Friday Reflection 6: Abrogating our Responsibility to Use Placebos
AC is a 45-year-old man who presents to a pain medicine practice with a C-7 radiculopathy. His pain developed after a fall two weeks prior to the visit.
For thousands of years, pretty much the only treatments a doctor had to offer were placebos.
This is not to say that my predecessors were useless. They were often excellent diagnosticians. They excelled at providing prognoses, having spent years observing the natural history of diseases. The best physicians were exceptional at comforting the sick. However, they did not have much in the way of effective treatments. Focusing just on medications, there are probably fewer than a dozen therapeutics I use today that were part the arsenal of the pre-20th century doctor: aspirin, digoxin, quinine, a few vitamins…
We generally define a placebo as a harmless pill or procedure prescribed more for psychological benefit than for any physiological effect. We should be a bit more expansive with this definition. The procedure might be invasive but is might also be a particularly therapeutic interaction. Good doctoring is, to a great extent, a placebo, with no negative connotations about that word. I place enormous value on good doctoring.
What doctors of old used for therapy was the skillful application of placebos: exquisite bedside manner; a root or herb; bloodletting. These treatments were effective. In the last 50 years we have learned that a doctor wielding a placebo can do a pretty job at making people feel better. In general, a well-employed placebo can be expected to have a modest, short-lived effect on subjective symptoms. Here are a few of my favorite examples of the power of the placebo.
A 1978 study published in The Lancet looked at patients undergoing surgery for impacted molars. In the first stage of the study, a subgroup of patients was identified as “placebo responders.” These were patients who, after receiving a placebo for post-operative pain experienced improvement, or at least no worsening in their pain, as their local anesthesia wore off. When these patients were subsequently given the drug naloxone, a drug that blocks the effect of opiates, the benefit of placebo disappeared. This study suggested that the placebo response is due to real physiologic changes in the body. When experiencing pain, our brains secrete natural substances similar to opiates.
Most of us know that a placebo helps with pain. Every one of us has experienced the analgesic effects of a placebo, witnessing the pain of a scraped knee being relieved by a parent’s kiss. But placebos work for more than pain.
People with asthma know the benefit of an albuterol inhaler. The drug rapidly dilates airways temporarily relieving the wheezing and shortness of breath of an asthma attack. A study published in the New England Journal of Medicine in 2011 showed that a placebo inhaler does just as well as albuterol. People in this study were randomized to four different therapies: an albuterol inhaler; a placebo inhaler; sham acupuncture; and no intervention. After use of the treatment the patients underwent spirometry, a test that measures how well air moves out of the lungs. They were also asked how they felt. The spirometry results, the objective measure of lung function, showed that only albuterol helped the asthma. Subjectively, however, the placebo treatments (inhaler or acupuncture) were as good as albuterol.
So, placebos work for pain and shortness of breath. Let’s go one step further.
A study published in the journal Neurology looked at a new treatment for seizures, responsive cortical stimulation. Patients with the most difficult to control seizures had a device implanted that sensed when a seizure was beginning and delivered a small jolt of electricity to abort the seizure. The study showed that this treatment was effective, reducing seizure frequency by 40-50%. This was a striking finding but the more fascinating finding was what was found in a subset of patients in whom the researchers tested a placebo. In these patients, the researchers implanted the device but did not turn it on – thus turning it into a sham intervention. It turned out that just telling patients they had a device that would reduce seizures, actually decreased seizure frequency by about 25%. As expected with a placebo intervention, the effect was modest and wore off with time.
Let’s look at another example that is more in line with what this piece is about, the effect of human interaction. In a beautiful study published in the BMJ, 262 people with irritable bowel syndrome were randomized to three different modes of therapy. The first group was placed on a waiting list, basically getting no therapy. The second group got a placebo procedure (sham acupuncture). The third group got sham acupuncture plus visits with a practitioner who focused on warmth, attention and confidence. Not surprisingly, the more attention paid to you, the more symptom relief you achieved.
The other illnesses that placebos have been shown to help, from meniscal tears of the knee to angina to spinal compression fractures, could fill an entire book. In this book, we would, of course, discuss how placebos even work if the patients know they are getting a placebo, the so-called honest placebo. But let’s get back to our patient and doctors forsaking the powerful effect of the placebo.
We can abandon anonymity here and I’ll describe the case in the first person. I was playing soccer with my kids, three of us, on Promontory Point in Hyde Park. I was fooling around, dribbling the ball to keep it away from my miniature defenders when I stepped on the ball and fell flat on my back. There was about a five-second pause before two children landed on top of me, a bit gleeful.
The next day, while working in the clinic, I noticed a dull ache in my left chest. The ache was positional and after bit of maneuvering, googling and browsing a primary care orthopedics textbook, I convinced myself that I had a pectoralis minor strain. The ache was annoying but intermittent and not that bad. I figured it would resolve with time.
The next week we traveled to see my mother-in-law. I took my standard position in the back seat of her car, between the two children, with her and my wife in the front. During the drive, needing to make some pithy comment, I grabbed onto the driver and passenger seats and pulled myself forward. I immediately felt a shooting, dysesthetic pain radiating from my neck to my left middle finger -- textbook C-7 neuropathic pain. I forgot what I was going to say and, instead, I explained my diagnosis.
