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Placebo Again.

Medicine is simultaneously both easy and hard. As an Infectious Disease doctor, my day can be summed up with the phrase “me find bug, me kill bug, me go home.” Sometimes it is just that simple. A lot of the time it isn’t. I may not be certain what the infection is, or even if the patient has an infection, or allergies and/or antibiotic resistance limit therapeutic options, the host has co-morbidities that limit effectiveness, and the patient has no financial resources for the needed treatment.

I am lucky, since most infections are acute, make people feel terrible, and require a relatively short course of therapy during which the patient feels better. I rarely have to worry about compliance with the treatment plan; it is the rare patient, usually a heroin user or a particularly irascible old man, who will not follow through with their antibiotic course. I do not have to worry about chronic or symptomless diseases like diabetes or hypertension or the complications of obesity where long term compliance often limit therapeutic success. Long term it is difficult for many people to stick with their therapeutic plan, much less their diet and exercise resolutions.

Infectious diseases is a job where I do not have to concern myself about placebo effects. As readers of the blog are well aware, I do not think there is any such thing as a placebo effect that has any clinically meaningful application, especially in the world of infectious diseases. Infections are usually a binary proposition: either you are infected or you are not and either I am curing you or I am not.

Still, there is more to medicine than me find bug, me kill bug, me go home. Often most of the time on a consult is spent talking with the patient: explaining what they have, why they have it, what we are going to do about it and what they can expect.

As an aside, while I ‘take a history’, as we say in the parlance of the field, patients provide a story, a narrative. Much of what the patient has to say is frequently of little importance to the medical matter at hand, and there is something about illness that lends people to philosophizing. At length. Especially at 4 o’clock in the afternoon on Friday. I hate to tell you this, but the details of your life and the philosophy of your existence are neither that interesting nor that original. You, like me, are really not that compelling.  I have heard the content and what you are saying before, more times than I can count.

At one of the hospitals I go to they report metrics on patient satisfaction, and one is “My Doctor listens carefully to what I said.” We are usually around 80%, but I point out that at least 20% of the time the patient is not saying anything worth listening to. The elderly male I saw last Friday at the end of the day felt obligated to go on about his grade and  high school GPA, I guess to let me know how smart he was. Such irrelevant soliloquies, at least irrelevant to making a diagnosis although they do add insight into the patient, are common. I pretended to listen with interest, looking for the right moment to interrupt, glad we are not telepathic.  I am often glad we are not a telepathic species.

I suspect part of the allure of alternative medicine providers is that the dull details of my life, which are of no interest to anyone but me and (maybe) my family, are of endless interest to the fake diagnosis and treatment by the homeopath or naturopath. The patient gives us a story, we extract the small amounts of information that are relevant to the diagnosis, but do not give a narrative back in return. We give data and odds and studies. Alt med providers return a narrative and a story, incorporating the faux uniqueness of their patient. The problem with medicine, and the source of its diagnostic and therapeutic power, is that there is usually nothing whatsoever special about you, or me. Humans operate under very tight and predictable operational parameters: physiologically, emotionally, and psychologically.  Human variations are usually trivial, since extreme variations are fatal. People prefer to operate under the delusion they are interesting and unique and SCAM practitioners feed into that.

I recognize that conversations with the patients are important for a variety of reasons, since the more they understand about their infection and its treatment, the better they will be able to adhere with their compliance. Or comply with their adherence. Whatever the current buzz word is for getting the patient to do what you want them to. While I think the patients attitude has nothing to do with whether I will successfully kill the MRSA on their aortic valve, being ill is difficult, and the better they cope and comply, the better will be the quality of their life during the illness.

We have four possibilities when treating an illness:

  • We can improve the pathophysiology and the patient feel better. That’s the best case scenario. It is what I strive to accomplish with my patients.
  • We can improve the pathophysiology , but the patient feels no better or feels worse. My fathers chemo for his non-Hodgkin’s lymphoma cured the tumor, but he never quite felt well after.
  • We can not improve the pathophysiology, but the patient feels better. In my world, that is mostly when patients are on hospice, but it applies to chronic pain.
  • We can fail to improve the pathophysiology and the patient feels worse. That is the worst case scenario.

I have long realized the importance of what we referred to as a resident as the supratentorial component of illness. It is a large part of being a doctor, but one of the more difficult parts since the approach differs with each patient.   I do not need to individualize the antibiotics for your MRSA osteomyelitis, but I do for how I communicate about your illness.  Is the patient smart?  Stupid?  Uneducated?  Overeducated?  Confused? Drugged? Depressed? Demented? Fatalistic?  Unrealistic?  The message needs to fit the recipient.

