customer service is far more important when patients are paying for premium procedures out of their own pockets.

If you watch the video interviews we filmed during ESCRS last year, you’ll see much discussion of the importance of excellent ocular biometry before (and in some cases, during) cataract surgery in order to give the best possible outcomes, and the fearsome rate of progress towards one biometer that can do it all with a single click. One point Florian Kretz made in his interview (1) resonated – you might be billing your patient for several procedures, but all the patient experiences is a single click that takes 5 seconds. The patient won’t care that the instrument costs five times more than the five-year old instruments, or that it saved them half an hour of waiting time. They might feel that they’ve missed out on the human interaction – “care” – that they would have received, and that they’ve been billed excessively for “just” a click. And what’s the outcome? A complaint.

I joke that you should have “placebo” machines – old ones, switched off, where you make the buzzing sound yourself, and if the patient asks where the light is, reply, “Oh, it’s infrared, so you can’t see it.” Joking aside, it’s interesting that clinical efficiency is at odds with patients’ expectations in this situation. So I ask: when you get your next ocular biometer or all-singing, all-dancing OCT, how will you handle a patient complaint?

Mark Hillen
Editor