“When I fell, I must has herniated a disc that is now pushing on my C-7 nerve root.”
When I returned home, I told my primary care doctor that I needed an MRI and an appointment in our pain unit. He knows which battles to fight so he made these appointments but also scheduled me in physical therapy.
The MRI confirmed a small C7 disk herniation. The pain therapy appointment followed soon after. My memory of the appointment might not be totally accurate – this was a decade or so ago – but maybe my impression is more important than fact. The physician, who never sat down, was uninterested in my story about the injury -- he had the MRI, what more was there to learn? The physical exam was brief, verifying that my reflexes and strength were intact. He explained why a cervical epidural steroid injection was not indicated (risk of harm outweighing the chance of benefit) and handed me a prescription for gabapentin. The visit lasted 10 minutes. The prescription lasted in my hand for even less time before it was deposited in the garbage.
How do we feel after hearing bad news? My own experiences and those of my patients tell me that uncertainty, sadness, and regret are common. How will I live with this new reality? It’s awful that my health has changed. I can’t believe I did X, Y or Z to get me into this situation. A little anger sometimes makes its way into the mix.
My next stop was to see the physical therapist. She and I spent the first 10 minutes of this visit discussing my history. We sat face to face, me on an exam table and her, positioned a little bit lower than me, on a chair. The therapist spent the next 30 minutes with her hands on me, fully engaged, figuring out what was wrong and what we would do. I left this visit feeling about 75% better. Knowing the anatomy and physiology, I don’t think anything actually changed in my neck. What changed is that I felt cared for and had some certainty about a plan and an outcome.
Over the next few weeks my pain resolved completely. I was adherent to the recommended exercises, but I suspect I would have recovered even if I wasn’t. I continued to see the physical therapist for the predictable aches and pains of an aging body over the next decade. When she moved out of town, I gave her a card with a stick figure diagram of me. I highlighted every part of my body to which she had attended.
The doctor, I never saw again.
If we assume that neither of these visits had much effect on what was actually happening with my condition, the fact that one made me feel better while the other made me feel, if anything, worse, is my personal testimonial to the power of the placebo.
Why have doctors who practice (conventional, allopathic, western) medicine stopped intentionally utilizing the power of the placebo? The placebo that was their most effective therapeutic tool for thousands of years. The modern Hippocratic Oath, written in 1964 by Louis Lasagna, the former Dean of the School of Medicine at Tufts states:
“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.”
Given that the impact of caring appears in our oath, maybe we haven’t just abandoned our use of the placebo, maybe we have abrogated our responsibility to use it.
Our changing practice is probably a victim of medicine’s success. We have treatments for illnesses that the placebo effect, whether in the guise of a caring physician, a sugar pill, or a harmless but ineffective procedure, could never match. Why use something that takes time to employ and whose benefit is small and temporary when we have treatments that can definitively change the course of illness?
Because many of our life-saving treatments also affect the body in measurable ways, we’ve become obsessed with benefits that are measurable. Nowadays, we often value quantitative improvements over improved well-being. It is more important that the systolic blood pressure has gone from 140 mm/Hg to 130 mm/Hg or the glycosylated hemoglobin from 8% to 7% than that our patient feels better. Physicians are judged by the numbers. I could get a bonus by demonstrating that my patients have better blood pressure control and higher rates of pap smears while failing to earn a dime if all my patients feel better. (Ooops, did I let some bitterness slip out?)
Saying we abandoned our use of placebos suggests that doctors in the past willfully, knowingly, employed them. It’s likely doctors never really considered their interventions to be placebos. It is probably because they were unaware that their use of placebos was effective. In this regard, they were similar to today’s practitioners of so-called alternative medicine, who I’ll leave unnamed to avoid their wrath, who don’t acknowledge that much of what they offer are placebos.[i]
Placebo treatments can, of course, be dangerous. Imagine a man diagnosed with a small cancer, one that could easily be resected for cure. Instead, he chooses to seek alternative care, a placebo. He spends thousands of dollars on various concoctions, some which cause terrible nausea. When he finally returns to seek conventional care for his disease, he learns that his cancer has metastasized. All that can be offered at this point is palliative care. A placebo is harmful if it is expensive, physically injurious, or delays treatment that is of proven benefit.
Of course, we should not abandon any of the remarkable advances that have led HIV to be treated as a chronic condition, markedly reduced the incidence of cardiovascular disease and, most recently, enabled us to prevent hundreds of thousands of deaths from COVID-19. Yet we have to find a way to incorporate the power of the placebo, primarily in the form of caring, into medicine. Placebo treatments are an adjunct to conventional care and they have a role to play when we treat problems for which we lack perfect therapy. Having a physician who cares about you, in addition to caring for you, whose office you leave feeling better than when you arrived, should not be an uncommon luxury. It should be an integral part of what we consider medical care.
[i] I am going to assume that these practitioners fully believe in their therapies. If they don’t, they are mere grifters.