Enjoyed this column. The placebo effect is even seen outside medicine as in the famous Hawthorne Effect. Human physiology and human behavior are both affected when changes are even thought to be the result of another human caring about us.
The corruption of our health students has become obvious to me during the past few years, especially with the Covid fiasco. Just as digital currency has degraded the humanity of transactions, so has data entry distanced modern nursing and student from hands on and empathic health care. It appalls me that a patient's first view of their attending staff is often their backs whilst they tick boxes on paperwork or tablets.
It is evident that digitisation and standardisation of health processes has robbed the patients of individualised health care based on the practitioners insight, expertise and experience. Non adherence to such standards increasingly gives rise to 'concern' or disclipinary action from the agents of clinical governance. Such processes and 'standards' are, of course, manipulated by industry to further their fiscal and influential advantage.
One of my nursing school teachers told of a time he was working in an oncology unit. One of the children on the unit had end stage bone Mets and was living on a PCA pump, to little avail. When he expressed concern to the charge nurse of the pain and agony this child was in, she said “follow me.” She grabbed a saline flush, and went to the child’s room. She said “so the pain’s really bad today, huh? Do you need your special pain medicine?” After the child’s assent, she flushed his other IV and the child visibly relaxed within about a half hour and slept much of the rest of the shift.
Oct 3, 2022·edited Nov 4, 2023Liked by Adam Cifu, MD
Honestly it should be that any sign/symptom related to the nervous system needs to be assessed under RCT for placebo effect. Voodoo "works" on some things that voodoo people believe in. The human mind is highly capable of delusion. 7000 years of believing in sky daddies proves this.
Patient here. Great timing on this article! Just last week, I arranged to see a new primary care doc for much of the reasons you discuss here. I want a doc who listens to me, sees me, educates me (when appropriate), and recognizes my agency (telling me what to do is unacceptable). Thx
I hadn't thought of the effectiveness of placebos in a long time, or using them purposefully. Too bad doctor's visits have been reduced to a 10-minute appointment. This is business-based medicine, and I don't even think the doctors like it.
I liked hearing about your experience with the physical therapist. That was my career and I loved it. 😊
The physical body is not separate from our consciousness or our emotional selves. Love caring and warmth is good for both the body and soul..
What do you think about the other problem with placebos: medicalization. When placebos are used, we medicalize problems that don’t really need medical attention. This is probably an issue that contributes to medical costs and possibly disparities, and definitely a system bursting at the seams. Deeper, it contributes to scenarios with friends and family of ‘you need to go see your doctor’ instead of conversations like ‘tell me more about that.’ I think we all might benefit more from a culture of ‘that’s going to need some time’ as opposed to ‘you need to see your doctor’. I think the fostering of problem with placebo starts early - like when a child falls during sports and parents run to get those ice packs that don’t even really get cold. The child really just needs some time not an ice pack. What do you think?
You authors probably haven't seen this...I've seen _hundreds_ of these covid vaccine harms tragedies on my news feeds. She was 20 y.o. and beautiful. Cardiac arrest the day after vaccination.
As a long time practitioner and medical school faculty, I have spent endless time on this. Much of this harks back to the "The top third of the class does the best research, the middle third make the best clinicians, and the bottom third make the most money" adage for medical school classes: the bottom third generally had the most/best interaction and made patients feel like they cared.
Making a patient feel like you care is an art form that is virtually never taught any more -- to the greater detriment of doctors and patients. And this gets worse, sadly, as most physicians now become employees of organizations who have great lip service about patients, but who fundamentally actually do not really care about any individual patient.
IT/EMR solutions which are NEVER patient-oriented (I can (and do) write books about this) suck valuable time away from patient interactions in the service of lawyers and documentation without value. Performance metrics based on throughput more than quality (the most abused term in health care) do not help either.
Finally, the recruitment of current students is only making this worse. There was a time when students were admitted to medical school because they were smart and they had a burden to do the best thing toward making people "get better". Now admissions are based on demographics and social justice warrior scores. Those SJW scores are all for some "cause" -- not for the patient sitting in front of you now. Because of the deprecation of admission criteria, we now no longer test students adequately (it is all pass/fail and people do not fail) to see how good they are at ANYTHING -- it is not hard to pass since no one wants to be stuck remediating these people and the boards are now pass/fail anyway so they will get through there, too. Students insist on "knowing the test questions" to make their lives easier -- even though the point of the test questions is to make sure you know THE MATERIAL so that you can APPLY IT TO REAL PATIENTS -- not to answer the test questions. But that sense is lost and/or they do not care.
