The S&A Health Report: The Power of Placebo
November 12, 2006
“He cures most successfully in whom the people have the most confidence”
- Galen of Pergamum, physician to a gladiator school in the second century A.D.
Did you know that Galen was a fantastic surgeon? And a trauma surgeon at that. Working in the gladiator school gave him experience, and the continuous trauma allowed him to see much anatomy. He was a prolific writer and student of anatomy – and I must admit I am jealous of his “office set-up.” Legend tells us that he had a dozen scribes doing nothing but writing down his every word and action (Porter’s dream office, too!). Interestingly enough, he also was considered by many to be a great cataract surgeon. (WARNING… Skip to the next paragraph if you dislike gore…) The technique involved inserting a long needle through the side of the eye into the cloudy lens… wiggling it around until the opacified lens material had fallen away (usually inside the eye)... and then pulling the needle out. PHEW!
However, the most interesting words from Galen are cited above and bring up the concept of placebo. Interestingly, your doctor (even your surgeon) doesn’t want you to know much about this, and worse… most don’t even think about the power of the placebo.
Since the 1950s, and arguably since the early 1900s, placebos have been used in formal scientific studies. In fact, when you hear of “double-blinded” (for obvious reasons in ophthalmology the preferred phrase is “double-masked”) studies with “randomized controls,” the control is often a sugar pill or a sham procedure. The thought by researchers is that the sugar pill provides data on the natural course of the disease and thus can be “subtracted” from the results, providing us with the true and pure effect of the drug or treatment. Make sense? Logically, the answer is correct, but guess what? Doctors (and others) have found that even the control pill can have unexplained effects. Stated simply, placebo is the measurable effect not attributed to the drug being studied. How can this be?
The word “placebo” comes from the Latin “I shall please” and evolved from medieval Catholic music, when people sang placebos. Over time the connotation has become corrupted to imply that the patient is trying to please the healer by getting better… suggesting that there was nothing wrong in the first place.
Nowhere is this more obvious than in some of the literature on psychiatric drugs. Many people (myself included) point out that much of the effectiveness of antidepressants can be attributed to the placebo effect. Several studies have analyzed the effect of placebo and conclude that 50%-75% of the drug’s power comes from the placebo effect. (STOP – before you bombard me with e-mails… I understand that this leaves 25%-50% attributed to the drug, and for many this can mean the difference between functioning in the world and being institutionalized, or even committing suicide). Truly, no one can doubt the power and certainty of this process. And it is consistent with studies about how important belief and attitudes are in final outcomes. Ask heart surgeons how they feel about operating on people who truly believe they are going to die regardless of the intervention? Some reports suggest that nearly 100% of those people die soon thereafter, regardless of the technical success of the cases.
Although beliefs are important, several researchers suggest it may also simply be the act of going through treatments that somehow triggers a healing response. The process of going to the doctor’s office (if the wait is under three hours) is perhaps what triggers the body to start healing. Through clinical interactions such as handshakes from your doctor, a blood-pressure cuff being placed, or even the conversation and moods of the clinical team, your immune system is stimulated and endorphins are released as well. These endorphins are powerful healing chemicals released by the body in times of exercise, happiness, and even laughter. It is funny how often I hear anecdotes of people going to the doctor, getting prescriptions, failing to get them filled, and lying to the doctor at the next visit, only to find they are healed.
In fact, several years ago, these sorts of anecdotes led Danish researchers to explore placebos in great depth and report a huge meta-analysis on placebos in the New England Journal of Medicine (Volume 344, #21, 2001). They examined 114 studies of placebo and concluded no benefit “on binary outcomes.” However, they point out that there was a benefit with “continuous outcomes” and argue that these studies were small and that was the reason. Sounds like a government economist talking. Many of you know how I feel about these large meta-analyses (the last one I wrote about was the Vitamin E nonsense from Hopkins this spring). But I digress. One problem is that the researchers’ conclusions are based on a limited set of studies. There are hundreds more studies and footnotes to clinical trials (that they conveniently did not include) showing not just positive but even negative side effects to the “placebo controls.” And amazingly, sham surgeries where cuts are made but nothing is done (except the patient is told things were fixed-up) have many times over shown positive effects – as reported by people, for example, with debilitating knee injuries. Placebo effects are real, just poorly understood. Make sure you are aware of the power of placebo next time you think you need a doctor.
When it comes to placebos... What do I do?
1. The real trick is in remembering how strongly connected my mind is to my body.
2. The next step is to remember that my mind and body are connected to others. If I am constantly in conflict in the world, my body will wear out before my mind will “give in” (I am male and stubborn). So I try to listen to that inner rhythm whereby my body is tiring but my mind won’t relent. At those moments, I seek friendship and coddling companions who for years have always been uplifting and conflict-free for me. They naturally bring peace to my mind and THUS my body. The healing begins immediately.
3. I also use the power of place as a placebo. There are some places that are truly healing for me. I try to find those places and visit them whenever the chance comes. New York City is a great example. Our family’s cabin in Northern Minnesota is another. Just being in those places is enough to provide physical, emotional, and mental balance
4. One power from placebo may be touch and physical connection. I make sure to get massaged regularly because of the power of that physical touch on my body’s ability to heal.
Here’s to our health,
David Eifrig Jr., M.D., M.B.A.
P.S. Right after last week’s piece, KFC announced it would cut out trans-fats… hoorah!