Tuesday, January 27, 2009

The Placebo Effect

Penicillin was a wonderful discovery. Before that doctors had very few medicines that worked - morphine, aspirin, digoxin, ether, chloroform, atropine, adrenaline, cocaine, and very few others. Penicillin opened the door to a huge pharmaceutical revolution that continues to this day. Despite this, there have been doctors around for thousands of years. Whatever did they do?

Their practice was very similar to that of the purveyors of alternative medicine today. First, they had a uniform. It differed from age to age, but when I was young it included a frock coat, top hat and arrogant affect. Later doctors had white coats and other paraphernalia. Nowadays it is likely to be surgical scrubs.

Second, they had equipment. To be honest it is very hard to distinguish the various noises heard down a stethoscope - chest physicians always believe the X-ray rather than their 'tubes' and cardiologists want an ECHO whatever their stethoscope tells them. Anyone other than an ophthalmologist looking with an ophthalmoscope is probably making it up, and ophthalmologists prefer to use a slit lamp.

Third, they had a ritual. Part of this is the medical examination. We hospital doctors are apt to scoff at general practitioners who don't examine their patients, and certainly the physical is good for some things. I once was referred a case of anemia to investigate by a consultant surgeon. Imagine his embarrassment when I stuck a finger in the rectum and detected a stonking great, bleeding carcinoma. Most complicated is the neurological examination with its reflexes and finger-nose pointing. But whenever a neurologist came to see one of my patients the first thing he would do was ask for an MRI scan, no matter what we had found on examination.

The physical examination is of absolutely no use when performed by a junior doctor. They do not have sufficient gravitas. The examination should be undertaken with a serious face at a deliberate pace, with pauses for reflection and many a "Hmm" interspacing the touching. "Say '99'" is a wonderful device; it shuts the patient up and adds a sense of mystery. It is very important that the patient completely disrobes. Stethoscopes poked through a gap in the clothing do not have the same therapeutic effect.

Ritual is very important. The consultation should always begin with the doctor rising to greet the patient. Hand shaking is very effective even if it does spread germs. Eye contact is good. Taking the history well is more important than anything and it is vital to let the patient tell his or her story in his or her own words. Leading the witness misleads the physician. It is important to get the story right, but of even more meaningful is the process of instilling in the patient the feeling that he or she is of value and worth listening to. Without the enormous modern medical bureaucracy the doctor of old had time to listen and put the patient at ease.

Never let anyone tell you that alternative practitioners have nothing to offer. Of course their oils and needles have no therapeutic effect, vast doses of vitamins and strange diets are completely useless. Enemas are good for constipation and colonic washouts are useful as preparation for colonoscopy, but they incorporate no magic cures. A recent study demonstrated that acupuncture needles stuck in the wrong places were as effective as needles stuck in the proper meridians - but they were effective. Just as doctors in the 1930s were effective. They all make use of the placebo effect.

'Placebo' is Latin for 'I please'. The placebo effect is what happens when a doctor goes through all the ritual of diagnosing and treating a patient and prescribes colored water. Although this sounds like deceit and fraud, the fact is that a proportion of patients will get better from whatever they are suffering. Ye, whatever they are suffering from. You might well expect a response from patients with chronic fatigue or headaches or backache, but placebos can heal up ulcers, abolish angina and even produce remissions in cancer.

Studies have been done on the placebo. Two pills are better than one. Injections are better than pills. Green pills are better than red ones, unless you are looking for a stimulant effect when red or orange ones are best. It is even possible to cure nausea by instilling a drug designed to make you vomit, directly into the stomach if you are able to convince the patient that what you are giving is an anti-emetic rather than an emetic.

You may believe that you are immune to the placebo effect, but if you are then why do you buy branded painkillers rather than straight ibuprofen. I know they work better but why? Because of the placebo effect. And they cost more. That's part of the placebo effect; expensive placebos work better than cheap ones.

Back in 1972, that sensible physician Richard Asher (yes, he was Jane's father) wrote, "If you can believe fervently in your treatment, even though controlled tests show that it is quite useless, then your results are much better, your patients are much better, and your income is much better too. I believe this accounts for the remarkable success of some of the less gifted, but more credulous members of our profession, and also for the violent dislike of statistics and controlled tests which fashionable and successful doctors are accustomed to display."

The problem with placebos is that they involve lying to patients. Placebos don't work if you say to a patient, "I'm giving you a sugar pill. There is absolutely no reason why it should make you better except for the 'placebo effect' which no-one understands but it probably acts psychologically." Or do they? A trial of sugar pills for pain that had been diagnosed as 'neurotic' was carried out at Johns Hopkins Hospital, with just such an explanation. The patients improved considerably.

Never apologise, never explain, goes the old adage. But we can't get away with that these days. We are obliged to tell patients the truth and to explain fully what we are about to do. The Philosopher and doctor Raymond Tallis has written, "The drive to keep patients fully informed has led to exponential increases in the formal requirements for consent that only serve to confuse and frighten patients while delaying their access to needed medical attention."

Alternative practitioners are not burdened by the same restrictions. They can look into your eyes and give you an explanation that sounds sciencey, but is in fact gobbledygook. Watch the TV for adverts for anti-aging creams to see what I mean by sciencey.

Actually, I think it is possible to invoke the placebo effect without telling lies and good doctors do it all the time. After I retired I handed on my patients to other physicians. I was surprised at how many of them promptly died. There was no change in treatment, only a change of treater. One patients illustrates the case starkly. She had cancer of the body of the uterus. She had refused surgery, chemotherapy and radiotherapy and all I did was see her, take a blood test and talk to her. I was astonished that her cancer did not progress. It remained static for three years. Then I retired and six months later she died. Somehow she had fixed on me as a walking placebo.

It should be possible to say to a patient without too much mendacity, "We have exhausted the latest treatment - we must now start thinking for ourselves. This is a concoction that I have tried before in cases like yours and it sometimes works. I don't know how it works - I could make up a scientific sounding explanation if you like - but I won't insult your intelligence. It is important though that you take it in the way that it is prescribed. You must take it on an empty stomach (and here you can invoke any ritual you think they will wear - standing on one leg, facing Mecca, drinking out of the back of the cup or prunes for breakfast) and I will see you every week if you can afford it. Unfortunately, it's not cheap, but if it works it will certainly be worth it."

Some of these people could sell snow to the Eskimos.


Andy said...

Hi Terry.How great it is to see such knowledge for us to share on blogger !. I recently joined the CLLC community, and followed the link to you blogger page. Are you involved at all with any aspect of the Anthony Nolan Trusts Cord Blood collection initiative at kings college ? I have spoken a few times to terie, the lady who handles the consent and collection of cord blood there, and I am currently attempting to establish some sort of scheme up here in the Midlands although it is proving a lot hareder than i imagined it would be !.Best wishes.Andy

Terry Hamblin said...

I go to Kings about once a month and my contact with the Anthony Nolan people is very peripheral.