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Rapid Responses: Rapid Responses published:
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What is this editorial worth?
- Donald M Marcus (2 May 2008)
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The importance of the human effect in medicine
- Robert W Leckridge (2 May 2008)
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Stick Out Your Tongue, Please
- Dr.Herbert H. Nehrlich (5 May 2008)
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The dangers of placebo
- Jean - Claude GRANGE (5 May 2008)
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Reconceptualising placebo.
- G. Lorimer Moseley (5 May 2008)
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powerful medicine
- Sebastian Kraemer (8 May 2008)
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Donald M Marcus, Prof. of Medicine & Immunology Dept. of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030
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Editorials that accompany original articles can provide a perspective that helps the reader evaluate the validity of the data, what the findings add to current knowledge and how they might affect medical practice. The editorial commentary by Spiegel and Harrington [1] on the article by Kaptchuk et al. [2] is congratulatory and contains little critical analysis. Kaptchuk et al. assigned patients with irritable bowel syndrome to three groups: a waiting list, and placebo acupuncture delivered either by an acupuncturist who was warm and sympathetic (augmented interaction) or cold and detached (limited interaction). The latter therapists told patients that this was “a scientific study” for which they had been “instructed not to converse with patients”. Unsurprisingly, patients in the augmented group improved more than the other two groups. The authors conclude that factors contributing to the placebo effect can be combined in a “dose escalation” manner. The editorial could have made several points. First, the message conveyed to patients by therapists in the limited interaction group was negative, rather than neutral, and it might have diminished the beneficial effect of the sham acupuncture treatment. Second, how did the larger attrition rate in the limited group (17/88) compared to the augmented group (5/87) affect the outcome? Third, a three-week period of treatment provides limited information about the value of a therapy for a chronic disease. Fourth, describing the combination of two well-known placebo maneuvers as a novel “dose escalation” study is a bit overstated. Instead of critically analyzing the study, the editorialists used the opportunity to restate the tired alternative medicine party line that only alternative practitioners provide holistic treatment, and that conventional physicians are unaware of the importance of patient-doctor interactions. Perhaps this commentary is an example of a new genre, the placebo editorial: pleasing, but lacking specific content. References 1. Spiegel D, Harrington A. What is the placebo worth? BMJ 2008 April 3 2. Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, et al. Components of the placebo effect: randomized controlled trial in patients with irritable bowel syndrome. BMJ 2008 April 3. Competing interests: None declared |
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Robert W Leckridge, Locum Consultant Glasgow Homeopathic Hospital. G12 0XQ
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The dismissal of non-specific effects of care, as placebo effects (which are rated as sham, pretend, dishonest or false) does a huge disservice to patients and to doctors. Your take home message is spot on - "We treat patients in a social and psychophysiological context that can either improve or, alas, worsen outcome. The meanings and expectations created by the interactions of doctors and patients matter physically, not just subjectively" It's time for doctors to reclaim the human aspects of their work. Caring for patients with due time and attention is not a luxury or superfluous. It has a direct impact on outcomes. We cannot reduce medical practice to the physical components of our interventions because human beings are more than their physical components. We are thinking, feeling, meaning-seeking creatures. Unless we are treated as such we cannot expect the best outcomes from our medical experiences. Thank you for this editorial. It is timely, considered and important. Competing interests: None declared |
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Dr.Herbert H. Nehrlich, Private Practice Bribie Island, Australia
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Placebo. Like Prosit. Just words you say. Much of what is wrong with modern medicine can be traced to its (what could politely be called) modernisation. Say what you will about the bumbling doctors that were our forefathers, their effectiveness cannot be measured so simply. With little to use in the way of tools, laboratory tests and the services of specialists at the other end of a telephone line, those physicians, most of them GP's, were lone heroes in often horrible times, battling the twins death and disease singlehandedly. Picture the time of Robert Koch, of Wilhelm Roentgen, imagine if you can the terror of tuberculosis, of diseases capable of wiping out millions and the pioneers who sat, glued to their microscopes and busy inventing a system that would at last uncover the evil agents eager to maim and kill. What did these doctors rely on? Two things. 1. Their powers of observation and ability to think and thus deduce. 