At the heart of the communication with patients is honesty and truthiness. I have to get a sense of who you are and then tell you what is occurring. The patient-physician relationship is based on honesty, and without honesty there can be no autonomy, the first of the on the principles of medical ethics:

Autonomy. The principle of autonomy recognizes the rights of individuals to self-determination. This is rooted in society’s respect for individuals’ ability to make informed decisions about personal matters.

Beneficence and Non-Maleficence, the other key principles, are always two and three on the list, perhaps it is always alphabetical.  A patient cannot make informed decisions if they are not told the truth.

As a rule, autonomy trumps beneficence and non-maleficence. I can’t lie to you, even if it is to your benefit. No weasel words or Romneyesque evasions, but of course there are many ways to tell the truth: do I say an 80% cure rate or a 20% failure rate? Emphasize the good? Dwell on the bad? It is not what you say, but how you tell the truth that can be important, but you always have to be aware of the line and not cross it. I wonder how well other docs do, as I not infrequently get a comment from a patient that they appreciated how clear I was in my explanation of the medical situation, good, bad and indifferent. That I told it like it is.

We all can manipulate our patients in subtle ways.  A classic example is sitting down when you go into a patients room. Patients will rate the time spent as longer if the doctor sits down instead of stands, even if the actual time is no different. There are other tricks (I am not certain I like that word) that can be used to enhance the therapeutic interaction. I don’t think of it as lying, but is part of being a good doctor, especially in an era when patients can be referred to (never, ever by me) as clients and consumers and it is our job to have happy customers.

Even if I thought the placebo effect existed in any meaningful way, I could never use it since at its heart it violates the prime directive of medical ethics. It is why editorials in JAMA, like Lessons From Recent Research About the Placebo Effect—From Art to Science  by Howard Brody MD, PhD and Franklin G. Miller PhD , besides only presenting half the information, give me the willies.

Dr Brody is the author of The Placebo Response: How You Can Release the Body’s Inner Pharmacy for Better Health, which I have not read, but the Amazon summary says

According to Brody, the placebo phenomenon–which he pronounces mysterious and unknowable at its very heart–is when the convergence of healing signals, assigned meaning, and human expectations stimulates the body’s inner healing power. The patient’s positive mental and emotional reaction to a medical intervention releases what Brody terms the “inner pharmacy.” In other words, even though the treatment is benign, the body’s biochemical pathways are stimulated to induce healing in the same manner actual medicines do. “Could harboring hope, faith, or expectation be genuinely potent factors in the healing process?” Brody asks, “I believe they are. In fact, I see them as the heart and soul of the placebo response.

Doesn’t look like a promising start. But what is placebo?

In popular understanding, placeb is giving a sugar pill instead of a real medicine, like Doc Martin did in the episode I saw yesterday. The teenage girl wanted a larger chest and he gave her some peppermint breath mints to take once a month for a year and he pointedly never contradicted her misunderstanding as to what she was receiving.  Of course the young lady instantly went from poor self esteem  who was easily bullied by the other girls to aggressive young lady who verbally slapped down her bullies with new found self confidence. Of course, in keeping with the true placebo effect, no anatomy was changed.  I have only seen a few Doc Martin episodes to date, but so far I have been impressed with accuracy of the medicine.

Placebo is also used in clinical trials, an inert treatment that is the surrogate for all the other confounding factors in patient treatments that can determine results: natural history of disease, physician and patient bias, regression to the mean, etc. Interactions with health care providers can have effects on patients, especially for subjective symptoms. As studies and their meta-analysis have consistently demonstrated, placebo in clinical medicine does not alter the underlying pathophysiology, the objective endpoints, only the subjective endpoints. Placebos do not treat the underlying disease, they only alter the symptoms, and not by much. Symptom relief is not a bad thing, as long is it does not violate autonomy, beneficence non-maleficence. Kind of hard to do when the placebo effect is based on lying to the patient.

The JAMA editorial completely ignores the first use of placebo, and ignores the data that placebo has no effect to alter pathophysiology. I suppose it is how you read the literature. Referring to Placebos without deception: a randomized controlled trial in irritable bowel syndrome (blogged about by Dr. Gorski when it came out)  that they interpret as

Recent research now challenges the prior beliefs that placebo treatments must be prescribed deceptively in order to work.

Patients were told in the study that

…placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes (bold mine).

