The Placebo
One of my very first “Friday Reflections” was titled “Abrogating our Responsibility to Use Placebos.” When I read this essay by Robert Eidus I was reminded of mine. I enjoyed it for so many reasons, maybe especially for his embrace of a placebo he once spurned.
Adam Cifu
As I looked at my afternoon schedule, I sighed. Lily was coming in. Lily had a very tough life, having grown up in Poland during WWII. She lived with her son, John. For several years, Lily had come in with a series of complaints that I could neither diagnose nor treat. Every treatment seemed to make her worse, but she kept coming back. As badly as I did with Lily, her visits to specialists resulted in even worse outcomes. Typically, she would say that whatever I prescribed caused a terrible burning on one side or the other of her head and body.
That afternoon, I greeted John and Lily and listened to her symptoms. “Primum Non Nocere” we are taught -- attributed to the English physician Thomas Sydenham. “First, do no harm”. Well, clearly, if all my treatments and referrals led to increased symptoms, then I was not living up to the dictum. After a few minutes of discussion, Lily asked, “Doctor, do you think that a B12 injection would help?” “Yes!” I exclaimed. This was the first time that Lily had suggested a treatment that she thought might benefit her. I felt that if Lily believed the B12 shot would work, it was more likely to help and less likely to harm, even if there was no biomedical mechanism of action to explain how it would help, beyond being “just a placebo”.
B12 is a perfect placebo. It is innocuous, inexpensive, red, and injectable. When I was a medical student, I learned that the most disparaging thing you could say about a local medical doctor was “He gives B12 shots.” The implication was that the physician was either a nonscientific know-nothing or a charlatan. But here I was, prescribing a B12 shot.
When Lily came back one month later, she still had her usual physical complaints, but did not complain about the effects of the B12, and in fact, asked for another shot. When Lily became frailer, we made house calls, first by me and then by my nurse practitioner, Dawn. We always took along a vial of B12.
When I hired a new associate, he began making house calls for Lily. Before his first house call to Lily, I told him to bring a vial of B12. “I don’t do that,” he grumbled. Dawn chimed in, “You’ll be sorry.”
Benjamin Franklin was one of the first to use the placebo as an experimental control. Placebos have been well established to produce real physiologic changes, so improvements or harms (the nocebo effect) are not necessarily imagined. There is now considerable evidence of fundamental biochemical changes induced by placebos, reflected in functional MRI scans of the brain.
Depending on the condition, the placebo effect can be considerable. Key chemicals and hormones such as endorphins, cortisol, and dopamine are affected by placebos. Well-established therapeutics like antidepressants for mild to moderate depression often have difficulty demonstrating better effectiveness than placebos.
We use the placebo effect in our daily practice, but we rarely acknowledge it. When I give a prescription medication to a patient instead of a comparably effective over-the-counter medication, am I not harnessing the placebo effect? When I prescribe an SSRI and the patient improves, I do not know, or really care, what got the patient better. If they have a side effect, is that the nocebo effect, and does it even matter? Far too many people are on SSRIs for too long. Have they been on this medication all the time as a placebo? If we stop or taper down an SSRI and the patient gets worse, is the patient having a rebound withdrawal effect, relapse, or is it due to the removal of the placebo? There are no answers to these questions..
In Reiki, a practitioner uses his or her hands to deliver energy, either touching the patient or hovering slightly above the patient. Western physicians often dismiss Reiki as hocus pocus. But aren’t we doing the same when we perform a routine physical examination as part of a wellness exam? The placebo effect is around us in almost everything we do as physicians. We should understand it, appreciate it, and, when appropriate, embrace it.
After a few months, I saw my new associate quietly slip a vial of B12 into his doctor’s bag before he went to see Lily. He continued to attend to Lily and support John. Lily reached her 100th birthday before she died. She suffered a lot, but I think the house calls and the B12 injections allowed her to suffer a little less. They certainly did no harm.
Coda: I spoke to Dawn while I was creating this piece, and this is what she had to say:
“Those years and years of house calls to give B12 injections provided the perfect provider-patient shared experience moment. Each time we were there to give that injection, we were also gifted the opportunity to listen to the stories of her life that she chose to share with us, and maybe that, too, added to the “magic” and power of the placebo effect for her.”
Robert Eidus, MD is a Family Physician in Walnut Creek, California
Photo Credit Tati Visual
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B12 or not. The real Healing was actually your empathy-compassion-listening power-and donation of your time. That was an expression of your character and a testament to being a great physician. Great job.
Under no circumstances can addressing a nutritional deficiency be considered a placebo treatment! Likewise, causing too much B12 can cause problems.
B12 injection, by definition, cannot be considered a placebo. Missing from this article is whether Dr. Eidus checked Lily's serum B12 levels, and whether she had transfer factor deficiency; both are common in elderly patients. Some brands of B12 injection also contain transfer factor.
It's also possible that her serum levels were low enough to cause symptoms noticeable to her, and the injections had real clinical benefit. It's interesting to note that in Japan, higher lab values are used to define and treat B12 deficiency than in the US. Especially with elderly patients, could we be under-diagnosing this in the US?
All that said, yes, placebo treatments can have real clinical benefit, and there may have been a placebo effect for Lily, with it without B12 deficiency. But still, it's inaccurate to call a B12 injection a placebo.