The doctor as placebo

"Maria Inês Reinert Azambuja"  to Cardiovascular

Dear Dr. Lown
Very beautiful text, and a necessary reflection at a time when medical doctors seem to be completely taken by the pharmaceutic industry mermaid
song...
Best regards,
Maria Inês Azambuja

The Doctor as Placebo

I am now convinced that the  placebo effect is not limited to drugs or surgical procedures, that it is a far more universal phenomenon. The words of doctors and other health professionals are the most potent placebos of all...

Lown RCTs (Random Clinical Thoughts): The doctor as placebo
Bernard Lown, MD

We are living in a paradoxical age. From medicine we expect miracles; from doctors, brush-offs. Physicians, no longer revered figures, communicate less and less with their patients. History gathering is hurried and frustrating, and even these precious minutes are misspent. Instead of focusing on the patient, the doctor peruses electronic records. Frequently, he or she does so facing a computer screen instead of the patient. The scene recalls a robotic transaction. Eyes do not bind, voices do not connect, communication is at cross-purposes. After a brief séance, patients are sent for a panoply of tests, imaging procedures, and visits to indifferent specialists.

The present disjuncture in medicine results from a market-driven health care system wherein doctors sell services to optimize their bottom line. They envision themselves not as healers but as medical technologists qua scientists. Thereby they have put themselves at odds with professional doctoring.

I would like to help restore the former health professionalism of physicians. Such a reinvention requires that doctors resume their role as placeboist. Some will recoil. Aren't placebos a "pious fraud," as Thomas Jefferson suggested nearly two centuries ago? For many the word evokes an image of fake treatments, of charlatans dispensing snake oil. This has been my opinion as well. I believed that the handing out of inert sugar pills to the worried-well ran against the grain of scientific medicine. Fifty years of medical practice has altered my views.

Clinical Experience
My rethinking of this issue began with an anecdote I heard many years ago about Mark Twain. One sweltering summer night he was in a cheap hotel in Mississippi. Soaked in sweat from the oppressive heat, he tossed and turned in the stagnant, stale air. Though dead tired he could not sleep. Growing desperate, he hurled a shoe against the closed window. As the glass shattered, he felt a cool breeze wafting off the Mississippi River. Sound sleep was immediate. The next morning he found the shattered glass of a mirror adjoining the still-closed window. The listener of this tale usually nods knowingly, ascribing the imagined breeze to the power of the mind. Indeed we are not disembodied from our executive brains.

What mainly made me gain respect for the placebo was clinical experience. The more extensive my experience, the more evident was the power of the placebo effect.

When in fellowship training with that masterful clinician Dr. Samuel A. Levine, I was frequently provoked by his cavalier response to patients with intractable symptoms. He would fish in a pocket and hand out a pill that was either a bromide, a barbiturate, or a vitamin. By contrast, before prescribing any medication, I would scrupulously comb the scientific literature for the latest evidence-based remedies. The difference in outcome between Levine's patients and mine was stark. His improved promptly; mine did not fare as well. In later years, I came to suspect that the explanation lay in the placebo effect.

The more patients I saw, the more frequently I encountered the magical placebo. I recall a middle-aged man, Mr. B., with angina pectoris. This was before introduction of a host of effective anti-anginal drugs, coronary bypass surgery, angioplasty, or coronary artery stenting. Nitroglycerin was then the sole remedy. Anginal attacks totally immobilized him, as the slightest exertion intensified the pain. Mercifully, a nitro pill under the tongue consistently and promptly resolved the discomfort. One day while walking on a beach in bathing trunks, Mr. B. experienced angina. Unable to find the pillbox, which he'd left in a pants pocket, he panicked. Mounting anxiety intensified the pain, and he was unable to move. Mr. B. asked a passerby to fetch the pills, pointing to his trousers under a beach umbrella twenty yards away. The man readily found the pillbox, and as he waved it in the air, Mr. B.'s pain abated as though the nitro had already dissolved under his tongue. He later related that on many occasions, the angina disappeared when he took out the pillbox. Many other patients have noted that merely handling the small nitroglycerine bottle assuaged their discomfort. The container acted as a placebo.

Historical Record
The placebo has a long history. Indeed, it was supreme during several millennia of medical treatment. Already in Roman times, the famous Galen Pharmacopeia contained 820 placebo remedies. Galen insightfully observed, "He cures most successfully in whom the people have the most confidence." The pioneer placebo researcher, Arthur Shapiro, maintains that nearly all of the 16,842 ancient remedies, with but few exceptions, were placebos. (1)

The modern mind is unable to comprehend the extent of public gullibility. Over many centuries people succumbed to bizarre, unpalatable, sickening, and sometimes lethal pharmaceutical concoctions. The chemist-pharmacist of old would grind dust from precious stones together with a maddening hodgepodge consisting of scorpions, worms, or wood lice, the entrails of animals, and perhaps a bit of human placenta, admixed with saliva, the sexual organs of executed convicts, and all sorts of excreta. These remedies, deemed panaceas, were indiscriminately prescribed for a wide spectrum of maladies.