These students (and I have been doing this for decades) are also characterized by having a disproportionate number who are mostly worried about their OWN life/health/balance/whatever -- not their patients'. This transition to self-focus (and I do not mean self-introspection) also deprecates the patient interaction as students/house staff walk out of the room when their "shift" is up, irrespective of the condition of the patient or the process.
So this is about more than placebo effect -- this is more the "caring" effect and it matters. Kudos for pointing that out in this article. But somehow we need to do more. Some of us try, but it seems too little, too late.
I agree the placebo effect is real. However, the designs of most trials do not allow us to differentiate between placebo response (any improvement that happens in the placebo group) and placebo effect (the physiologic response). For example, a large amount of the placebo response seen in seizure trials can be accounted for by the high levels of natural seizure frequency variability, regression to the mean, inaccurate seizure diaries and the use of change from baseline statistics with dichotomization. See the work done by Dr. Goldenholz's lab at MGH. This does not discount that there isn't a placebo effect in seizure frequency, but certainly shrinks the possible size of the effect. I recently made a video on migraine trials and why trial design makes them difficult to interpret and can exacerbate the placebo response. I hypothesize migraines have a large placebo effect compared to the effect in seizure trials, but the size is hard to measure based on current trial design. See https://www.youtube.com/watch?v=wqhWYmRfJPI
Lastly, if the argument is a plea for physicians to be validating, warm and kind to their patients because placebos work then I worry we are attracting the wrong people to the profession. Being warm and kind to others is good irregardless if it heals. It is something we should want to do. I once read a book on parental influence that summed it up nicely. After reviewing all the different parenting methods and being inconclusive of what was effective she wrote, don't hug and kiss your kids because you think it will make them better people, do it because that's what you want to do, you love them and want to be with them.
I have never met you, but everything I have read about you makes me think you are a genuinely kind and compassionate human being. I am willing to wager that you would not change one iota of how you treat your fellow human beings if you read a trial that lessened your belief in the power of the placebo effect.
Sep 30, 2022·edited Sep 30, 2022Liked by Adam Cifu, MD
“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.”
- The Modern Hippocratic Oath
Thank you Dr. Cifu. Being a woman of a certain age, I remember when doctors were true physicians with a warm caring bedside manner, who you could call at night if someone was sick and they made housecalls. The family doctor would arrive with his black doctor bag, sit on your bed, take your temperature, have you say " AHHH", listen to your chest, make you take a few deep breaths , take your blood pressure , whatever physical exam was appropriate. He would pat your hand assuringly, if you were a kid
maybe tell you a silly joke, ask you about your dog smile at you, look in your eyes and ask you if it hurt anywhere. These doctors (and we also had a great female pediatrician who would come to the house) made you feel better just by their presence.
A visit to the doctor not only included a proper physical exam done by the doctor himself but after you'd gotten dressed you were shown into the doctor's office where are you sat with him and talked for a good amount of time. He asked you questions and it was a conversation. chances are he knew your whole family too. Any diagnosis or prescriptions were given at that time and the whole thing was very civilized. You left feeling that you had really been seen, heard and cared for as a person. Your doctor knew you and cared about you. He was your family doctor and often it was a lifelong relationship unless you moved away.
My godfather was such a physician. He was a country doctor in Connecticut. He knew everybody by name in the community. His patients returned for generations. He watched children grow up and have children of their own and he knew all their names. Everybody loved him because they knew he cared about them and he was smart and always put you at ease with his gentle voice and Carolina accent. Uncle Craig had a lovely sense of humor anr knew just what tsay to assure you'd be right as rain soon. He also knew when to prescribe a placebo
(years later he confided in me about this).
I love this article and I hope it will be shared far and wide. THANK YOU.
✨🩺 Every doctor in America should be required to memorize, recite and retake the Hippocratic oath on a yearly basis!
I agree with a number of your points along your main thesis, but had difficulty getting past the first few paragraphs. I'm not quite sure how roots and herbs are categorized as placebos. Especially considering aspirin is found in white willow bark, digoxin/digitalis in foxglove, and quinine in cinchona trees. The World Health Organization acknowledges the botanical sources of so many drugs used today. Surely you don't consider those placebos?
Enjoyed this column. The placebo effect is even seen outside medicine as in the famous Hawthorne Effect. Human physiology and human behavior are both affected when changes are even thought to be the result of another human caring about us.
