Reclaiming the placebo effect

Where do doctors add most value? Larry Brilliant—a public health doctor who has worked on programmes to eradicate smallpox, blindness, and polio—has found his niche as executive director of Google.org (p 986; doi: 10.1136/bmj.39548.369977.AD). Through an initiative called Predict and Prevent, launched earlier this year as one of five core initiatives that will focus Google’s philanthropic efforts over the next 5-10 years, Brilliant is building a global system to detect new disease outbreaks or disasters quickly and enable rapid responses. Compared to the one to one doctor-patient relationship, he says this role was harder and more fraught with moral error.

But for most of you who are reading this column, the biggest scope for adding value is in the clinical encounter. How? By making the right diagnosis and giving the right treatment, certainly. But how much of that added value is or could be achieved by what we tend to dismiss as the placebo effect?

For some conditions, the placebo effect may after all be one of the most powerful tools in your medical bag—but only if you know how to use it. It’s more than just a neutral comparator against which active treatments are evaluated in randomised controlled trials, and more than just a sugar pill. As a study in this week’s BMJ illustrates, at its most effective the placebo effect consists of both a sham treatment and what used to be called good bedside manner.

Kaptchuk and colleagues have cleverly unpicked the placebo effect (p 999; doi: 10.1136/bmj.39524.439618.25). They randomised patients with irritable bowel disease into three groups: observation alone, sham acupuncture with no interaction between clinician and patient, and sham acupuncture plus a positive, caring, doctor-patient interaction. They found a clear and impressive dose-response relationship: the second group improved significantly more than the first group but significantly less than the third, who improved by 37%. As the authors of our linked editorial conclude, a constructive doctor-patient relationship can tangibly improve patients’ responsiveness to treatment, be it placebo or otherwise (p 967; 10.1136/bmj.39535.344201.BE). Good doctors know this and don’t let alternative practitioners monopolise this crucial aspect of medical care.

If a sham treatment plus a good doctor-patient interaction can be so powerful, doesn’t this become a useful treatment in its own right? And if so, can we get over the ethical problem that giving a placebo traditionally involves deceiving the patient? Rudiger Pittrof and Ian Rubenstein think we can (p 1020; doi: 10.1136/bmj.39564.454502.C2). Placebo now has its own evidence base, with before and after benefit shown in a range of conditions and an excellent safety profile. The authors conclude that where an effective placebo treatment exists, not offering it may be unethical. They will no doubt be ready to reply to your rapid responses on their proposal’s limitation—that the evidence is based on studies of patients who did not know for sure that they were receiving placebo.