Back in January I reported on some research which had discovered that of a sample of North American doctors polled on their prescribing habits, about half of them had prescribed placebos. The subject of the placebo effect in medicine came up again in this week’s copy of the British Medical Journal. The power of the placebo response was tested in a group of 262 individuals suffering from irritable bowel syndrome [1]. These individuals were randomly assigned to one of three ‘treatments’:

1. No treatment (just observation)

3. Sham acupuncture with a 45 minute consultation with a caring, sharing doctor

The percentage of individuals who reported moderate or substantial improve in symptoms were:

3 per cent in group 1

37 per cent in group 3

There was a statistically significant difference here between groups 2 and 1 and groups 3 and 2. In other words, a ‘placebo’ treatment gave significant relief from IBS symptoms, but a placebo treatment plus some ‘supportive’ medical input worked even better.

Even more interesting that this study, I think, is the editorial that goes with it [2]. The editorial draws our attention to the fact that the placebo effects was essentially doubled when some doctor derived ‘care’ was added to the sham treatment. The authors draw the obvious conclusion from this that individuals may respond better to treatment (be they real or placebo) if they are associated with a ‘good doctor-patient relationship’.

The editorial also makes the point that the never-ending compression of the time that patients have with their doctors and the overemphasis of drugs and procedures may be “penny wise and pound foolish”.

The editorial then turns its attention from conventional medicine to ‘alternative’ medicine. The authors of the editorial make the point that if an alternative treatment is found to have a powerful placebo effect, but no ‘real’ effect can be demonstrated, then it can easily be dismissed as ‘quackery’.

However, instead of opting for this usual line on the placebo effect, the authors take a more challenging stance. They ask: “Is it possible that the alternative medical community has tended historically to understand something important about the experience of illness and the ritual of doctor-patient interactions that the rest of medicine might do well to hear? Many people may be drawn to alternative practitioners because of the holistic concern for their wellbeing they are likely to experience, and many may also experience appreciable placebo responses. Why shouldn’t we try to understand what alternative practitioners know and do, as this may help explain why so many patients are prepared to pay to be treated by them, even when many of the treatments are unproven?”

I like very much the suggestion that conventional doctors may have something to learn from more naturally-oriented practitioners. I would like to point out however, that the idea that much of complementary medicine is ‘unproven’ goes for conventional medicine too.

There is also recognition from the editorial authors of not just the placebo response, but the ‘nocebo’ response, when they write: “We treat patients in a social and psychophysiological context that can either improve or, alas, worsen outcome.” In other words, a poor doctor-patient relationship can reduce the effectiveness of a potentially useful treatment and may possibly even exacerbate the symptoms from which the patient is looking for relief.

Overall, the editorial concludes: “…it seems fair to conclude that a good doctor-patient relationship can tangibly improve patients’ responses to treatment, placebo or otherwise.”

One way that doctors can improve their relationships with patients is to stay ‘patient-focused’. I see my job as a doctor to do whatever is in my power to help my patients achieve their health objectives, while at the same time not risking their health either. Good medicine, I believe, is about being a good advocate for one’s patients.

I was reminded of this during a social conversation I had with a stroke specialist at the weekend. He told that one of his patients had lost the use of one of his arms, and was therefore finding it impossible to roll his own cigarettes. This doctor had instructed the occupational therapists in his department to teach the man how to roll his own cigarettes one-handed. A senior nurse in the department was outraged by this. Whatever one’s personal view, there is one thing that is for sure: the doctor in this instance is demonstrating a very patient-focused approach. Bearing in mind the ability of a good doctor-patient relationship to stimulate healing, who knows what good may come of this doctor supporting his patient in his desire to roll his own cigarettes?

References:

1. Kapchuk TJ, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008;336:999-1006

2. Spiegel D, et al. What is the placebo worth? BMJ 2008;336:967-968

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