Why You Wanna Treat Me So Bad?

"Good morning Mrs Smith. I've not seen you for a while"

"I know, Doctor. I've been ill"

This fictitious exchange between a made up patient and a made up doctor is a very old, though still quite amusing, joke but this Thursday, at Skeptics in the Pub - Online, I came to realise that, throughout most of history, it probably would not have read like a joke. Or at least should have not done.

'Why patients want bad medicine', presented by Micheal de Barra - a lecturer in psychology in the Centre for Culture and Evolution at Brunel University in London and a man, it's worth noting, that has two pet chickens (who were spending the night in a "chicken hotel") - was an evening, anchored by Clio from the Winchester branch of Skeptics, that aimed to tell us why that was.

Why, before the 1900s, the vast majority of treatments had no real benefits to the patients who received them, often quite the reverse, and how, even now, an element of that remains in our thinking on the subject of medicine and treatment. It was not a talk without contention, even I became a sceptical Skeptic when stents were ruled to be far less beneficiary than is believed, but neither was it a talk that did not make some very interesting points.

When the first American president George Washington  reported feeling feverish and suffering throat pain he consulted, as you might expect from a wealthy and powerful man, the best medical advisors he could find. He was given molasses, vinegar, and butter. He had half a pint of blood removed from his arm. He had a hot poultice applied to his neck and then another poultice of the Spanish fly applied (which, being toxic, caused blisters). Finally, he underwent a second 'bleeding' and this time a whole pint of the red stuff was taken from him.

His condition didn't improve and not long after, perhaps unsurprisingly, he died. A little more than a century earlier King Charles II of England suffered a fit while out hunting. He was given purgatives, laxatives, and enemas and, like Washington, he was bled and had Spanish fly applied to him. 

The results were remarkably similar. Charles II died. Aged 54. Micheal de Barra's belief is that if a time machine is ever invented and you travel back further than 1900 and suffer any kind of illness or accident, it would be best not to take whatever medical advice is given.

That's a little cheeky but it's possibly true. People in the old times didn't have the scientific knowledge we - as a global community - have now so they did their best with what they had. More up for debate, perhaps, is de Barra's contention that bad medicine still persists. He went on to explain four reasons why he thought that was the case.

(1) PEOPLE USUALLY JUST GET BETTER

Obviously there are serious illnesses that people don't get better from but think how many times you have been sick. Unless it's something that will eventually kill you, every single time you recovered. So whichever treatment you took, if you did, will appear to have worked. People are more likely to seek treatment when they feel particularly bad - understandably - but regression to mean says they will probably get better soon anyway and this accentuates the belief that the treatment, rather than natural causes and the body's remarkable power to heal itself, is responsible.

(2) SUCCESS STORIES SPREAD FASTER THAN FAILURES

Clearly not true if you're talking about a bad dining experience. A quick look at Trip Advisor would confirm that. But seemingly so when considering medical outcomes. Even considering reporting bias and intentionally distorted reports, Amazon reviews suggest people are always pleased to loudly announce that a new treatment, or diet, has worked for them and less keen to admit it has failed. Perhaps, fearing this will paint them, not the treatment, as a failure.

(3) INTUITIVE TREATMENTS ARE OFTEN BAD TREATMENTS

Biology is extremely complicated and information changes, evolves, and modifies as it passes through groups of people. An example:- An Amazonian man wants to go out hunting but he's got a headache. The next day he cuts his toe but that same day - he also feels better - so he can go out hunting. As the story is passed on the cut toe becomes not incidental to the improvement but the reason for it. Or, eventually, the story changes and it's not a toe that was cut but the head, the aching body part itself, that has been 'bled'. Which explains, partially, the poor treatment given to George Washington and Charles II as well as beliefs in treatments such as leeching and vacuum-cupping - once popular with the American swimmer Michael Phelps.

(4) THE GOAL OF MEDICINE IS TO SIGNAL NEED, NOT TO TREAT DISEASE

An interesting one this and perhaps worthy of a lecture in its own right. The Darwinian view of 'resource transfer' touches on how important it is that when you're sick you have somebody to care for you. You need food, water, and shelter and you may be too unwell to ensure you can provide these things for yourself.

You need to be cared for. You need care. A less charitable view would consider malingering, secondary gain, and fictitious disorders and the reasons they exist. Lumped together in a group that de Barra handily called 'illness deceptions". Intentional or otherwise, these illness deceptions can be quite easy to pass off.

Many people with obvious symptoms are able to look after themselves and will require little care and many people with seemingly no, or at least few, symptoms may not be able to do so. Conditions with few symptoms are easy to fake and in societies where, thankfully, care is available for all of us to access many of us choose to take advantage of that. A small percentage will exploit that situation. An even smaller percentage mendaciously. When they improve it will appear that whatever treatment they received has been successful but, really, they were never ill in the first place.

It all says a lot about how society considers illness, more than it did about bad medicine come to think of it. The signalling value of various treatments is higher than others. If you tell someone you're ill and you've had a paracetamol you'll get much less sympathy than if you tell them you've been put on a course of antibiotics and, with mental health, the signalling value of 'meds' is higher than that of other NHS approved treatments like exercise, therapy, and self-help.

So people often prefer to use what will send a message to society, or family, or colleagues, that they are getting treatment rather than doing what is right for them. It's a tricky area and it's such a huge one that Micheal de Barra couldn't possibly hope to cover it in one forty-five minute Skeptics talk and an equally long Q&A. He raised more questions than he did answer them and, for a Skeptics event, that seems good enough for me. Plus, I wasn't feeling very well so wanted to go to bed. As I'm feeling better now does that mean going to bed cures all illnesses? If only.