2. The Placebo Effect. Placebo.A placebo works with the patient's expectation to get well. Without going into the psychological nooks and crannies of this, we can readily see the role of the doctor as not only advisor but as the facilitator.We used to speak Latin in front of the sick.We wore white coats and a little mysterious leather bag inside which was stuffed what no one else could supply and what would most likely save you from any manner of dire consequences.We were our patients' HOPE, often their last hope. The doctor of the past was seen from below, standing proud and all- knowing on a pedestal and wearing a benevolent but barely visible smile.His deeds outclassed his few words and he was an Altruist with an attitude and, lucky for you, with the right priorities. Much of the image of the physician has changed and the stethoscope is almost the only remnant remaining; even that has been assigned a different (and awkward?) position. The recent revelations concerning antidepressants are but one example of how important the placebo effect is and it impresses few that "studies have shown" that this effect is really rather trivial and deserves, therefore, no place in modern medicine. I say that a very large part of the clinical successes of alternative practitioners can readily be explained by the placebo effect of RAPPORT. Unconscious human interaction. It would serve many modern colleagues well to incorporate more time and the manners of those who were looked up to as healers and who could do the job all by themselves. But then, I can see that so many have long ago found this to to be an important part of practicing. As my late father used to say, you can prove that homeopathy works by treating a sick animal with it. But you must stroke the animal. Competing interests: None declared |
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Jean - Claude GRANGE, GP 78200 Mantes-La-Jolie FRANCE
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Sir, The ins and outs of placebo use in medicine are unfortunately forgotten by the physicians especially when it concerns controlled clinical trials. So I would emphasise a number of points regarding the use of placebo which: a) spoils the physician / patient relationship; b) enhances the asymmetric relation, i.e. paternalism, between physician who knows and patient who is primitively a sufferer; c) can be medically dangerous especially when the aim of the physician is to determine whether a patients has an organic disease or not; d) strengthens medical arrogance and infantilizes even more the patients. I would quote a sentence by Howard M Shapiro (Doctors, patients, and placebos. 1986, Yale university Press): “Finally we have to consider what may be the great danger of all for the physician, that giving a placebo will give him an even higher opinion oh his own abilities to help.” Sincerely yours. JC GRANGE, MD Competing interests: None declared |
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G. Lorimer Moseley, Nuffield Medical Research Fellow Oxford University OX1 3QX
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The placebo response just won't go away will it? It remains a great way to fire up debate and recruit terrifically good arguments from both sides of the Great Placebo Divide. However, staple to the debate is this notion that placebo responses are responses that are evoked by nothing. This is nonsense. I think the Kaptchuk et al study and the Waber et al study in JAMA illustrate clearly that the 'placebo' responses observed are in fact responses to things other than the thing to which we hypothesise a response. Therefore, placebo responses reflect the limitations of our experimental design, our appreciation of the contributors to a patient's symptoms and our appreciation of what might change those underpinning factors. The convincing placebo data concern symptoms. Symptoms are experiences reported by patients. That means that symptoms are outputs of the brain. That a placebo response occurs means that something has changed the brain's evaluation of whether or not to evoke that symptom. This makes a placebo response not a response to nothing, but to something we haven't identified or measured. Take pain for instance: Pain emerges according to an implicit evaluation of the threat to body tissue and the need for action. It is sensible that anything that changes this implicit evaluation of threat should change pain. Rather than interpreting 'placebo' responses as mysterious unexplainable responses to nothing, we should, as this editorial hints, get excited about what else might have led the patient's brain to conclude that the need for symptoms had just reduced. To suggest we should utilise the placebo response in clinical practice seems a bit daft to me because it is the other things (we are yet to identify, accept or understand), which change the brain's evaluation of the need for symptoms, that we should utilise. I agree that the alternative therapies are way in front of us here - they KNOW they are using some of these things, it just doesn't make THEM conclude that what they do is useless. Competing interests: None declared |
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Sebastian Kraemer, consultant child and adolescent psychiatrist Whittington Hospital, London N19 5NF
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Placebo need not be deceptive. The power of randomised controlled trials has bewitched a generation of doctors and others into thinking that, because it has to be ruled out in the research, it has no place in the treatment. Placebo is powerful medicine and is a necessary element of therapeutic care (Kraemer, 2006). Kraemer, S. Something happens: elements of therapeutic change. Clinical Child Psychology and Psychiatry 2006, 11: 239-248 http://ccp.sagepub.com/cgi/content/refs/11/2/239 Competing interests: None declared |
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