Placebos and the doctor-patient relationship

Judith Graham

Chicago Tribune

What gives placebos -- substances with no known physiological effect on a medical condition -- their power to alleviate symptoms and ease illness?

It's not what they're made of: the salt in saline injections, the sugar in dummy pills, or the nutrients in multi-vitamins. It's their ability to inspire the placebo effect.

The distinction may seem like splitting hairs but it's quite important, insists Dr. W. Grant Thompson, author of The Placebo Effect and Health and a professor emeritus at the University of Ottawa.

Placebos, whether nutritional supplements or sugar pills, are mere props in the medical drama that occurs between doctor and patient, he says.

The real action has to do with a patient's willingness to believe that a doctor can help him and the impact that belief has, independent of the natural course of an illness or other physiological interventions, Thompson explains.

That's the placebo effect. It's essential to the very foundation of medicine -- and a large part what made it possible for doctors to help patients before the mid-20th century, when treatments were largely ineffective.

Today, doctors tend to think that the placebo effect is activated by doing something -- telling a patient to use an over-the-counter painkiller or take vitamins or try acupuncture. And, indeed, almost half of U.S. physicians recommend placebos to patients, according to a new survey in the BMJ published on Friday.

But Thompson thinks that all those pills are, for the most part, beside the point.

"The placebo effect can be engendered without any pill at all by the positivity and the personality of the physician...by simply talking to patients and reassuring them and empathizing with them," he told me Thursday, during a phone conversation from his home in Canada.

"The mere handing of a pill to a patient is a shortcut for this and often, I believe, would not be necessary if physicians took time to communicate with patients about their experience of illness," he continued.

In other words, it is the communication of caring, the feeling of being attended to, the transmission of confidence, the quality of the relationship between doctor and patient that holds the potential to ignite the placebo effect.Of course, what is most lacking in doctor-patient encounters these days is time. So, as Grant notes, pills have become the medium of exchange in medical transactions, a symbol of the doctor's power to heal and the patient's willingness to be healed.

The problem is that this trains people to look to medication as the be-all and end-all. Which is why so many people want an antibiotic anyway, even when their doctors tell them they have a viral flu or respiratory infection and explain that antibiotics don't work against those conditions.

The expectation that something will be done, some medication dispensed or some intervention tried, even when there is nothing to be done, really, ends up distorting the doctor-patient encounter, turning it into a transactional interaction.

The harm comes when antibiotics are dispensed needlessly, heightening the risk that bacteria will develop antibiotic resistance, one of the most dangerous medical phenomenon of our time. Or when patients are given sedatives -- drugs that can have serious side-effects -- only because the doctor wants to give something.(Or, for that matter, when people demand interventions at the end of life that can't really hold death at bay for more than a short time.)

The recent BMJ report documents that doctors are indulging in both practices, typically without fully disclosing to patients the fact that the medications are being given with the hopes of inciting the placebo effect.

Practically, the placebo effect may still underlie much of what's done in day-to-day medical practice, Thompson notes.

"Evidence-based medicine only started in the 1930s, and it's still the case that treatments subjected to clinical trials are almost always new drugs," he said. "That leaves a whole host of things that we do for patients that we believe are important untested scientifically. It could be that the effects that have been observed have more to do with the placebo effect than any other factor."

Source:
http://newsblogs.chicagotribune.com/triage/2008/10/placebos-and-th.html
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