Map of life expectancy at birth from Global Education Project.

Tuesday, November 23, 2010

A slightly tough question

I guess. At least it seems to be to a lot of people. For reasons I cannot disclose, I've been thinking a bit lately about the placebo effect -- or possibly effects. Due to some combination of expecting to get better, and therapeutic attention, people who get treatments that have no specific biological effect tend to report that they feel better than people who get no treatment. This only works, obviously, with symptoms. There is a strong response to placebos in depression, and many people also respond who have chronic pain.

Now, this is philosophically a bit tricky to begin with. Pain and depression are more or less defined as particular ways that people feel. There could be "objectively" measurable correlates, such as range of motion in the case of pain or appetite in the case of depression, but if people say they feel better, then it seems pretty ridiculous to say the treatment wasn't really effective. Feeling better is what they want.

Accordingly, Brian Berman and colleagues raised quite a few hackles back in July when they argued in NEJM that physicians ought to refer people with idiopathic chronic low back pain (CLBP) to acupuncturists. CLBP is a real pain in the backside because most of the time, it doesn't correspond to any identifiable physical cause and it doesn't respond well to analgesics, physical therapy, or anything else. Surgeons used to do spinal fusion all the time, until it was shown that the surgery was actually a placebo. People responded just as well to fake surgery, in which they were opened and closed but nothing else was done, as they did to the real surgery.*

It turns out that people with CLBP also respond to acupuncture, even though it is well established that acupuncture is actually bogus. It doesn't matter where you insert the needles, or even whether you insert them at all. As long as people think they've had acupuncture, they often report feeling better. The same is true of homeopathy. Homeopathic 'remedies' are completely useless, but homeopathic consultations make people feel better.

So should doctors give people fake pills, or fake physical interventions such as pretending to stick needles in them? It only works, remember, if you tell the people that it will make them feel better. Actually, that's true, but it's only true because you're saying it. In other words, you're fooling them, sort of, but as long as they are fooled, it's not fooling . . . And this sentence is a lie.

Okay, here's what I think. There is no need to pay money to fake therapists for fake treatments. We can instead have real doctors who are engaged, empathetic, take time with their patients, and give them whatever treatments they can that have been shown to be more effective than placebo, along with encouragement and sound advice about coping. As Edzard Ernst writes (in the essay whose abstract is linked above):

Modern mainstream medicine seems to neglect the importance of medical core values such as empathy, sympathy, time, understanding and holism. This creates a situation where alternative practitioners tend to provide the non-specific and mainstream doctors the specific effects. Clearly this is wrong and may be one reason why patients consult alternative practitioners.

*Yes, this resulted in the famous defunding of the Agency for Health Care Policy and Research at the behest of spinal surgeons who cared more about money than they did about their patients.

1 comment:

kathy a. said...

spinal surgery may be a placebo, but it is one that carries significant downsides and risks -- everyone risks infection and complications from anesthesia and/or post-op meds, all surgical patients need time off, and many patients end up worse off. [i'm not totally sure about that last point in relation to this specific surgery.]

i agree with your conclusion about real doctors being more engaged and responsive, obviously.

but i also believe that people have chronic pain, and people have depression, and not enough is known about these things. they are real enough to the people experiencing them, but as you say, hard to objectively measure. it is discouraging in the extreme for a patient to hear things like "it's all in your head," or "just think about happy things," or "just get more exercise."