Study Finds Half of Doctors Give Placebos to Patients
October 24th, 2008
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According to a new survey which interviewed several hundred rheumatologists and internists in the United States, half responded by saying that they have given patients placebos as medication. Although the findings were based on too small a data sample to be sure that its an accurate reflection of the medical profession, it does show that the practice is not entirely uncommon. It would not be a far stretch to think that this practice may also be common in other countries, even though the study, which appeared in the British Medical Journal only interviewed doctors in the United States.
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In this case, the “placebo” given to patients was not a placebo of the standard type, that is a simulated medication which actually contains an inert ingredient, sometimes known as a “sugar pill.” Rather the medication prescribed was normally something like an OTC pain killer or some other medication which the doctor prescribed more out of a hope that it would be psychologically beneficial than the actual clinical effectiveness of the medication in treating the condition in question.
From a New York Times Article on the findings:
The most common placebos the American doctors reported using were headache pills and vitamins, but a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.In most cases, doctors who recommended placebos described them to patients as “a medicine not typically used for your condition but might benefit you,” the survey found. Only 5 percent described the treatment to patients as “a placebo.”
Well, I have two comments on this. First, why would any doctor describe the treatment as “a placebo?” Then it won’t work! Unless, perhaps, the patient doesn’t know what a placebo is.
But as far as giving medication without good clinical reasoning, I find the idea to be a bit unnerving, as it does undermine the idea of trusting a medical care provider to be completely honest and forthcoming with information. However, it is likely to be unavoidable in many cases. There are a very very large number of people who go to the doctor with an expectation to get a pill to address a problem. For such patients, it may be hard to get them to calm down without some kind of acknowledgment that they have a problem and some kind of treatment.
The authors of the study stated:
Prescribing placebo treatments seems to be common and is viewed as ethically permissible among the surveyed U.S. internists and rheumatologists…. Physicians might not be fully transparent with their patients about the use of placebos and might have mixed motivations for recommending such treatments.
There’s also clearly going to be a gray area, for example, a patient might come in complaining of head and body aches. In such a case, it’s easy to see how a doctor would agree to prescribe a mild pain medication, in part because of the fact that it treats pain, but also because it will make the person think they have something to address their pains, which are exaggerated or completely imagined. (And also, make them go away).
The idea of a dedicated placebo pill has come up before, but it would likely only complicate the ethical dilemma. At least when the drug prescribed is somewhat effective on some symptoms (such as Tylenol for a patient who complains of headaches that might be real, but are almost certainly exaggerated), there is some therapeutic justification.
That being said, I’m really made uneasy by the idea of prescriptions for sedatives or antibiotics being made without good cause. These are medications with real dangers, and with antibiotics, misuse and overuse can lead to the evolution of more antibiotic-resistant pathogens. However, people seem to have gotten to the point of believing that ALL diseases are cured or treated by antibiotics and it’s easy to see how some might not leave the office without a prescription for something.
Unfortunately, these persistent hypochondriacs who can’t deal with not getting a therapy often are referred to homeopaths or other quacks to get them off the backs of physicians.
In general, there are certain things which many people just can’t seem to tolerate hearing from a medical care professional:
“There’s not much we can do for that. Just let it run its course and get some rest and you should feel better in a few days”
“You say it hurts when you do that? Well then don’t do that!”
“It’s part of getting older that you’ll get aches from time to time. Just take an asprin and try not to put too much strain on it.”
“Some people occasionally get that. If it’s not that severe, just rest for a bit.”
“Eat less acidic foods. If that doesn’t work, take an antacid when you get heartburn. You don’t need a prescription acid blocker.”
“Everyone has trouble sleeping sometimes. Try reading a book.”
“You’re fine. Really.”
“You’d feel a lot better and improve your health if you started exercising… maybe tried to loose some of that excess weight.”
This entry was posted on Friday, October 24th, 2008 at 1:00 am and is filed under Bad Science, Good Science, Misc, Quackery. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.
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October 24th, 2008 at 2:46 am
Sometimes it is appropriate for a doctor to prescribe an OTC medication for even a legitimate, non-exaggerated medical condition. I had a bad case of bursitis in my shoulder, and was given a referral to a physical therapist and put on 3200mg of ibuprofen daily (far more than the recommended OTC dose). They said if the ibuprofen didn’t control the pain and swelling, to come back and they would put me on something stronger, but happily, it did the trick. I can totally understand a doctor wanting to try an OTC medication before something with an addiction potential, e.g. vicoprofen.
