What is the placebo worth?

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39535.344201.BE (Published 01 May 2008) Cite this as: BMJ 2008;336:967
  1. David Spiegel, Willson professor 1,
  2. Anne Harrington, professor and chair2
  1. 1Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305-5718, USA
  2. 2Department of the History of Science, Science Center 371, Harvard University, Cambridge, MA 02138, USA
  1. dspiegel{at}stanford.edu

    The doctor-patient relationship is a crucial part of its value

    George Bernard Shaw described a miracle as “an event that creates faith.” Belief is a powerful tool, and many factors influence it. A recent study testing pain relief from analgesics showed that merely telling people that a novel form of codeine they were taking (actually a placebo) was worth $2.50 (£1.25; €1.58) rather than 10 cents increased the proportion of people who reported pain relief from 61% to 85.4%.1 When the “price” of the placebo was reduced, so was the pain relief. A meta-analysis of decades of clinical trials proposed that the placebo effect was more hype than reality.2 However, the resulting backlash against it has had the implicit effect of clarifying what is best practice with regard to the placebo.3

    Hovering over much of the research is a practical question for clinicians—what does all this mean for patient care? In the accompanying randomised controlled trial, Kaptchuk and colleagues undertake a dismantling approach to the examination of placebo effects.4 In 262 adults with irritable bowel syndrome, they examined the effects of placebo acupuncture in circumstances that involved observation only (evaluating a “Hawthorne effect”), sham acupuncture alone, and an enriched relationship with the treating doctor along with the sham procedure. The proportion of patients who reported moderate or substantial improvement on the irritable bowel syndrome global improvement scale was 3% in the observation group, 20% in the procedure alone group, and 37% in the augmented intervention group (P<0.001 for trend).

    Clearly the group with the greatest relief of symptoms was the one that received not only sham acupuncture but 45 minutes of quality contact with a clinician. This contact involved questions about the patient’s symptoms and beliefs about them, a “warm, friendly manner,” empathy, and communication of confidence and positive expectations. In contrast, the doctor-patient relationship in the sham acupuncture only group sounds like a caricature of procedure based medicine practised under strict time limitations:the practitioners explained that this was “a scientific study” and they had been instructed not to talk about it with patients.

    Global improvement scores were higher and quality of life and amelioration in symptom severity were almost doubled in people receiving augmented care, which raises some interesting questions. Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on drugs and procedures is “penny wise and pound foolish.” Patients might respond better to real as well as placebo interventions if they were associated with a good doctor-patient relationship. Although the increased time and concern may enhance the effects of the placebo, it also changes the context of associations with the treatment—the doctor may enhance the effect of the sham needle, but the needle also becomes a reminder of the enriched relationship.

    That this study chose to evaluate placebo effects associated with an unconventional treatment raises further interesting questions. It is already widely assumed by sceptics that most if not all of the benefit of “alternative” or integrative medicine comes from the placebo effect. It is then assumed that demonstration of a powerful placebo effect, without proving a specific effect, is enough to consign the treatment to the realm of quackery.

    But what if we asked a different question? 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?5

    In seeking such understanding we should think about the conditions for which patients often seek alternative treatment, and what that might teach us. Patients with irritable bowel syndrome have a chronic condition that can deeply affect their quality of life. They usually have a story to tell about their suffering and want it to be heard, and an empathetic ear may be just what they need. Both the emotional and physical needs of a patient needing emergency surgery, however, might be very different. Such patients might well have a strong placebo response to a calm, orderly, high-tech hospital environment and a kind but focused doctor who does not stop long to chat but instead brings his or her full attention to the pressing business at hand.

    Whatever the specifics, the take home message is clear. 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. Recent brain imaging research on pain and the placebo effect has shown functional connectivity between specific brain regions that process attention (the anterior cingulate gyrus) and pain (periaqueductal grey), involving endogenous opiate receptors.6 Techniques such as hypnosis improve a range of objective symptoms of irritable bowel syndrome and produce subjective reductions in distress.7 8 The word “placebo” is Latin for “I will please.” On the basis of these and related studies, it seems fair to conclude that a good doctor-patient relationship can tangibly improve patients’ responses to treatment, placebo or otherwise.