Leadership

Therapeutic Illusion — A Common Language for Physicians and Executives

Article · January 27, 2017

It’s not uncommon for clinicians and health care executives to see one another as adversaries. It’s understandable when you consider the differences in training, schedules, and languages. But what these groups share is meaningful commitment to better outcomes for patients. Each side faces challenges, and I believe finding a common language would help all of us build a better, more effective health care system.

As clinicians, how do we know which of our treatments work best for patients? The “therapeutic illusion,” as it’s called, is the idea that we believe our interventions are more effective than they actually are in practice. In a classic example, a 1978 study found that for outpatients without definite evidence of illness, the outcomes of treatment versus no treatment were equivalent. In other words, there was no value received from the treatment, despite the best intentions of the physician (and the patient). Perhaps that example is too dramatic, possibly even absurd. But the idea that clinicians overestimate the impact of their treatments is not new. A recent New England Journal of Medicine article contained examples of overconfidence in treatment of back pain and cancer chemotherapy.

In the parlance of evidence-based medicine, this bias is an underestimation of the number-needed-to-treat. The number-needed-to-treat is an estimate of the effectiveness of a therapy —  how many patients must be treated in order to achieve the desired outcome for a single patient. Said differently: for every treatment, some patients benefit, some are harmed, and some are unaffected. For example, the number-needed-to-treat for taking a daily aspirin to prevent a first heart attack or stroke within one year is 1,667. This means that for every 1,667th person who takes the drug, 1,666 either have no benefit or are harmed. Only one person avoids a heart attack or stroke. Here are a few more examples:

herapeutic Illusion - Number Needed to Treat

  Click To Enlarge.

The number-needed-to-treat can be extended to topics in the realm of public policy and delivery system design. Let’s apply the concept to non-clinical leaders: how do we know if our systems strategies improve care for our population? A notable study in the American Journal of Public Health found that adults without insurance had measurably higher mortality rates than those with insurance. The number-needed-to-treat in this study to prevent death by providing adults insurance is 333 — for every 333 adults who receive health insurance, a life is saved. While very meaningful methodological and statistical caveats abound in this example, the logic alone suggests there may be as much value in delivery systems design as there is in the treatments those systems are designed to deliver. This feels like prime opportunity for collaboration.

For policymakers and leaders of health care organizations, these ideas should bring with them a sense of obligation: mistakes made in the boardroom can have the same consequences as mistakes in the exam room. If these number-needed-to-treat data come as a surprise, that suggests we are at risk of underestimating the value of delivery systems design. The therapeutic illusion can apply both ways. We seem to overestimate the effect of medical decisions, yet we may also underestimate the impact of system-wide design choices.

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
Framework for Comprehensive Community Wellness

A Vision for Upending the Siloed Status Quo

A five-point plan unveils ways that leaders of health care and public health organizations can take action to enhance community wellness.

Mangi01_pullquote - patient flow dynamic work design

Improving Patient Flow with Dynamic Work Design

Staff make big improvements in post-operative care by changing small details.

Lerman01_pullquote leadership development

Leadership Development in Medicine

It is time for a critical assessment of the ways in which health systems develop, select, and support emerging physician leaders.

Perlo01_pullquote community organizing principles for restoring joy in work in health care

Applying Community Organizing Principles to Restore Joy in Work

IHI offers four lessons on how to nurture joy in the health care workforce.

MHCM Physician Leaders Career Paths Post-Graduation

Physician Leader Training: The Value, Impact, and Challenges

Alumni of Harvard’s postgraduate Master in Health Care Management degree program reveal the benefits of academic training, and the real-world challenges for new clinical leaders that can lead to success as well as frustration.

Nurok02_pullquote - physician-hero - team-based care

The Adverse Impact of the Physician-Hero

In a value-based world, the sickest patients need the benefit of a comprehensive team to provide evidence-based treatment that will deliver desirable clinical outcomes while optimizing the cost of care.

Patel01_pullquote - interprofessional education and collaboration

Interprofessional Collaboration for a Health System in Crisis

To overcome current failures within our health systems, we need to improve interprofessional education and collaboration.

Tina Freese Decker

Cultivating “Systemness” to Create Personalized, High-Reliability Health Care

Becoming a high-reliability health system that is personalized, efficient, and effective means making some tough choices.

Shapiro01_pullquote - Using Simulations to Improve Physician Leadership Hiring

Using Simulations to Improve Physician Leadership Hiring

Department chairs are expected to motivate and inspire a diverse group of smart, ambitious, overworked physicians. But for most, it’s a challenge.

Standard Daily Management Visual Board at Baptist Health

Using Daily Management and Visual Boards to Improve Key Indicators and Staff Engagement

Baptist Health leverages Daily Management as a way to engage frontline staff and create a data-driven problem-solving culture to help the health system achieve its goals.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Leading Transformation

205 Articles

A Vision for Upending the Siloed…

A five-point plan unveils ways that leaders of health care and public health organizations can…

Moving from a Sickness Model of…

The expense of the U.S. health care system is so misaligned from what we need…

Physician Burnout

37 Articles

Applying Community Organizing Principles to Restore…

IHI offers four lessons on how to nurture joy in the health care workforce.

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now