The corruption of our health students has become obvious to me during the past few years, especially with the Covid fiasco. Just as digital currency has degraded the humanity of transactions, so has data entry distanced modern nursing and student from hands on and empathic health care. It appalls me that a patient's first view of their attending staff is often their backs whilst they tick boxes on paperwork or tablets.
It is evident that digitisation and standardisation of health processes has robbed the patients of individualised health care based on the practitioners insight, expertise and experience. Non adherence to such standards increasingly gives rise to 'concern' or disclipinary action from the agents of clinical governance. Such processes and 'standards' are, of course, manipulated by industry to further their fiscal and influential advantage.
One of my nursing school teachers told of a time he was working in an oncology unit. One of the children on the unit had end stage bone Mets and was living on a PCA pump, to little avail. When he expressed concern to the charge nurse of the pain and agony this child was in, she said “follow me.” She grabbed a saline flush, and went to the child’s room. She said “so the pain’s really bad today, huh? Do you need your special pain medicine?” After the child’s assent, she flushed his other IV and the child visibly relaxed within about a half hour and slept much of the rest of the shift.
The body is powerful!
Honestly it should be that any sign/symptom related to the nervous system needs to be assessed under RCT for placebo effect. Voodoo "works" on some things that voodoo people believe in. The human mind is highly capable of delusion. 7000 years of believing in sky daddies proves this.
Patient here. Great timing on this article! Just last week, I arranged to see a new primary care doc for much of the reasons you discuss here. I want a doc who listens to me, sees me, educates me (when appropriate), and recognizes my agency (telling me what to do is unacceptable). Thx
I hadn't thought of the effectiveness of placebos in a long time, or using them purposefully. Too bad doctor's visits have been reduced to a 10-minute appointment. This is business-based medicine, and I don't even think the doctors like it.
I liked hearing about your experience with the physical therapist. That was my career and I loved it. 😊
The physical body is not separate from our consciousness or our emotional selves. Love caring and warmth is good for both the body and soul..
Adam -
Excellent!
Your article should be required reading for all physicians.
What do you think about the other problem with placebos: medicalization. When placebos are used, we medicalize problems that don’t really need medical attention. This is probably an issue that contributes to medical costs and possibly disparities, and definitely a system bursting at the seams. Deeper, it contributes to scenarios with friends and family of ‘you need to go see your doctor’ instead of conversations like ‘tell me more about that.’ I think we all might benefit more from a culture of ‘that’s going to need some time’ as opposed to ‘you need to see your doctor’. I think the fostering of problem with placebo starts early - like when a child falls during sports and parents run to get those ice packs that don’t even really get cold. The child really just needs some time not an ice pack. What do you think?
You authors probably haven't seen this...I've seen _hundreds_ of these covid vaccine harms tragedies on my news feeds. She was 20 y.o. and beautiful. Cardiac arrest the day after vaccination.
https://citizenfreepress.com/breaking/healthy-young-student-is-dead-one-day-after-covid-vaccine/
Come for the study analyses, subscribe for the Friday reflections :)
So nice to see this in writing, having learned it from experience in life, and not as a doctor. Thank YOU for taking the TIME to write! Dana
As a long time practitioner and medical school faculty, I have spent endless time on this. Much of this harks back to the "The top third of the class does the best research, the middle third make the best clinicians, and the bottom third make the most money" adage for medical school classes: the bottom third generally had the most/best interaction and made patients feel like they cared.
Making a patient feel like you care is an art form that is virtually never taught any more -- to the greater detriment of doctors and patients. And this gets worse, sadly, as most physicians now become employees of organizations who have great lip service about patients, but who fundamentally actually do not really care about any individual patient.
IT/EMR solutions which are NEVER patient-oriented (I can (and do) write books about this) suck valuable time away from patient interactions in the service of lawyers and documentation without value. Performance metrics based on throughput more than quality (the most abused term in health care) do not help either.
Finally, the recruitment of current students is only making this worse. There was a time when students were admitted to medical school because they were smart and they had a burden to do the best thing toward making people "get better". Now admissions are based on demographics and social justice warrior scores. Those SJW scores are all for some "cause" -- not for the patient sitting in front of you now. Because of the deprecation of admission criteria, we now no longer test students adequately (it is all pass/fail and people do not fail) to see how good they are at ANYTHING -- it is not hard to pass since no one wants to be stuck remediating these people and the boards are now pass/fail anyway so they will get through there, too. Students insist on "knowing the test questions" to make their lives easier -- even though the point of the test questions is to make sure you know THE MATERIAL so that you can APPLY IT TO REAL PATIENTS -- not to answer the test questions. But that sense is lost and/or they do not care.
