The word placebo has many connotations. Many think of it simply as a fake pill containing sugar.
Some see the term as derogatory since its effect could imply that a problem is not "real."
Some see it as proof of the incredible power of the mind.
But my question is not about the research value of placebos or how effective they are.
My question is: Am I a placebo?
A recent study in the British Medical Journal led by Ted Kaptchuk found patients who received better communication and more attention from their doctors saw a dramatic improvement in their medical condition than those who had a "colder" relationship and little face time with their physician.
Researchers looked at 262 adults with irritable bowel syndrome, a very common condition. IBS is typically associated with consistent abdominal pain and bloating in the absence of any other obvious diagnosis. There is no reliable cure, although stress management helps, and the placebo effect in IBS trials has been high (30 to 50 per cent).
Dr. Kaptchuk did not provide the subjects with any "real" treatment but divided them into three different groups. With the first group he did nothing more than tell the patients they were being studied and outcomes were being collected. The second group received "sham" acupuncture (putting needles into the skin in a random way that is not based on the principles of acupuncture). The last group received sham acupuncture and an "enriched relationship" with the doctor.
The proportion of patients who reported moderate or substantial improvement in their IBS was 3 per cent in the observation group, 20 per cent in the procedure-alone group, and 37 per cent in the augmented interaction group.
So what made the "augmented" response so much better? It was what we in the harried and increasingly technological world of medicine often forget about, despite the fact that it is often at the top of the list of things patients look for in a doctor - good communication skills. The group with the greatest relief of symptoms was the one that received 45 minutes of quality contact with a clinician. Patients were able to tell their stories and share their ideas and feelings about their symptoms. The doctors conveyed warmth, and realistic but positive expectations.
In contrast, the doctor-patient relationship in the sham acupuncture-only group was a caricature of the typical hurried clinic: Practitioners explained it was "a scientific study" and they were unable to talk about it with patients.
Doctors David Spiegel and Anne Harrington wonder in the accompanying editorial whether, "Perhaps the ratcheting down of the time that doctors spend with patients and our modern overemphasis on drugs and procedures is 'penny wise and pound foolish.' "
The Latin translation of placebo is "I will please." When doctors want to know how well they're performing their jobs, they tend to focus on measurables such as how often they monitor their patients' cholesterol levels or blood pressure rates. It's more difficult to measure their ability to communicate and provide an understandable explanation of a patient's illness while also giving him or her a sense of personal meaning and control. But if doctors make a consistent effort to do this, they may be able to improve not only the fake interventions but also the proven ones.
That the investigators used an "alternative" intervention such as acupuncture is also curious. The system in which I work rewards high-tech diagnostics and interventions that have proven results. We complain that many alternative interventions are not proven, but we lose sight of the value they place on communication. Alternative medicine has a long tradition of explaining illness within a larger holistic and sometimes cultural framework.
Perhaps we need to consider George Bernard Shaw's comment that, "The single biggest problem in communication is the illusion that it has taken place."
A cold and disinterested clinician may encourage a poor recovery response while an empathetic and hands-on caregiver may be the most powerful, if undervalued, placebo we have.