A Potent Tool Within the Doctor’s Toolbox
By D. Ofri, M.D.; August 15, 2013; New York Times
It was well past midnight and many of the patients had settled in. The hospital ward was quiet, aside from “the howler.”
The howler was a patient as part of his 30s who earned his nickname for his nightly bouts of yelling. This was in the early 1990s, throughout the peak of the AIDS epidemic. I was a second-year medical resident at Bellevue Hospital, in charge from the sprawling AIDS ward that night. Admissions were rolling in, one after another, each more feverish and emaciated compared to the previous.
This patient is receiving hefty doses of pain medication, yet he kept screaming to the nurses about his pain. This took, night after night, despite extensive medical evaluations to see if there were any missed explanations for his pain.
Nothing did actually help, as well as the nightly yowling was agitating another patients and driving the nursing staff to distraction. The head nurse paged me at 3 a.m. “You ought to do something,” she said.
I visited the patient’s room. It was my fourth visit from the night, as well as the patient and I were both pretty exasperated with one another. He was sullen and cranky; I was exhausted and inside my wits’ end.
I got out a syringe and carefully drew up one c.c. of plain saline. “You know about Tylenol,” I said, showing him the liquid-filled syringe. “You’ve got word of Tylenol #3. There’s a Tylenol #4. This” — and here I paused for dramatic effect— “this is Tylenol #5.”
The patient stopped howling and set it up an interested look. Then he lowered his pajamas and allowed me to inject his gluteus maximus. Afterward, I pulled up a chair to his bedside and now we waited together, allowing the minutes to tick unhurriedly by.
After what seemed like a mutually agreeable time, I stood up and bid him goodnight. The patient put his head to the pillow and promptly fell asleep. The ward was silent for your rest of the night.
I felt terribly guilty that I had committed an outright deception with this particular patient — something that's a true no-no. But on the opposite hand, it was the first night he got a full evening of sleep, to express nothing of all one other patients about the ward as well as the rest of the staff.
When I related this story to Dr. Ted J. Kaptchuk, director in the program in placebo studies at Harvard, he gave a sigh of recognition. “We all have our moments of desperation,” he said. “Usually around midnight.”
Dr. Kaptchuk won't condone deception, but his research bears out that how caregivers present and administer treatments has a powerful influence on clinical outcomes.
Patients, by way of example, who received pain medicine directly from a doctor achieved better pain alleviation than patients who unknowingly received the identical medicine, even at higher doses, automatically in their IVs. The rituals the physician performs — drawing up the medication, visibly injecting it into the IV, discussing expected benefits — not to mention the eye and caring that accompany the presence of an authentic human being — effected all the pain relief as doubling the dose with the medicine.
Placebos had been thought of as psychological mumbo-jumbo more akin to hypnotism than real medicine. The biological breakthrough came in 1978, when researchers established that not only was the placebo effect real, but that it could be reversed by administering naloxone — the chemical that blocks our endorphins, our natural painkillers.
Suddenly there was a plausible pharmacological mechanism for the way placebos work and research within the field flowered. In June, Harvard Medical School and also the Robert Wood Johnson Foundation held a worldwide medical conference devoted entirely to placebo science.
Dr. Kaptchuk describes placebos as not merely the traditional sugar pill, but also “precisely what surrounds a medical treatment”: how caregivers describe the medication, how they administer it, the expectations they have to the medicine, their tone of voice, their strength of eye contact. In short, exactly what doctors and nurses do in the interaction having a patient.
This is not especially surprising. Healers and shamans have known intuitively about the importance of this interaction since the dawn of time. Before there was developed treatments that could significantly impact the pathology of disease — antibiotics, chemotherapy, stents, organ transplants, transfusions — the “everything else” was the mainstay of medical treatment.
Doctors and nurses always feel a lttle bit uneasy in relation to placebos. Somehow it seems wrong, unethical, deceptive. But patients, it turns out, are most often more flexible within their thinking. Studies have shown symptom relief even when patients are told they are getting a placebo; many patients may be amenable to such “open-label” placebos. “If it gets rid from the pain,” a patient once informed me, “I don’t care if it’s a dill pickle!”
The ethics are evolving, though the general consensus is that transparency may be the bottom line. What I did being a young — and desperate — resident wouldn’t pass muster, because I deceived my patient in regards to the medication. But if I’d told him that it was inert saline and if he was amenable to having a go, it might have been an acceptable treatment option. And it still may have helped him, especially if there was been able to possess a detailed and compassionate conversation about his pain.
Dr. Kaptchuk mentions placebo effects as just one from the many things inside the toolkit of medicine. It would not be a substitute for appropriate medical treatment, but it is something that can enhance health care greatly. Wise doctors and nurses already do this. They’ve found, usually simply by personal experience, that their “everything else” — respect, attention, comfort, empathy, touch — often does the lion’s share of medical care, no deception required. Sometimes the prescription is just the afterthought.