The study included four talking points:

“…1) the placebo effect is powerful, 2) the body can automatically respond to taking placebo pills like Pavlov’s dogs who salivated when they heard a bell, 3) a positive attitude helps but is not necessary, and 4) taking the pills faithfully is critical. ”

That, to my mind, is deceptive, and while I am not surprised that patients reported feeling better, as they often do after a visit with the doctor, it was based on several lies, and the study would violate patient autonomy if applied outside of a clinical study. You tell a patient up front that a positive attitude helps, and you are not surprised when they report doing better.  Being in a medical trial will lead to the patient trying to please the researcher, a clinical trial Stockholm syndrome.

I’ll grant you that there are “Two intertwined psychological mechanisms are thought to underlie placebo effects—expectancy and conditioning” and that patients can be manipulated in clinical trials to report feeling better. Placebo effects are neither clinically impressive in their effect nor an ethical for a practicing clinician, but ones man’s ethics is another man belly laugh.  Note, the authors start out saying the effects are psychological, and changing psychology will not make your breast cancer remit.

But then, something changes. One moment I see a Victorian woman looking in a mirror, then suddenly I see a skull. Because placebo becomes more than a sugar pill, more than the placeholder for the numerous confounding variables and biases that muddy the waters of a clinical trials.  The placebo effect are pleural and are as many as sands in the hour glass.

Neurophysiology and neurochemistry suggest that there are multiple placebo effects, with different neurobiological mechanisms, depending on the organ system and the target illness.

Good. It there are as many placebo effects as there are illness, perhaps I can use it. Failure rates with vancomycin for MRSA hover around 30%. Maybe I can use placebo effects to help, but it never seems to be the case. Infections are recalcitrant to placebo effects. Instead they mention the usual suspects of subjective experience: pain and irritable bowel syndrome. But it turns out that I have been practicing placebo medicine all this time after all. You can elicit the placebo effect by being, well, a good doctor.

Good ways to enhance everyday encounters include inviting and listening carefully to the patient’s story of illness experience, offering a satisfying explanation for the patient’s distress, expressing care and concern, communicating positive expectations for therapeutic benefit, and helping the patient to feel more in control of life in the face of the illness.

Everything you do as a clinician evidently can elicit the placebo effect. Even “rather than advising the patient to get more exercise, a physician can write a prescription for exercise on a prescription pad, thus using ritual in a way designed to elicit a placebo response along with increased adherence.” is a placebo effect. Every interaction becomes the opportunity to elicit a placebo response and I suppose, failing in these characteristics will enhance the nocebo effect.

It is a definition of placebo so broad as to be useless. What isn’t an opportunity to elicit a placebo or nocebo effect? When a definition apparently encompasses everything, it becomes nothing.

Although patient beliefs vary depending on geography, culture, and education, at least some of today’s patients are eager to become active collaborators in mind-body healing practices. Many patients will be relieved to learn that the physician wishes to avoid unnecessary and potentially harmful drugs and wants to maximize the powers of the mind alongside those drugs and other modalities that are well supported by scientific evidence.

Show of hands; how many out there like to prescribe to “unnecessary and potentially harmful drugs”?  And the sentence suggests the authors knows that maximizing the powers of the mind is not well supported by scientific evidence.

The patient-physician interaction can be complex and multifaceted. All human interactions can be complex and multifaceted. As health care providers we are trying to influence the patients behavior and attitude in an attempt to heal the patient. In the old days it was called a good bed side manner; as I have said before no different, but more complex, than the salubrious effect one ape has on another when they are groomed. A good bedside manner helps the patient feel better but doesn’t make their brain tumor or liver abscess shrink.

Having a good bedside manner and helping the patient feel better about the psychological/subjective components of their illness has always been part of medicine, although obviously some are better at it than others, and some are more interested than others.  You don’t become a pathologist because you like to work with people.  A good bedside manner has always helped the patient feel better, there is no mystical underpinnings to the process.   It is not “the practitioner has many means to help each person activate the potentially powerful inner pathways that assist healing.”

There’s the leap that drives me nuts: placebo is good for symptom relief, nothing more. Nothing is healed, although I have an old school idea of healing: the process is cured. A healed wound is closed and has a scar, not having less pain. Placebo heals nothing, There are no potentially powerful inner pathways by which placebo heals. At best, when lied to, you will feel better.

But what about low-risk interventions such as acupuncture to treat low back pain? Today, if rigorous clinical trial evidence shows such modalities to be better than no treatment or usual care but no better than placebo, the treatment is often summarily dismissed.

As it should be. If trials show an intervention does nothing, it should not be used. Substitute ‘pharmaceutical medication’ for ‘acupuncture’. Would you still recommend it?

An open question for future research and ethical reflection is whether such modalities can be recommended consistent with informed consent.

