What medical training can learn from placebo research

Placebos work. This isn’t news. The term “placebo” was coined 60 years ago to describe how one-third of people respond to pills without any active drug in them. Twenty-five years later, we learned how they work: through endorphins produced by the body that work just like morphine. Today placebos are everywhere: from mothers kissing boo-boos to international drug trials.

recent paper, though, shows that all placebos aren’t created equal. As expected, the authors found placebo pills effective for reducing migraines in about one-fifth of patients. But it gets better. Take sham acupuncture, which doesn’t target traditional pressure points and doesn’t penetrate the skin. Despite being “fake,” sham acupuncture reduced migraines in 38% of patients, making it as effective as real migraine drugs. The authors also studied sham surgery, in which doctors give anesthesia and cut the skin, but stitch it back together without doing anything to the tissues underneath. These fake operations helped 58% of migraine patients, potentially even more than active drugs.

What does this tell us? It depends on whom you ask. Some might say we need to figure out how to predict a good response to placebo (and are trying to do just that). Others might say we need to test more procedures against shams, to make sure they’re effective. Yet others might say sham surgery is unethical outright. These are questions without quick answers. For the rest of us, what can the placebo effect teach us about medicine as a whole?

No treatments — drugs, placebos, shams — exist in a vacuum. They’re part of a complex ritual of storytelling and listening, examining and touching, teaching and prescribing. Patients expect this ritual and I, like any medical student, am working to master it. Yesterday’s medicine might’ve been a prayer or a poultice; today’s it’s delivered on blue slips and under blue drapes. But one thing that hasn’t changed is that ailing humans want intervention. And the benefits of medicine transcend pills and procedures. Words, touch, and hope can be therapeutic.

Wielded inappropriately, they can do harm too. Medicine embraces lots of treatments without proven benefit. Many doctors still stent narrowed blood vessels in the heart when patients have stable chest pain, even though the right pills extend life just as much. (Stents do appear better at preventing pain – but is that another placebo effect?) Some patients with early prostate cancer are also receiving expensive proton beam therapy instead of conventional radiation, again without evidence of benefit. Some doctors may be recommending these treatments for the wrong reasons. But I imagine many are working to satisfy a basic human impulse: to act aggressively in the face of disease. Our bodies respond better to high-touch, high-tech interventions: we get more pain relief from a $2.50 placebo than one that costs a dime. But bigger is not always better. Bigger is often more likely to do harm, through costs or complications.

What I take away from placebo research is that how we do our job is just as important as what we do. The notion that drugs and surgery are the only treatment we can offer has become a self-fulfilling prophecy. Medical training and research are decidedly focused on what drugs to give when – knowledge necessary, but not sufficient, to serve our patients. This may distract us from the psychological and social mechanisms beneath the human response to treatment. Rather than inventing a new procedure that might not be more effective than sham, we should be inventing ways to get the benefits of a sham without cutting the skin.

Many of our most common yet most frustrating afflictions have a psychological component: for example back pain, irritable bowel syndrome, and of course headaches. So it makes sense that these conditions have been shown again and again to respond to the placebo effect. It’s now our duty to figure out how we can put that power to good use. What combination of advice, empathy, and touch unlocks our body’s natural painkillers? Can we be high-touch without being high-tech? Can that be taught? Experienced clinicians may have the answer without even knowing it. But students like myself could use a bit more training on how to be our patients’ placebos.

I’m not referring to prescribing placebos, though some are trying to figure out how to do so without deception. We must learn how to make a patient’s body expect relief without the scalpel, needle, or prescription pad. Are there questions that make a patient feel heard, exam maneuvers that show I’m paying attention? When there’s no medical answer, can words themselves heal? After years and years of training, is there something I can do that pills cannot?

Karan Chhabra is a medical student who blogs at Project Millenial. He can be reached on Twitter @KRChhabra. This article originally appeared in the Boston Globe’s Short White Coat.

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  • Myron Shank

    Interpreting responses to the nonspecific activation of the endorphin and enkephalin systems to mean these “afflictions have a psychological component” is just as erroneous as saying that, because they are nonspecifically responsive to extracts of Papaver somniferum, these afflictions have a botanical component. These conditions are not caused by a “psychological component” any more than by a deficiency of botanicals. Myron Shank, M.D., Ph.D.

    • Karan

      Dr. Shank, thanks for reading my post and sharing your thoughts. It sounds like we agree that there’s some activation of the endorphin and enkephalin systems. What do you think is responsible for it, if not psychology? Sham treatments by nature don’t alter one’s underlying physiology — so what’s the basis for endorphin/enkephalin activation?

      • Myron Shank

        Actually, as a Ph.D. in Physiology and Biophysics (as well as M.D.), I believe that sham treatments do alter physiology–that is why they have effects that must be controlled for in studies. I do not believe that the effects of sham treatments proves anything about the underlying cause of the condition, however.

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