Even more remarkable was that patients submitted to bleeding, sweating, purging, puking, leeching, poisoning, cutting, cupping, blistering, freezing, burning, shocking, and a host of other bodily harms. While rehydration and the preservation of blood volume are now a focus of therapy, the very opposite was practiced before the advent of the scientific age. George Washington did not die from a tonsillar abscess, as is commonly believed, but to the leaching out of more than 2.5 quarts of blood within 12 hours. A similar fate of phlebotomy until death befell Giuseppe Mazzini, the founder of the modern Italian republic. One wonders why people accepted noxious methods. One also wonders why physicians were honored though their practice was often irrational and at times fatal.

Modern Clinical Experience
Back in the early 1950s, I came across a case report that left a lasting impression. A pregnant woman suffering from severe and intractable nausea had a balloon inflated in her stomach to record the gastric contractions that provoked the nausea. The vigorous contractions were observed to coincide with her complaint. She was given ipecac-a drug that causes vomiting-and assured that it would bring relief. Within minutes after the ipecac, the intense stomach contractions ceased and with it the nausea. (2)

Investigations by Dr. Henry Beecher, the distinguished Massachusetts General Hospital anesthesiologist, removed placebos from the realm of humbug. As a surgeon in World War II, he observed that the pain experienced by severely wounded soldiers was relieved by small doses of opiates. This contrasted with his civilian experience. At times even massive doses of narcotics failed to ease the pain of young victims injured in car accidents. Beecher concluded that analgesia involved more than the pharmacological action of drugs. The wounded soldier was a hero who no longer had to face the frightening ordeal of battle and the possibility of being killed. The victim of a car crash foresaw no such redemption. He was more likely to face parental censure and perhaps punishment for wrecking the family car.

These observations intrigued Beecher and led him to an extensive exploration of the role of the placebo. (3) He studied 1082 patients with pain from diverse causes. Placebos afforded satisfactory relief in 35% of the cases, (4) a result that has since been consistently confirmed. Beecher was persuaded that placebos activate physiological and biochemical mediators that alter brain function and affect perception of noxious stimuli. He suggested that some of the benefits of surgery are due to placebo mechanisms. Beecher concluded that all drugs exert dual effects, one related to intrinsic pharmacological properties and the other inseparable from placebo action.

Just like drugs, placebo pills exert stronger effects when prescribed in larger doses. The effect is more marked when the capsules are bigger. Relief is greater when the dose is doubled and is more marked when the placebo is injected than when taken orally.(5) Pills colored red, yellow, or orange are likely to stimulate; while blue or green tend to tranquilize.(6,7)

Knowing of the reputed benefit of a remedy is itself likely to increase the efficacy of a placebo. A doctor's affirmation of the value of a prescribed measure will promote a positive placebo effect, especially if the clinician is highly reputed and conveys the aura of long experience and authority.

Patient confidence in the placebo treatment enhances its curative effect. It has long been known that patients who rigorously comply with instructions for taking a drug fare better than those who do not. And those who have faith in a treatment are more likely to comply. What is astonishing, though, is that patients who comply with a placebo regimen also do better than those who haphazardly take the pills. In a large randomized placebo-controlled trial of cholesterol-lowering drugs among coronary heart disease patients, those who took the placebo pills consistently had a lower mortality than those who did not. (8) Even more striking is that the imagined effects of a substance can sometimes directly countermand its actual pharmacology. For example, if a stimulant is given but the patient is informed that it is a sedative, the response will be relaxation and sleep rather than agitation and wakefulness.

Notwithstanding the indubitable power as well as potential benefits of placebos, many physicians harbor a distrust of placebos and contempt for patients who are "fooled" by them, as though responding to an imaginary medication stems from a character defect. A prevailing impression is that the poorly educated, the less intelligent, and the submissive are placebo prone. Psychological studies provide no support for these assumptions. Response to a placebo appears to be far more related to immediate situational and interpersonal factors such as the quality of the doctor-patient relationship, the gravity and type of illness, the severity of symptoms, and a host of others. (9)

Words and doctors as placebos
I am now convinced that the placebo effect is not limited to drugs or surgical procedures, that it is a far more universal phenomenon. The words of doctors and other health professionals are the most potent placebos of all. The capacity of a doctor's word, either to heal or to maim, is determined by the physician's demeanor, the certainty with which information is communicated, the level of empathy displayed, and above all a readiness to listen.