Informed consent: Acupuncture does nothing. There are no meridians, there is no chi, and studies are clear acupuncture does nothing to alter your underlying disease. At best you may think your pain is decreased, but the effect is not sustained. Besides having no efficacy, there are the occasional severe and even fatal complications from the procedure and many practitioners are not particularly fastidious with the techniques of infection prevention. It will cost you $100.

Doesn’t take much ethical reflection for me.

Of course virtually all of SCAM, from acupuncture on down the alphabet, does nothing to alter underlying anatomy or physiology. No healing is accomplished.  And all SCAM results is placebo: the psychological effect of a lie believed to be beneficial.  A good therapeutic relationship with a SCAM provider that is based on a lie is not, in my narrow world, ethical. I am not a means justifies the ends kind of guy.

They go from the well defined effect of placebos for modifying symptoms in clinical trials to every interaction being able to cause placebo effect to placebos can heal. I tend to like clear thought, and these essays are written in no small part to help me clarify my own thoughts on the topics about which I write. When everything is placebo, and somehow the mild decrease in IBS symptoms is translated into a powerful mind-body medicine beyond mild symptom relief, I look in vain for clear thinking. And how understanding how a mild decrease in symptoms heralds a “bridging the long-standing gap between the scientific and humanistic orientations of modern medicine,” I can’t see.  I also don’t see the gap in my practice.  The gap is not in medicine, but in the variation in providers, not all of whom are proficient or interested in maximizing the doctor-patient relationship.

Give half the data and wildly extrapolate. That is not from Art to Science. That is from molehill to mountain.

Addendum.  As I finish this essay, eradicating all the typos and grammatical mistakes for Dr. Gorski’s sake, an interesting study crossed my desk:  Adherence to placebo and mortality in the Beta Blocker Evaluation of Survival Trial (BEST),  which concluded

Analyses of the BEST trial data support a strong association between adherence to placebo study medication and total mortality. While probably not due to publication bias or simple confounding by healthy lifestyle factors, the underlying explanation for the association remains a mystery.

It takes a while for me to read and digest an new article, my initial take is that being adherent in one sphere of your care probably means you are adherent on other spheres of your care.  Being adherent in general leads to to better outcomes, and there are a multiplicity of factors that decrease adherence and worsen outcomes.  It is never one intervention that leads to good, or bad, outcomes, but the summation of many small interventions.  Adherence to placebo is probably  such a marker.  I saw no reason to invoke  powerful mind-body effects at work.

Posted in: Acupuncture, Medical Ethics, Science and Medicine

Leave a Comment (34) ↓

34 thoughts on “Placebo Again.

  1. Jan Willem Nienhuys says:

    eradicating all the typos and grammatical mistakes

    change pleural into plural …

    If you wonder what to say, 80% chance to cure, and 20% to fail, why not say: “The odds of cure are 4:1, in other words, the odds that it doesn’t work are 1:4.” Then at least you have presented the chances as fairly and symmetrically as possible.

    It is known that even doctors, who ought to know better, rate a treatment as far better when they only hear ’90% survival’ compared to when they only hear ’10% fatalities’. One would think that they know very well that 100-90=10, but the human intuitive mind doesn’t work that way, and unless you present the complementary data explicitly the mind will be more impressed with what is seen and heard (‘survival’, ‘close to 100′) then what is derived by thinking and calculating.

    It’s like the Müller-Lyer illusion: (you know, with the vs. >—< ): even if you know that the lines are the same length, and if you know that the illusion is caused by the automatic perpective correction module in your optical cortex, you will see them intuitively as different. The same with numerical data about chances: what one sees and hears takes precedence over what one calculates if one thinks about it.

  2. windriven says:

    Brilliant:

    “Humans operate under very tight and predictable operational parameters: physiologically, emotionally, and psychologically. Human variations are usually trivial, since extreme variations are fatal. People prefer to operate under the delusion they are interesting and unique and SCAM practitioners feed into that.”

  3. Jan Willem Nienhuys says:

    Oops! I had intended to illustrate the Müller-Lyer illusion, i.e. (—-) vs. )—-( , but with pointy brackets rather than round brackets, but due to html-mysteries this failed.

  4. David Gorski says:

    As I finish this essay, eradicating all the typos and grammatical mistakes for Dr. Gorski’s sake

    Shockingly, you actually did a pretty good job. I didn’t have to do very much, although I did add bullet points to your four possibilities above. It reads clearer that way.:-)

    I miss Paul, who is temporarily unavailable. (Paul Ingraham is our usual proofreader, although sometimes, given that we finish blog posts late the night before they are published, he can’t proofread them until after they’ve “gone live,” which sometimes accounts for grammatical and formatting errors disappearing mysteriously hours (or even days) after posts publish.)