It is important for patients who have been prescribed high doses of OTC medications to stay in touch with their doctor, since in many cases, high doses are okay for a short period of time but very very bad in the long run. Acetaminophen in particular should not be used in large doses for very long, as it has a hepatotoxic metabolite, called NAPQI, which is usually metabolized further in conjugation with glutathione — but over time, the liver’s glutathione resources can be depleted and then the NAPQI is free to bind to liver cells and cause hepatic centrilobular necrosis.
Anyway, I’m curious whether the study also counted doctors prescribing non-OTC levels of OTC medications as prescribing placebos. If so, then the numbers are likely skewed a bit.
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October 24th, 2008 at 4:25 am
You imply that placebos work best against exagerated / imagined. In fact they work well against real illness. Placebo surgery on knees has results that can be seen on xray scans.
Have a look at http://www.badscience.net/?p=620 and so on.
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October 24th, 2008 at 6:33 am
One goes to a physician to be treated. If in that professional’s opinion a patient will benefit from such a treatment, then then a placebo is indicated. This is very different from the actions of an alternative medicine fraud, who is using the placebo effect to reinforce the lie that a needle stuck in your toe, or an ultra dilute solution of salt can cure chronic depression even if the underling effect is the same, because the physician knows when a placebo is OK and when more aggressive intervention is required.
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October 24th, 2008 at 7:44 am
There is no doubt that the placebo effect has some medical value. Drug trials are designed to demonstrate that the drug’s benefits exceed that of its value as a placebo. In some cases drugs used in standard medical treatments may not greatly exceed the effectiveness of placebos, so placebos can serve as low cost alternatives.
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October 24th, 2008 at 8:30 am
Fun little anecdote. My wife concluded that as a registered nurse, basically *everything* she does for a patient must be something that has had a documented effect. If she goes on to do things that cannot be proven to have some kind of effect, she could be in trouble for it.
- So, she said, if I do as much as go open a window because a patient asks me to, that can be questioned! I have to be able to say *why* I opened the damned window. And quite frankly, I won’t be able to tell that.
- Hmm, I replied, didn’t you tell me that comfort is something that has been clinically proven to have positive effect on a patient’s general health, and that discomfort also is detrimental to the recovery process?
She pondered for a second… then broke out in a smile.
- Why, yes… yes, you’re right!
Hence she concluded that she can, by finding the right studies, prove that opening the window for a patient is in fact clinically proven to be good for a patient’s health and if the patient asks her for it, she’s next to obliged to comply! Unless of course other factors associated with that action are counter-indicative… say for instance that some idiot is standing outside the cancer ward window smoking.
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October 24th, 2008 at 8:54 am
First, why would any doctor describe the treatment as “a placebo?” Then it won’t work!
They’re describing it as a placebo in the study, but they haven’t told the patient that they’re prescribing it as a placebo. I know doctors who have done this. They explicitly do not tell the patient that they don’t expect the drug to do anything pharmacological to benefit them. One (now retired) used to give a drug known to cause nausea but not do a whole lot else. He’d warn his patients that it would cause nausea, but not to worry — that only meant it was working. (Kind of like Listerine’s old advertising campaign. “If you can feel it burning, that means it’s working!”) That’s a thornier ethical situation than a vitamin, since one could argue he was deliberately giving his patients an unpleasant experience for no real benefit — except to fool them into thinking they’d taken a drug which was effective for their complaint.
I don’t think it’s right to knowingly deceive patients, except in the context of a clinical trial. If nothing else, the patient may discover that you deceived them and then not only will the placebo stop working, but you will have completely destroyed their trust in you. The best-case scenario is that they’ll conclude you’re incompetent. More likely, they’ll conclude that you think they’re a pathetic, overly-emotional person who is easily deceived and who isn’t really sick. They may also generalize that impression to doctors as a whole.
No, it is never right to lie to a patient. Despite the temptation to give them a pill to shut them up and make them go away, doctors should never prescribe fake medicine on the pretense of it being effective. There are words for that: quackery, fraud, and theft by swindle.
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October 25th, 2008 at 12:25 am
I can’t remember who said it but “feeling better is not being better” is a good quote. Placebos can’t really cure underlying ailments, even if they make people feel better.
But then again, how do you deal with someone who is just constantly thinking they’re sick when they’re really not sick or they’re just experiencing some minor things. I guess refer them to a shrink?
I do know people who would put a doctor in a bad spot. Every once in a while I wake up with a stiff lower back. It happens from sleeping on it wrong. I just need to stretch out a bit and take an asprin if its bad.
I had an ex who was such a drama queen if that ever happened to hear I swear she would be complaining she couldn’t walk and demanding that her back must be broken and begging a doctor to help her because she was on the brink of going paralyzed. That’s just how she was.
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