If you were alive and kicking in the 1950s and happened to own a TV set, you probably remember hearing a pitch for a vitamin tonic named Geritol. Listen to the commercials, and you'll notice how often the announcer mentions doctors. Then as now, you instill in us a good deal of authority and trust. It might surprise to you realize that we MDs - like television pitchmen, market tests and treatments - everything from MRIs to chemo. In theory, I'm supposed to tell you about the benefits and the risks and let you decide. But in the real world, the surgeon who is ready to open your belly must be skilled at getting you to say yes.
This week we present three stories about the art of patient persuasion. I talk with anaesthesia residents who say the hardest part of learning how to give epidurals to pregnant women in labour isn't figuring out where to put the needle but getting them to say yes to the needle - in a hurry. When it comes to medical treatments, there's facts and there's branding. Family doc and health communications guru Dr. Michael Evans schools me on how to work both into an a slick yet accurate medical pitch. And, take a look at electroconvulsive therapy or ECT, a controversial medical treatment that comes with some heavy negative branding.
That's Saturday, November 5 at 11:30 am (noon NT) and again on Monday, November 7 (3:30 pm NT) on CBC Radio One. Or click below to listen now or download the podcast:
Electroconvulsive therapy (ECT), is a bona fide form of psychiatric therapy for severe depression that was first introduced in 1938 by Italian psychiatrists Ugo Cerletti and Lucio Bini. The mechanism by which the treatment works is unknown. What is known is that a jolt of electricity is delivered to the brain to induce a convulsion.
It's the way the convulsion is delivered and the way the patient is prepared that's open to misinterpretation and some very negative marketing. When you think of ECT, chances are you picture a scene from the film One Flew Over the Cuckoo's Nest, in which the character Randle Patrick McMurphy, played by Oscar winner Jack Nicholson, receives the treatment.
It's one of the most disturbing scenes ever filmed. Back in 1963, the year in which the film is set, McMurphy was wide awake when doctors flipped the switch. Brutal, forced, and punitive: that is what most people picture when they think of ECT - even though it's not accurate.
Recently, I observed and recorded (with the prior consent of the patient) an ECT treatment administered by doctors at the Royal Ottawa Mental Health Centre. Prior to the treatment, the patient received an injection of fentanyl, a narcotic that relieves pain and provides sedation. An anesthesiologist gave the patient propofol, a short-acting general anesthetic, so that the patient was under anesthesia when the shock was administered.
I watched as a psychiatrist puts some gooey conducting gel on the patient's temples, and then pressed an electrode - a round flat surface with a long handle - on each side of the patient's head. A switch was thrown, sending 33 joules of electricity into the brain. That's far less than I use in the ER to shock the heart. Unlike the convulsion seen in the film, the one I witnessed was barely visible because the patient was given a drug that relaxes the muscles.
The whole thing - which lasted less than a minute - was almost anti-climactic.
Still, some people - among them former psychiatric patients - are so opposed to ECT no amount of positive branding will change their minds. For those who seldom give the treatment a moment's thought, the challenge is to painstakingly correct public misconceptions. That's the job of Andrew Wiens, a geriatric psychiatrist at the Royal in Ottawa. I asked Wiens what people tend to picture when they imagine a patient having ECT.
"In the past, it was a little bit easier to answer that question because more people had the movie 'One Flew Over the Cuckoo's Nest' which shows a true ECT that was the way that it was given prior to the use of anesthetic agents," he told WCBA.
"Mostly, people know that it's electricity going to the head so they see us maybe in an almost Frankenstein-like fashion - that we're putting someone on a bed, strapping them down, putting electrodes on their head and pulling a big lever that gives people a shock. And as a result of that, we're damaging their brain."
Wiens says it's important to realize that ECT is a recognized and accepted form of treatment that is indicated for patients with severe depression that does not respond to antidepressant medications. And even though ECT is adminstered with medications that make the experience less painful, it is not without side effects.
"The most important side effect to talk about is memory impairment, which is common," Dr. Wiens told WCBA. "Some say up to thirty percent might have forgetfulness especially around the time when they were having ECT."
