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Semiotics and the placebo

It has long been acknowledged that the ‘doctor’ can have a therapeutic effect without ever ordering a test, prescribing a medicine or performing surgery. Indeed the earliest thinkers about the the role of the doctor talked about the ‘drug-doctor‘. But what are the constituent parts of this most powerful of placebos and what impact does this have on our attempts to improve outcomes?

The placebo pill, the saline injection, and the invasive procedure or device that works by virtue of a placebo effect are each signs, or sets of signs, that convey information to patients or research subjects. Additionally, the placebo intervention, like a standard treatment, is delivered within and surrounded by a context, which includes a host of other signs that convey information with the potential for producing therapeutic (and also counter-therapeutic or nocebo) responses. These include the clinician’s white coat, diagnostic instruments, the appearance of the doctor’s office or hospital room, the words communicated by the physician, the physician’s disposition in listening and responding to the patient, gestures, and touch. The patient does not come to the clinical encounter as a blank slate but with a history of experiences and memories evoked by prior responses to signs related to the milieu of therapy, some of which may influence the way in which the patient processes the information from signs emanating from the present clinical encounter. Franklin G. Miller and Luana Colloca

More recently evidence has emerged that hints at more specific ways in which these elements might be improved. When I was training our mentors recommending that we should never be casually dressed when consulting patients. This was based on their impressions of patient expectations. Later in my career my wife who was a staff nurse at our local hospital was amused that the patients I had admitted overnight were  impressed that their doctor was wearing a neck tie even at 2am. I’m not sure whether that was by design or accident.

Rehman and colleagues conducted a study of patient preferences about how they preferred their doctor to dress. Within a North American context it was clear that patients preferred their doctor to wear a white coat, whether the doctor worked in a hospital setting or not. According to the respondents to the survey doctors in white coats were more likely to be knowledgable, competent, caring compassionate, responsible and authoritative. It was evident from this study as well as a study from the UK that older patients in particular prefer their doctor to wear a white coat. There are differences in attitude based on geography and culture. However it is important to consider the importance of this question if only because patients who trust their doctors are more likely to take advice. It is argued how much of a difference attire makes to patient trust but the consensus appears to be that business wear and formal clothing generally inspire more confidence than tee shirts and shorts.

A second issue has recently become relevant. Research has documented negative stigma by health providers toward overweight and obese patients, but it is unknown whether physicians themselves are vulnerable to weight bias from patients. Puhl and colleagues surveyed 358 adults. Respondents were less trusting of physicians who were overweight or obese, were less inclined to follow medical advice, and were more likely to change providers if the physician was perceived to be overweight.  Normal-weight physicians elicited significantly more favorable reactions. These weight biases remained present regardless of participants’ own body weight. A more recent study from Johns Hopkins University School of Medicine suggests that although patients might trust their doctor regardless of his or her weight, those seeing obese primary care physicians, as compared to normal BMI physicians, were significantly more likely to report feeling judged because of their weight.

Therefore attending to how we come across to patients might be an important place to start improving the chances that they will trust us. This is based on intuition and a little bit of evidence, it doesn’t require a grant or a change in government policy. If you think it needs work- start today.


  1. I suspect that wearing casual clothes and being friendly also results in patients transferring attitudes to the patient-doctor relationship, which are habitual for them in other relationships (perhaps especially with their parent of the same sex, in my case – being 73 and so fitting into the appropriate age group for a parent.) This would have variable results, depending on the quality of the original relationship.

  2. Very good points, Moyez. But as Dr Rose points-out, the extension of your correct observations is that different people will respond differently to particular cues in the doctor’s appearance and manner. While I strongly agree that all doctors need to be self-aware and reflect on how their appearance and behaviour affects the “core content” (diagnosis and advice) they are wishing to impart to patients, they also need to be themselves. One of the most important subliminal cues that people attend to is a person’s ‘authenticity’ and It is a mistake to try to act ‘as-if’ you are someone that you truly are not – this will profoundly sabotage your relationship with your patient. If you feel over-dressed wearing a tie or dowdy without make-up, it will show. You can’t be the ‘right’ doctor for everybody and as a clinician, rather than a public health physician, you don’t have to be.

  3. I agree gentlemen. To take the comparison to placebos further- the size and look of pills matter a lot but so does their chemical constitution. That may have a very significant effect but also nasty side effects. I wouldn’t suggest that appearance is everything. We know however that rogues have been able to masquerade as doctors simply by donning a white coat and stethoscope and sounding ‘right’. The point is appearance matters a lot but isn’t the whole package.


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