These students (and I have been doing this for decades) are also characterized by having a disproportionate number who are mostly worried about their OWN life/health/balance/whatever -- not their patients'. This transition to self-focus (and I do not mean self-introspection) also deprecates the patient interaction as students/house staff walk out of the room when their "shift" is up, irrespective of the condition of the patient or the process.
So this is about more than placebo effect -- this is more the "caring" effect and it matters. Kudos for pointing that out in this article. But somehow we need to do more. Some of us try, but it seems too little, too late.
I agree the placebo effect is real. However, the designs of most trials do not allow us to differentiate between placebo response (any improvement that happens in the placebo group) and placebo effect (the physiologic response). For example, a large amount of the placebo response seen in seizure trials can be accounted for by the high levels of natural seizure frequency variability, regression to the mean, inaccurate seizure diaries and the use of change from baseline statistics with dichotomization. See the work done by Dr. Goldenholz's lab at MGH. This does not discount that there isn't a placebo effect in seizure frequency, but certainly shrinks the possible size of the effect. I recently made a video on migraine trials and why trial design makes them difficult to interpret and can exacerbate the placebo response. I hypothesize migraines have a large placebo effect compared to the effect in seizure trials, but the size is hard to measure based on current trial design. See https://www.youtube.com/watch?v=wqhWYmRfJPI
Lastly, if the argument is a plea for physicians to be validating, warm and kind to their patients because placebos work then I worry we are attracting the wrong people to the profession. Being warm and kind to others is good irregardless if it heals. It is something we should want to do. I once read a book on parental influence that summed it up nicely. After reviewing all the different parenting methods and being inconclusive of what was effective she wrote, don't hug and kiss your kids because you think it will make them better people, do it because that's what you want to do, you love them and want to be with them.
I have never met you, but everything I have read about you makes me think you are a genuinely kind and compassionate human being. I am willing to wager that you would not change one iota of how you treat your fellow human beings if you read a trial that lessened your belief in the power of the placebo effect.
I love the evidence based approach, which includes "alternative" modalities.
“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.”
- The Modern Hippocratic Oath
Thank you Dr. Cifu. Being a woman of a certain age, I remember when doctors were true physicians with a warm caring bedside manner, who you could call at night if someone was sick and they made housecalls. The family doctor would arrive with his black doctor bag, sit on your bed, take your temperature, have you say " AHHH", listen to your chest, make you take a few deep breaths , take your blood pressure , whatever physical exam was appropriate. He would pat your hand assuringly, if you were a kid
maybe tell you a silly joke, ask you about your dog smile at you, look in your eyes and ask you if it hurt anywhere. These doctors (and we also had a great female pediatrician who would come to the house) made you feel better just by their presence.
A visit to the doctor not only included a proper physical exam done by the doctor himself but after you'd gotten dressed you were shown into the doctor's office where are you sat with him and talked for a good amount of time. He asked you questions and it was a conversation. chances are he knew your whole family too. Any diagnosis or prescriptions were given at that time and the whole thing was very civilized. You left feeling that you had really been seen, heard and cared for as a person. Your doctor knew you and cared about you. He was your family doctor and often it was a lifelong relationship unless you moved away.
My godfather was such a physician. He was a country doctor in Connecticut. He knew everybody by name in the community. His patients returned for generations. He watched children grow up and have children of their own and he knew all their names. Everybody loved him because they knew he cared about them and he was smart and always put you at ease with his gentle voice and Carolina accent. Uncle Craig had a lovely sense of humor anr knew just what tsay to assure you'd be right as rain soon. He also knew when to prescribe a placebo
(years later he confided in me about this).
I love this article and I hope it will be shared far and wide. THANK YOU.
✨🩺 Every doctor in America should be required to memorize, recite and retake the Hippocratic oath on a yearly basis!
I agree with a number of your points along your main thesis, but had difficulty getting past the first few paragraphs. I'm not quite sure how roots and herbs are categorized as placebos. Especially considering aspirin is found in white willow bark, digoxin/digitalis in foxglove, and quinine in cinchona trees. The World Health Organization acknowledges the botanical sources of so many drugs used today. Surely you don't consider those placebos?