Image is everything. This is one of the fundamental governing principles of our current society propagated by our collective narcissism and ignorance. Reality is irrelevant. Truth is irrelevant. The only thing that matters is how carefully one can construct their image that casts them in the most favorable light. People spend hours perfecting their selfies, timing their posts for maximal viewing, and openly identifying with subjects that best represent how they feel they want to be viewed. One only need to browse Twitter, Instagram, Snapchat, Facebook, or take a time machine back to the early 2000s and find a Myspace account to fully appreciate the fact that we prefer our Matrix constructs over our IRL alternatives. I imagine many would view these self-constructed echo chambers as benign. The assumption being that those who are doing “important” things are not equally engrossed in this triviality. However, assumptions are bad when those making them are clueless. And they are dangerous when the subject of those assumptions believes in them.

Just look at medicine.

Physicians serve as a quintessential example of what many would classify as “people doing important work”. Most would like to believe that the decisions physicians arrive to and the actions they take are driven by objective facts derived from an objective reality. Physicians are rational beings with years of training and practice. They are superior beings capable of accurately weighing all options and assessing all scenarios in order to formulate an appropriate treatment plan. They are Mommy AND Daddy. This is the first lie.

Physicians are not perfect. Many physicians may not even be competent. But that truth, that objective reality, is not pleasant or comforting. Quality is assumed not because we are trusting but because we are fearful; our parents are perfect until a judge says otherwise. Perfection is a hard standard to meet and this image of physician perfection was not constructed by physicians but by patients. Even in an age where you can find any number of stories about physicians doing dumb and corrupt things, the expectation of excellence is still there; no one intends to see Dr. Just Barely. Despite this being a childish expectation, many patients can’t be faulted for maintaining it. The practice of medicine is equivalent to voodoo crossed with applied physics in the minds of most patients. They know there has to be something to it but it all still looks like hand waving and jibberish. This image becomes nothing more than a defense mechanism against anxiety which ends up being directly proportional to physician pedestal height. And as protective at this image may be for some patients, it is equally toxic to the physicians of interest. Perfection is a high bar and most physicians would prefer to not make that jump if only because many who try often end up at the bottom of a tall building.

“So patients are to blame for everything?! Doctors are blameless?”

Not hardly. We may not have created the image but we don’t do much to refute it either. It is ingratiating and we are cowards. Many of us secretly enjoy the feeling of perceived superiority no matter the consequences. It’s the closest thing to power most of us will ever get to experience. It also serves as the gateway for our own delusions involving patient care.

When it comes to patient care, physicians make a lot of decisions. Most physicians believe that the decisions they make are based off information acquired from high quality clinical trials and supported by official recommendations from medical organizations represented by an alphabet soup of abbreviations. The ACC/AHA, AMA, AFP, ACP, USPSTF, ACOG, AGA, ADA, APA, and IDK must know something! Never mind the fact that most guidelines are frequently based off “expert opinion”, that most experts cannot agree on anything, that most studies exclude large portions of patients with medically relevant co-morbidities, or that IDK is not even a medical organization. None of that is relevant. The only relevant part is that there are groups of wizards behind curtains conjuring forth guidelines, misinterpreted as mandates, that ensure appropriate patient care and positive outcomes. In an attempt to be more succinct, patient care is driven not necessarily by what is right or wrong but by what many physicians view as the image of appropriate treatment.

“But that’s the standard of care! Are you advocating that we not provide standard care for all of our patients?! What if there was a bad outcome? How would you defend yourself then?!”

That’s the visceral response programmed into all of us when confronted with guideline dissent. It’s a response generated partially by fear and deference to authority and maintained by our own delusions. We need to believe that what we are doing is correct. We need to believe that we are doing the “right” thing and not simply following arbitrary rules or practices because we know what is best for the patient. We strive to project the image of good care even if that care turns out to be harmful. One only need to take a close look at the protocols for Surviving Sepsis and the consequences associated with iatrogenic salt water drowning. Despite objective evidence telling us otherwise, it is still common practice to flood the septic patient with ungodly amounts of fluid and then pat ourselves on the shoulder when they are intubated for pulmonary edema. “But we did everything by the book!” Can’t argue with that. But that doesn’t make it right. “I don’t get it.” I know.

This concept that “Image is Everything” is so deeply ingrained in medicine at this point that I doubt many people even see it. Or worse, I doubt many even see a problem with it. “Doesn’t it serve as a means of improving compliance?” Well, yes, but that’s the problem. Compliance seems to always be the goal. What does it say about a group of people whose only goal in life is to be compliant? Or better yet, to view the perception of compliance as the main objective? How deep will we travel down this hole and with what tools are we willing to use to maintain this folie simultanée?


I imagine if anyone in the medical field read this they may vehemently reject the entire premise. I get it. It’s difficult to face such an unflattering reality. It’s much easier to continue in a state of ignorance focusing on the optics instead of the outcomes. After all, this is America! But at some point, we will need to determine what is more important. Do we value the practice of medicine or do we value the image of practicing medicine?

And how does that look?

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