Summertime, time, time
Child, the living’s easy.
Fish are jumping out
And the handicap, Lord
Handicaps high, Lord so high
~ Janis Joplin
It is summer. Time for the kids and the outside, not the computer. What follows is a summertime blog entry, for which I admit to feeling guilty for the comparatively little time I have spent on it, but as I have said before, no dying patient has ever told me “Doc, I wish I had spent more time at work.”
Mt. Hood has been a constant feature to the east my entire life. The mountain, on a clear day at least, is Portland’s most impressive geologic feature. If you are in the right part of the city, you may see Mt. St. Helens or the tips of Jefferson, Adams and even Rainier, but Mt. Hood dominates. It is solitary mass of rock, (diminishing) ice and snow only 50 miles from where I live. I have spent uncountable hours hiking in the Mt. Hood wilderness. When I think of Mt. Hood, in my mind’s eye it is from the perspective of west Portland looking east.
Last week was our yearly summer vacation in Sunriver, just south of Bend Oregon on the eastern side of the cascades in the Oregon High Desert. Driving north/south on highway 97 puts Mt. Hood in a different perspective. From the high desert you can see the huge swaths of the Cascades: calderas, mountains, lava fields and cinder cones. You see Mt. Hood differently. Not a single mountain to the east, but part of a chain of recent and distant historical volcanic activity along the Rim of Fire. Photographs do not do the view of the Cascades justice from this vantage point.
The eastern view puts Mt. Hood in a broader geologic and time perspective. It is still the same Mt. Hood, but in a different context. Like running into a nurse outside of the hospital, you have to recalibrate the context in which you understand and know the person.
I have written on placebo, the placebo effect, and its relationship to SCAM. To my understanding the preponderance of literature indicates there is no placebo effect upon any objective medical problem, only a change in the patients perspective of the problem.
The placebo effect is, as I have mentioned before, the Beer Goggles of Medicine. I look a lot better and am infinitely more amusing if you have consumed a pint or two of Mirror Pond, but really, I remain the same. Of course, for treating pain a change in perspective can be of benefit. Depending on whether you are an ends-justifies-the-means kind of guy, placebo outside the context of a clinical trial is not ethical as it requires lying to the patient.
SCAMs are usually no better than placebo in well-performed trials and have no efficacy in the treatment of disease. There has been a tendency to suggest that when a SCAM has the same outcome as placebo, but is better than doing nothing, that the effect of the SCAM is due to powerful placebo effect. I have this long standing rant in my infectious disease lectures that the only thing in medicine that has 100% sensitivity and specificity is when a health care provider uses the terms “big-gun”, “strong” or “powerful” in relationship to antibiotics they know nothing, zip, zero, zilch about the treatment of infectious diseases. It is always the mark if profound ID ignorance. Similarly if someone refers to the placebo effect as “powerful” they are equally guilty of imitating Jon Snow, at least when it comes to altering physiology.
I would be the last to argue that interaction between patient and physician is not important. What is said and how it is said is very important in numerous ways, as long it says within the bounds of honesty. Part of my job is to ‘sell’ a particular course of action to a patient. I do not want to leave anyone nonplussed as to my use of the word sell. I am not talking monetary exchange. I am using it with the definition “To persuade (another) to recognize the worth or desirability of something.”
I need to convince people that I know what needs to be done diagnostically and therapeutically, interventions that can he painful, expensive and prolonged. Telling someone we need to take out their artificial hip, get a 6 week course of IV antibiotics at a nursing home, wait another few months and only then get another hip is no small undertaking. Part of the placebo effect, of changing the patient perspective, is, I suppose, part of the cheerleading and encouragement you need to do to coax people through very difficult times.
Although I have not considered placebo with this term before, my interventions with patients are a form of advertisement where I choose my words that help convince patients that their therapies are working and effective. I am trying to generate a positive placebo effect. Antibiotic goggles anyone?
What started me thinking about placebo and advertising was a curious reference “Advertisements impact the physiological efficacy of a branded drug” sent by a colleague.
The study is curious and I think the results are spurious, mostly noise of questionable significance rather than a manifestation of a real effect. The big cut and paste:
A subject was given a skin allergy test for common allergens. A research technician administered a histamine challenge on the subject’s forearm, and a baseline measurement of the wheal reaction was taken. The wheal reaction is the slightly reddened, elevated area at the site of the challenge and is a well-established measure of histamine response (2). All normal individuals, whether they have allergies or not, develop a wheal reaction to a histamine challenge. The subject reported her belief about the efficacy of Claritin. She was given 10 mg Claritin and was made aware that it was Claritin. She was shown a movie spliced with naturally timed advertisement breaks. In one condition (Claritin advertisements), one advertisement in each break was an advertisement for Claritin. In the other condition (Zyrtec advertisements), one advertisement in each break was an advertisement for Zyrtec. The Zyrtec advertisement stated that Zyrtec “starts working two hours faster than Claritin.” The histamine challenge and wheal measurement were repeated during the movie, 60 and 120 min after Claritin was administered. At the end of the experiment, the subject was again asked her belief about the efficacy of Claritin. We define the efficacy of Claritin (at 60 and 120 min) as the percentage decrease in the size of the wheal reaction relative to the baseline. We thus have a subject-specific measure of efficacy. By comparing the efficacy across the subjects in the two advertisement conditions, we identify the impact of advertisements on the efficacy of Claritin. In the subpopulation without allergies, we find that the efficacy of Claritin at 120 min is substantially higher for subjects who were exposed to Claritin advertisements. Claritin advertisements have no significant impact on efficacy 60 min after the drug is taken. This pattern is consistent with the observed changes in the subjects’ beliefs. Exposure to Claritin advertisements in this sub- population greatly increases the belief in the efficacy of Claritin. At the same time, the realized efficacy of Claritin at 120 min (but not at 60 min) is strongly correlated with the change in beliefs. In the subpopulation with allergies, we find no relationship between exposure to Claritin advertisements and the change in beliefs. Moreover, the advertisements have no impact on the efficacy of Claritin at 120 min. We do find a curious negative impact of Claritin advertisements on Claritin’s efficacy at 60 min in this subpopulation, but this effect cannot be mediated by the (nonexistent) impact of advertisements on beliefs.
After reading the study, the effect is barely statistically significant but clinically irrelevant results from the noise of clinical studies.
But it does bring up the issue of the importance of advertising in promoting efficacy of placebo effects. As they note in the paper,
A small existing literature examines the impact of commercial features of drugs on their efficacy. Previous experiments show that the color, the packaging, and the price of drugs affect their perceived efficacy.
What are most SCAMs but advertising an unneeded and useless product to people who do not need it?
My perspective of most SCAM has been focused on the truth and reality of their claims, but truth and reality have little to do with advertising. I have been shaving for 40 plus years and never, not once, has a female rubbed my cheek with the back of her hand after a shave. Never, even though that appears to be a common effect of shaving in most advertising see on TV.
The tools of rational thought and science may not be the best approach for an industry, SCAM, that is based on advertising. I need a different perspective to analyze SCAM, that of the psychology of desire. Not why people believe weird things, but why they buy weird things. I ran across an enormous number of books and journals, all behind paywalls, on the techniques used by advertisers to entice people to part with their money for sugared water.
That may be the paradigm, the perspective, to understand SCAM, but that will have to wait for a rainy winter’s day. I have a tee time with my kids and a mere two weeks before they disappear into school. Gotta run.