  5. DugganSC says:

    Excellent article. Very enjoyable and informative reading.

    The bit about the rituals of patient care and their effects kind of reminds me of that bit from Snow Crash where one of the protagonists is pointing out that a large part of religion is ritual because people just won’t buy the truth without the ritual. Similarly, you get people who parrot the ritual without the truth (alternative medicine) because they’ve learned the ritual sells and people who reject the truth because all they see is the ritual. ^_^ Or maybe I’m torturing a metaphor here.

    Nevertheless, very much enjoyed the article.

  6. WilliamLawrenceUtridge says:

    I’ve started thinking of CAM treatments as a form of low cost, low benefit psychotherapy. In most cases, you get to spend the entire consultation session listing and exploring in absurd detail all the ins and outs of your illness with someone who not only pays attention, but appears to be curious. They should all be retrained as psychotherapists specializing in health and illness-based counseling.

  7. rork says:

    I’m glad you made it clear that you do want to know a bit about patient’s ability to apprehend, after early complaint about the guy boring you trying to prove he was smart, and that how to communicate to patient matters – cause that’s a pet peeve of mine about docs, at least for issues where I know quite a bit (not infections).
    That was a nice read. It made me wonder about things like physical therapy or massage for stuff like back pain, perhaps recently discussed here. We see acupuncture does about as well as massage. Maybe we should conclude massage doesn’t really work, and that the acupuncture was useful after all – as a control.

  8. DugganSC says:

    @WilliamLawrenceUtridgeon:

    ^_^ Reminds me of the multiple science fiction books I’ve read where both bartenders and prostitutes are required to be licensed psychotherapists on account of that they’re who people talk to. I’m similarly heard that a surprisingly large amount of phone sex time doesn’t involve talking dirty, but rather lonely people desperately seeking for someone to listen to them.

  9. Quill says:

    It is a definition of placebo so broad as to be useless. What isn’t an opportunity to elicit a placebo or nocebo effect? When a definition apparently encompasses everything, it becomes nothing.

    That’s essentially the problem I have with reading the literature of placebo. Proponents of using placebo effects make it into anything they like, which always seems wonderful and magical. However, even reading SBM posts and reports here on PubMed articles, it often sounds like medical researchers are turning themselves into dualists of a religious persuasion. All this talk of the “mind-body problem” and trying to deal with subjective information in science tells me it is time for someone to come up with some better terms to discuss all this.

    @DugganSC: Those sci-fi books sound good. I would prefer, though, for all psychotherapists to be licensed bartenders. I really thing this would improve much of society. ;-)

  10. trrll says:

    I see a logical problem in Dr. Gorski’s objection to telling the patients in the irritable bowels syndrome study that “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes ” and that “…1) the placebo effect is powerful, 2) the body can automatically respond to taking placebo pills like Pavlov’s dogs who salivated when they heard a bell, 3) a positive attitude helps but is not necessary, and 4) taking the pills faithfully is critical. ”

    It seems to me that it is only reasonable to characterize those statements to the patient as “lies” if the placebo does not work. If the placebo does in fact improve the patient’s condition compared to the no-treatment option, in spite of the patient being informed that he was receiving a placebo, then those statements were correct, and thus there is no confound. One could perhaps raise ethical objections (particularly if the experimenter did not himself believe those statements at the time he made them), but I don’t see how it can be said to invalidate the study design or the results if they turn out positive.

  11. Jan Willem Nienhuys says:

    Some time ago I asked several physicians who were active in the Dutch antiquackery association why they thought giving placebos was unethical.

    There were several opinions.
    One (the chairman, a gynecologist) said: one can use the placebo effect without lying to the patient. Taking the patient serious, try to find out what the patient really is saying, especially do a thorough physical examination to check for a serious ‘underlying problem’, honestly tell the patienbt what are the prospects, try to say encouraging things, especially when the complaints are of type that resolve themselves in the course of time. In many cases simple life style advices taylored to the personal situation of the patient can be effective. Under all circumstances one should be able to explain to the patient what one does and why, from a scientific point of view.

    Another one (a retired family doctor) pointed out that recommending a placebo therapy (e.g. homeopathy) not only means one lies, but that one risks that the lie is discovered, for example when the patient is seriously ill and asks for more of the same placebo. If one has to confess that the former advice was a lie, then one risks a breach of trust. If the patient recovers he or she may think ‘I don’t care as long as I get better’, but in the more serious opposite case the patient may be angry and justly so upon discovery of the lie. At best the placebo effect is small and unpredictable. Moreover, the cure can be an illusion. There are many ways in which a cure can be a illusion and when the doctor and the patient both fall for such an illusion one has the situation of a folie à deux.