"We do have examples of patients who can wake up right away and know exactly where they are. They'll recognize me and use my name. But there are some that never do remember the period around which they had ECT."
"The other side effect that we also talk about is changes in heart rhythm," he added.
Perhaps surprising to some is the fact that post-graduate residents who are training to become psychiatrists likewise hold popular misconceptions regarding ECT. It's the job of Dr. Kiran Rabheru, a geriatric psychiatrist in Ottawa who trains residents on how and when to do ECT - to dispel these. Recently, he began a training program with an unorthodox first lesson.
"I actually showed them the movie 'One Flew Over the Cuckoo's Nest'," Rabheru told WCBA. "The whole idea was for them to see it and then actually learn how to do it properly. It was done so they would 'get' the stigma part of it."
To put things in perspective, geriatric psychiatrist Dr. Andrew Wiens thinks ECT is regarded more harshly than other treatments that would look even more brutal to an unenlightened observer.
"If you were in a culture in which there was no surgery, and I brought you into an operating room where it was going on, and you saw these people sticking a knife in someone's chest, they would consider this to be probably much worse than if they saw someone putting electrodes on someone's head," Wiens told WCBA.
ECT is not the only example of a procedure that needs some favorable branding. So does epidural analgesia for pregnant women in labour. Epidural analgesia is a commonly employed technique of providing pain relief. The technique involves threading a catheter or slender tube through a needle placed between the vertebrae in the lower spine. The most common complications occurring with epidural analgesia are a drop in blood pressure and headaches.
In the film 'Knocked Up' Katherine Heigl's all-natural Birth Plan didn't include an epidural. However, once she's fully dilated and pushing, Heigl's character wishes it did.
Though over the top, the scene and the dilemma are surprisingly accurate. Just ask Drs. Zoe Unger, Tina Kurelska, and David Orlov, three third year residents in anaesthesia who have learned not just how to do epidurals but how to talk about them with stressed out pregnant women. In an interview, they described in detail the standard pitch they give to women in labor; as with ECT, much of it involves dispelling misconceptions.
Dr. Tina Kurelska says one of the biggest is that epidurals frequently cause paralysis.
"I will ask them 'do you know anybody or have you heard of anybody having something like this?'", she told WCBA. "What I commonly tell them is that the risk of dying in a car accident in Canada is one in ten thousand and the risk of having any nerve damage is way less."
Another misconception that's easy to dispel: that a tattoo located on the lower back is an absolute contraindication to an epidural. Or, that an epidural makes it impossible for a woman to push. Both are untrue.
David Orlov said he was surprised how important it is to learn how to 'market' epidurals on the fly.
"It's something you do kind of pick up when we learn how to do epidural," he told WCBA. "We do watch a lot of the staff and a lot of the residents before we actually start doing them ourselves. That helps us get the patter down pat and helps us with the troubleshooting. There's only so many problems to encounter when we put the epidural in. And when you get the gist of some of these problems, that's when you feel more comfortable."
When it comes to marketing epidurals, one big part of the anesthesiologist's toolkiit is a big dose of empathy.
"It's such a charged environment being in a room with a labouring woman," says anesthesia resident Dr. Zoe Unger. "Obviously, you don't take on what she's feeling but you get so enmeshed in their dynamic and the stress and you do have a sense of what's going on."
"You end up being tied into it and being a part of it," she concludes.
The empathy that anesthesia resident Zoe Unger talked about should be marketed right along with being slick with an epidural needle.
People like me tend to be purveyors of medical information, not mavens of marketing. Dr. Michael Evans is an exception. He founded Mini Med School - teaching thousands of you the basics of what we do. And, he's founder and director of Health Design Lab in Toronto, which brings together doctors, patients, technologists, designers, filmmakers and -- you guessed it -- marketers to bring high quality health information to you.
Evans believes in providing accurate information on the benefits and the risks of tests and treatments. But he agrees that marketing goes along with information.
"I think we can learn a lot from the marketing industry and we should probably start up a dialogue of social networking with them," he told WCBA.
"Take the obesity epidemic, for example. At fifty to sixty percent obesity in our society, it's the people who have those good marketing skills who are winning the battle. We have to counteract that with some of our own marketing."