More Power to the Placebo
by Danielle Ofri
New York Times
It was well past midnight and most of the patients had settled in. The hospital ward was quiet, except for “the howler.” The howler was a patient in his thirties who earned his nickname for his nightly bouts of yelling. This was in the mid 1990s, during the peak of the AIDS epidemic. I was a second-year medical resident at Bellevue Hospital, in charge of the sprawling AIDS ward that night. Admissions were rolling in, one after another, each more feverish and emaciated than the previous.
This patient was already receiving hefty doses of pain medication, yet he kept screaming to the nurses about his pain. This went on, night after night, despite extensive medical evaluations to see if there were any missed explanations for his pain.
Nothing seemed to help, and the nightly yowling was agitating the other patients and driving the nursing staff to distraction. The head nurse paged me at 3 a.m. “You have to do something,” she said.
I went to the patient’s room. It was my fourth visit of the night, and the patient and I were both pretty exasperated with each other. He was sullen and cranky; I was exhausted and at my wits’ end.
I pulled out a syringe and carefully drew up one cc of plain saline. “Mr. H,” I said, showing him the liquid-filled syringe. “You know about Tylenol. You’ve heard of Tylenol #3. There’s even a Tylenol #4. This”—and here I paused for dramatic effect, slowing my voice to enunciate every syllable—“is Tylenol #5.”
The patient stopped howling and gave me an interested look. Then he lowered his pajamas and allowed me to inject his gluteus maximus. We waited together for the medicine to sink in.
After what seemed like a mutually agreeable time, I stood up and buttoned my coat. The patient put his head to the pillow and promptly fell asleep. The ward was silent for the rest of the night.
I felt terribly guilty that I had committed an outright deception with this patient—something that is a true no-no. But on the other hand, it was the first night he got a full night of sleep, to say nothing of all the other patients on the ward and the rest of the staff.
When I related this story to Ted Kaptchuk, Director of the Program in Placebo Studies at Harvard, he gave a sigh of recognition. “We all have our moments of desperation,” he said. “Usually around midnight.”
Kaptchuk does not condone deception, but his research bears out that that how caregivers present and administer treatments has a powerful affect on clinical outcome.
Patients, for example, who received pain medicine directly from a doctor achieved better pain relief than patients who unknowingly received the same medicine, even at higher doses, automatically in their IVs. The rituals of the doctor—drawing up the medication, visibly injecting it into the IV, discussing of expected benefits—not to mention the attention and caring that comes with an actual human being—effected as much pain relief as doubling the dose of the medicine.
Placebos used to be thought of as psychological mumbo-jumbo more akin to hypnotism than real medicine. The biological breakthrough came in 1978 when researchers showed that not only was the placebo effect real, but that it could be reversed by administering naloxone—the chemical that blocks our endorphins. Suddenly there was a plausible pharmacological mechanism for placebo affects, and the research in the field had flowered. Last month, Harvard Medical School and the Robert Wood Johnson Foundation held an international medical conference entirely to placebo science.
Kaptchuk describes placebo as not just the traditional sugar pill, but also the “everything that surrounds a medical treatment”—how caregivers describe the medication, how they administer it, the expectations they have for the medicine, their tone of voice, their strength of eye contact. In short, everything that doctors and nurses do in an interaction with a patient.
This is not especially surprising. Healers and shamans have known this intuitively since the dawn of time. Especially in the eras in which we lacked treatments that could significantly impact the pathology of disease—antibiotics, chemotherapy, stents, organ transplants, transfusions—the “everything else” was the mainstay of medical care.
Doctors and nurses always feel a bit uneasy when it comes to placebos. Somehow it seems wrong, unethical, deceptive. But patients are actually more flexible in their thinking. Studies have shown symptom relief even when patients are told they are getting a placebo; many patients are quite amenable to open-label placebo. “If it gets rid of the pain,” a patient once told me, “I don’t care if it’s a jelly bean!”
The ethics are evolving, but the general consensus is that transparency is the bottom line. What I did as a young (and desperate) resident wouldn’t pass muster because I deceived my patient about the medication. But if I’d told him that it was inert saline and if he was amenable to trying it, this could have been a reasonable treatment option. And it still might have helped him, especially if we’d been able to have a detailed and compassionate conversation about his pain.
Kaptchuk thinks of placebo effects as just one of the many things in the toolkit of medicine. It would never be a substitute for appropriate medical care, but it’s something that can enhance medical care greatly. Wise doctors and crème-de-la-crème nurses already do this. They’ve found, usually just by personal experience, that their “everything else”—respect, attention, comfort, empathy, touch—often do the lion’s share of medical care, no deception required. Sometimes the prescription is just the afterthought.