Placebos (1)

The headline of a recent New York Times article was cause for public alarm: “Half of Doctors Routinely Prescribe Placebos.”  A casual glance might have given the impression that doctors dispense sugar pills half the time, but this would be a misreading of the reported finding.  The article followed a research report that appeared in the October 23rd issue of BMJ (formerly the British Medical Journal).  A national survey of 679 U.S. internists and rheumatologists found that half routinely prescribe medication when, in the opinion of the clinician, the benefits “derive from positive patient expectations and not from the physiological mechanism of the treatment itself.”

This definition goes well beyond our usual notion of a placebo as a fake medication, e.g., a sugar pill or an injection of sterile salt water.  In fact, only two or three percent of the doctors reportedly used these.  Much more commonly the “placebo” consisted of over-the-counter analgesics (painkillers), vitamins, and sometimes antibiotics and sedatives.  Leaving the loaded word “placebo” out of it, half the doctors admitted to offering some treatments purely because they are psychologically comforting to their patients.

This nicely illustrates something psychiatrists, and many alternative/complementary healers, have known for a long time: There is no sharp distinction between mind and body.  Each affects the other.  Feeling ill and seeking help are not mechanical processes, like the engine light coming on in one’s car.  A doctor’s attention and concern can help a patient feel better even if no treatment is given.  Often medications work for no good reason, or fail to work when they “should.”  The doctor-patient relationship is a complex dance of expectations and hopes, full of subtle cues and interactions at conscious and unconscious levels.  Western medical science shines a light so bright it can blind us as well as illuminate.  Of course doctors sometimes offer remedies that are primarily psychological.  How could anyone have thought otherwise?

While I have never given anyone a sugar pill, I have often been faced with choosing among several equally acceptable antidepressants for a patient.  The published efficacies, side-effect profiles, and even costs of the medications are essentially the same.  Just as I am about to throw a dart into my mental dartboard to pick one, the patient tells me of a friend who had great success with one of them.  Suddenly the choice is clear.  In such situations I (enthusiastically) prescribe that particular medication due to “positive patient expectations,” and not due to “the physiological mechanism of the treatment itself.”  To take another example, occasionally patients tell me that plain aspirin or Tylenol helps them sleep.  Who am I to tell them they must be mistaken?

The greatest cliche of medicine, “take two aspirin and call me in the morning,” is a testament to this principle in internal medicine, rheumatology, and similar specialties.  If a newspaper headline in 2008 can shock and alarm us over a practice as old as this cliche, Western culture has strayed very far indeed from the essence of healing.