    A third one (a psychiatrist, I think) opined that complaints caused by suggestion can be cured by suggestive techniques, but not as first option and if it seems to have no effect, one should stop immediately.

    Finally (I don’t recall who said that), the placebo effect is somewhat akin to the manner in which mommy kisses the pain away. In other words relying on the placebo effect means treating the patient as a child.

    Of course placebos have a use, namely in scientific research. But then we have the situation of informed consent. The patient knows that in the interest of science he or she may get an inert pill.

  12. BillyJoe says:

    trrll,

    The researchers were trying to show that the placebo effect works even when patients are informed that they are receiving placebo and that therefore you can ethically prescribe placebo because you do not need to lie to them.

    But, by telling them what the placebo effect is, they did lie to their patients.

    “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes ”

    There is no evidence that placebo produce significant improvement in IBS symptoms. Studies show only that patients reports of their subjective experience was improved but that objective measurements remained unchanged.
    And there is no evidential support for “mind-body self-healing processes” but phrases such as this one appealed to the people who were encouraged to take part in the study (ie the way the study was advertised would likely have attracted believers in “mind-body medicine” to participate.

    “the placebo effect is powerful”

    There is no justification for this statement. In fact, the placebo effect has been shown to be mild and transient.

  13. David Gorski says:

    It seems to me that it is only reasonable to characterize those statements to the patient as “lies” if the placebo does not work. If the placebo does in fact improve the patient’s condition compared to the no-treatment option, in spite of the patient being informed that he was receiving a placebo, then those statements were correct, and thus there is no confound.

    Wrong. Even using your logic, there was no way the investigators could know enough to make such assertive statements before the study. I stand by my characterization.

  14. Richard says:

    I enjoyed most of your post, but I must say that I was a little irked by your griping that your patients often “didn’t have anything to say that was worth listening to.” While I can understand why you might feel that way, being an empathetic listener is part of what you’re getting paid for (quite handsomely, I’m sure). So stop complaining and just do it. I do agree with you that the placebo effect is the latest talking point of the altmed movement and so it must be refuted. One way to counter altmed is to try to be more empathetic.

  15. trrll says:

    Wrong. Even using your logic, there was no way the investigators could know enough to make such assertive statements before the study. I stand by my characterization.

    Logically, what the investigators did or did not know before the study cannot affect the validity of the study. So while one can reasonably object that the investigators made a true statement to the patients without having enough information at the time to justify that statement, that is only an ethical concern for the IRB at their institution; it cannot be used as a basis to discount the results.

  16. Mark Crislip says:

    I think you mistake it for the old days.

    25% of my pateints have no insurance. I see them for free.

    Medicare, about 1/3 my practice, pays 44 dollars at most for a consult that will take a hour to an hour and a half.

    In the last 10 years my real income from private practive has fallen by 60% and the most I ever made in a year was 120,000, and that was last century

    I am the sole ID doc at three hospitals and am on call 24 x 7.

    Handsomely? No. Do I listen? Yeah. Always. Do I care about what you say? Maybe, maybe not. It depends on what you have to say and how relevant it is to you care.

  17. pmoran says:

    To a surgeon, the word “healing” has a very specific meaning i.e. tissue repair following trauma or other injury.

    So it drives me nuts, too, when the same word is used as though there is no difference between the knitting up of a fracture and, say, getting over the loss of a loved one. I agree with Mark, those who talk about “healing” within serious medical discourse are likely to have a woolly comprehension of what medicine is all about. I also agree that there is very little evidence that placebos affect healing in the normal medical sense of the word.

    The antidote to this vague arm-chair theorising is to ask for specific examples of how their ideas might work in practice. It then usually becomes clear that they are talking to the field of the psychology of illness, not the pathophysiology.

    The one virtue of “holism” as usually practiced within CAM, is that it provides the “healer” permission to delve into all aspects of the patient’s personal life and devise a “multifacetted” approach to the patient’s problem wherein the main operative influences are almost certainly going to be non-specific and psychological. These might include placebo responses breaking a cycle of excessive focus upon symptoms, the offering of explanations for vague, previously unexplained illness, and other patient-acceptable ways of validating the illness experience.

    A really good, well-trusted family doctor can probably do much the same, so long as he is allowed some flexibility in conceptualising the illness and in prescribing and he/she doesn’t spook the patient with clumsy hints that it is “all in the mind”. (It rarely is, in my opinion.)