The placeboic power of words was brought home to me by a critically ill patient. (10) Two weeks after a heart attack, he was still in a coronary intensive care unit. He had experienced nearly every complication in the book. The problem was easy to define: More than half of his myocardium was infarcted. He was in florid congestive heart failure. Severe hypotension reflected a markedly reduced ventricular ejection fraction. He could not sit up due to dizziness and near syncope. Breathless and weak, he had no energy to eat; he also lacked appetite, as the smell of food provoked nausea. Sleep was restless and disrupted. He was cyanotic and periodically gasped for air as though drowning.

Each morning, medical rounds were like visitations from a morose bunch of undertakers. We had exhausted all the encouraging platitudes. In any case, I believed that any reassurance would have insulted the patient's intelligence and further undermined his trust. We sped up the morning visits to avoid his scared, questioning stare. Every day the situation deteriorated. His family agreed to a DNR status.

One morning he looked better, he claimed to feel better, and indeed his vital signs were improved. I could not account for the change. The prognosis was nonetheless grim, whatever the temporary improvement. Believing that a change to a less turbulent environment than the CCU would be less stressful and would afford him a night's sleep, I had him transferred to a step-down care unit. I lost track of the patient when he was discharged a week later.

After about six months he showed up in my office. Free of lung congestion and largely asymptomatic, he looked remarkably fit. I was astonished and puzzled. "A miracle, a miracle!" I exclaimed. "Hell no, this was no miracle," he responded. I was taken aback by his certainty that divine intervention had played no role in the miraculous recovery. "What happened?" I asked.

He stated emphatically that he knew exactly when the so-called miracle happened. He was aware that we were at our wits' end, blundering and confused, and did not seem to know how to help him. We had convinced him that we had given up hope and that "his goose was cooked."

He continued, "One Thursday morning, April 25th, you come in with your gang, surround the bed, and look as though I was already in a casket. You put your stethoscope on my chest and urge everyone to listen to the 'wholesome gallop.' I figured that if my heart was still capable of a healthy gallop, I couldn't be dying, and so I got well. So you see doc, it was no miracle. It was mind over matter." The patient was of course unaware that a gallop was a bad sign. A wholesome gallop is an oxymoron.

Words are the most powerful resource a doctor possesses. Patients crave caring, which is dispensed largely with words. Talk can be therapeutic. It is one of the most underrated tools in the physician's armamentarium. Medical experience provides constant reminders of the healing power of words. I know of few remedies more effective than a carefully chosen word. (10)

But the doctor's possibility of acting as a placebo is not limited to words. Minimizing the waiting time begins the process. Greeting a patient with a warm handshake followed by an unhurried, uninterrupted visit further enhances the placebo effect. A careful history, taken without interrupting the patient, fosters trust. An affirmative demeanor, a ready smile, a positive word, speech that is direct rather than equivocating, helps a doctor connect with another human being and form an enduring relationship.

In the most cloudy situation, one can discover a silver lining. This has little to do with truth or falsehood. It flows from the deepest intent of doctoring, to help a patient cope with a condition. Even when a cure is impossible, that does not mean healing is impossible. The very sick are not taken in by phony optimism, but they are eager for a warm touch and the caress of human concern. While medical science has limits, hope does not. I believe the maxim proposed by the physician Edward Trudeau about a century ago: "To cure sometimes, to relieve often, to comfort always." Miracles reside in the capacity for comforting and healing. Doctors can reclaim medical professionalism by resuming the role of a "placeboist."

Citations:
1. Shapiro AK, Shapiro E. The placebo: Is it much ado about nothing? In The Placebo Effect, edited by Anne Harrington. Cambridge, Mass.: Harvard University Press, 1997:12.
2. Wolf S. Effects of suggestions and conditioning on the action of chemical agents in human subjects: the pharmacology of placebos. J Clin Inv1950; 29: 100-109.
3. Beecher HK. The powerful placebo. JAMA. 1955;159:1602.
4. Beecher HK. Surgery as placebo. JAMA 1961;176:1102.
5. Blackwell B, et al. Demonstration to medical students of placebo responses and non-drug factors. Lancet 1972; I; 12:79-82.
6. Buckalew LW, et al. An investigation of drug expectancy as a function of capsule color, size and preparation form. J Clin Psychopharmacol 1982; 2: 245-48.
7. de Craen AJM, et al. Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness. BMJ 1996; 313: 1624.
8. Coronary drug project research group. Influence of adherence to treatment and response of cholesterol on mortality in the coronary drug project. NEJM 1980; 303: 1038-41.
9. Frank J and Frank JB. Persuasion and Healing. 3rd ed.. Baltimore, Md.: Johns Hopkins University Press; 1991.
10. Lown B. The Lost Art of Healing. New York: Random House; 1999.