  18. DW says:

    I think this post absolutely nailed it.

    To the person who wrote, “being an empathetic listener is part of what you’re getting paid for,” I say no. Just no. Get a therapist if you want an empathetic listener. If you want your physical symptoms treated, go to an MD, but there is absolutely no reason he needs to listen to your life story. You are wasting his time, wasting your own time, paying far more than you probably should for therapy, and taking the doctor’s very valuable time away from other patients, who also have real problems.

  19. trrll says:

    It depends upon whether you think the doctor should be only take responsible for the patient’s physical well-being, or should accept some responsibility for how the patient feels. Pain, after all, is substantially subjective (which is probably why the most clearly documented placebo effects are for pain). While I agree that a doctor should not deceive a patient, does that mean that the doctor also should not trouble to give the patient a reassuring therapeutic experience such that the patient leaves feeling that the doctor has been genuinely attentive to the patient’s needs, and perhaps feeling a bit better simply because of that? To some extent, that means listening to the patient, even though a non-medically trained patient often has a poor comprehension of what is and is not likely to be relevant to the physician’s medical decisions. To the extent that physicians abdicate this responsibility, they become complicit in handing over many people to the dispensers of woo. I am sympathetic to the demands upon the physician’s time and the financial pressures imposed by insurers, but a primary care physician, in particular, needs to develop the skills to convey the impression of listening to the patient’s concerns (even those which he perceives as medically irrelevant), while keeping the interview on track. Of course, this is easier with some people than others. In some cases, a well-trained nurse or medical assistant can lift some of this burden from the physician’s shoulders.

  20. laportama says:

    Eons of understanding discarded in the name of science. Professionalism can be a scourge!
    What if it’s true that “it starts in the mind but doesn’t stay there” which seems to represent a store-hold of wisdom, free for the receiving but too easy to lose. And if you can’t understand the contributing causes into a situation, how do we find our way out?
    I feel bad for the man of any profession who loses entire dimensions of possibility through cherished in-bred short-sightedness.
    That’s why my life and my work are based on “take what you need, and leave the rest”. Even if it means making a specialty out of chemotherapy and the attention to the details that allow one to diminish the importance of the sick person in the bed.
    We’ve turned healthcare (often– usually — neither health, nor care) into the worlds second-largest expression of codependency, the first being government.
    If it is true that mind affects matter, why aren’t we including this into the patient’s equation, allowing them to arrive at their own personal calculus? Ignore the facts at your own peril: “Listen to the patient long enough and he’ll tell you the diagnosis.” — Osler. Dia-Gnosis means THOROUGH UNDERSTANDING.
    Here’s the question I ask almost every patient with a significant problem: “What are you willing to do to get better?”
    Lastly, who defines a cure? Improvement? That’s merely applied Disraeli-Twain statistics.(So is calling a result “binary”) We impress each other with studies and methods, but have we added value to life?

    That’s a very individual question.

    Science: http://www.etymonline.com/index.php?term=science

    MAL MD FACP

  21. Purenoiz says:

    @latroma,

    I am going out on a limb by making this assumption, but I believe the kind of stories Mark Crislip is being told resemble the stories of Abe Simpson… they go something like this…
    http://www.youtube.com/watch?v=ARXfQzfl9EQ
    “We can’t bust heads like we used to, but we have our ways. One trick is to tell ‘em stories that don’t go anywhere – like the time I caught the ferry over to Shelbyville. I needed a new heel for my shoe, so, I decided to go to Morganville, which is what they called Shelbyville in those days. So I tied an onion to my belt, which was the style at the time. Now, to take the ferry cost a nickel, and in those days, nickels had pictures of bumblebees on ‘em. Give me five bees for a quarter, you’d say.

    Now where were we? Oh yeah: the important thing was I had an onion on my belt, which was the style at the time. They didn’t have white onions because of the war. The only thing you could get was those big yellow ones…”

    These are not the stories that inform him on the proper method of treatment for the illness at hand. Some people like to talk and tell stories for a number of reasons, the problem is nobody wants to hear their stories. So they tell them to a “captive” audience. When I worked in retail I would get this kind of customer frequently, so often we had a nickname for them, psychic vampires, since they sucked the life out of you with their rambling go no where onion on a belt stories.

    You can be an empathic listener and still find these monologues to be droll. You can find that they hinder your ability to serve the patient, however don’t confuse them for a conversation since they are not a conversation.

    “We’ve turned healthcare (often– usually — neither health, nor care) into the worlds second-largest expression of codependency, the first being government.” No, Insurance companies and HMO’s only care about the bottom line, and they use their lobbyists in Washington to guarantee that this cash cow never dies. Even as doctors and nurses and administrators are handicapped to the point of patients getting the short end of a stick.

  22. Mark Crislip says:

    Bingo. I use the onion on the belt reference all the time, and completely forgot it when writing this entry. Spot on. Exactly what I should have said.

  23. Purenoiz says:

    I would also like to point out latroma’s reading comprehension skills, and lack there of. Dr Crislips’ had several key points, a minor one being onions on the belt rarely improve medical outcomes.

    latroma, you’re a Dr, you should be able to comprehend that for Dr Crislip, the outcome is binary, either the infection is gone, or it isn’t. No other author was writing. Perhaps in your field the cure really isn’t all that distinct. I can’t presume to know where and what you practice. But Dr Crislip made it very clear in this piece whose voice he was using, it was the first person.

    Your gripes about medical “meh”-care while interesting are not relevant to the conversation at hand. You should be ashamed for bringing them up and not furthering the conversation. Why not start a blog from a Dr’s perspective on how the system is failing the patient?

    @trrll
    “Logically, what the investigators did or did not know before the study cannot affect the validity of the study. So while one can reasonably object that the investigators made a true statement to the patients without having enough information at the time to justify that statement,…”

    Logically if you don’t have the facts before a study has begun, you can’t make claims about the results without lying to your patients. It’s pretty simple, if you don’t know, but say you do, you are lying.

  24. pmoran says:

    “Logically, what the investigators did or did not know before the study cannot affect the validity of the study. So while one can reasonably object that the investigators made a true statement to the patients without having enough information at the time to justify that statement,…”

    Purenoiz: Logically if you don’t have the facts before a study has begun, you can’t make claims about the results without lying to your patients. It’s pretty simple, if you don’t know, but say you do, you are lying.

    The statements made to the trial subjects concerning placebo may have guilded the placebo lily a bit, but they were surely based upon about 50,000 (a guess!) other clinical studies showing what happens to subjective outcomes in the placebo arm of RCTs, and in experimental pain studies, including some studies wherein placebo was compared to no treatment.

    The minor exaggerations would result in some manipulation of patient expectations but, of course, that is one of the ways in which placebo influences “do” what they do. The only uncertainty is the extent to which patients are lying about their true levels of discomfort. Lots of luck if that is the only path you wish to tread.

  25. pmoran says:

    Sorry, formating error. The last two paragraphs are mine.

  26. Purenoiz says:

    Placebo’s offer a unique aspect into how the brain interprets signals from other parts of the body. The research by Dr Benedetti is exciting as it gets in the world of placebo’s. Check out his interview on the brain science podcast here http://www.brainsciencepodcast.com/bsp/neurobiology-of-placebos-with-fabrizio-benedetti-bsp-77.html .

    pmoran, I think we are in the same boat but not sure what you mean by the lots of luck statement. I agree that the statistical deviation from the mean would probably insignificant, no pun intended. Generally speaking, I think many patients and non scientists feel like an American in England when dealing with the scientific literature. to quote the movie Snatch

    Bullet Tooth Tony: A bookie’s got blagged last night.
    Avi: Blagged? Speak English to me, Tony. I thought this country spawned the @#$~ language, and so far nobody seems to speak it.

    i.e.
    Healing process
    Cured
    Normal population
    Significant

  27. On the topic of being an empathetic listener, I appreciate the “onion on the belt” clarification. I do get disgruntled with doctor’s who seem unwilling to give you a chance to describe your relevant concerns, ask a question or a follow-up question. I once had a medical practitioner who routinely interrupted me while I was attempting to ask relevant questions AND then went on to present a 15 minute or more lecture on what she seemed to think I should have been asking. I do think that a good doctor should understand that a patient who isn’t necessarily well verse in medicine may not describe their symptoms or ask questions in the most concise manner.

    On the other hand, since I sell my work to the public, I am familiar with folks who will take advantage of a captive audience to share their endless opinions, stories, etc. Once I was hanging a show and had a customer follow me around telling me his various opinions about art for FOUR hours. Psychic vampires is right.

  28. sarah007 says:

    As an Infectious Disease doctor, my day can be summed up with the phrase “me find bug, me kill bug, me go home.” Mark it’s not really working is it, I mean all those antibiotics haven’t got rid of bugs but it has made them stronger.

    Do you not want to know why some people ‘catch’ these bugs and others don’t?

  29. Scott says:

    We know a lot of the reasons. In particular, people who get vaccines are far less likely to catch the bugs they’re for.

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