How thorough are you when you prescribe medication? You check the patient’s list of allergies and current medications. You make sure that the dose is appropriate for the patient’s weight. Hopefully, you spend a minute or 2 describing the most common side effects. You prescribe the correct amount of medication and an appropriate number of refills. If you think you can distill it into one or two sentences, you also explain the medication’s mechanism of action. That is if you understand it yourself.
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What about placebos? How often do you believe that your patient has gotten better because of the placebo effect? Do you ever intentionally recommend or prescribe a placebo? Do you share with the patient that there is no current explanation of why the treatment you are recommending should work? Or, do you just play dumb?
Whether you admit to being a frequent prescriber of placebos or not you should take the 20 minutes it will take to read a New York Times article titled “What if the Placebo Effect Isn’t a Trick” (Gary Greenberg, Nov 7, 2018). You will learn a bit about the history of the placebo effect including some recent functional MRI studies that have uncovered consistent brain activity patterns in subjects that respond to placebos.
You will read about some exciting research indicating that certain people with a genomic variant of an enzyme that has been shown to affect the response to painkillers generally have the weakest response to placebo. While in some studies the association between the patient’s response and the level of the enzyme is the reverse, Kathryn Hall, PhD, the molecular biologist overseeing these studies, feels that at this point in her research the fact that there is an association that varies with genotype is a critical finding. She suspects that the placebo effect and the drug operate on the same biochemical highway that includes this enzyme and that “clinician warmth” is particularly effective in patients with a certain genotype.
Ted Kaptchuk, who heads up Harvard Medical School’s Program in Placebo Studies and the Therapeutic Encounter and has collaborated with Dr. Hall, hypothesizes “that the placebo effect is a biological response to an act of caring.” Is Dr. Hall’s work the first step in defining that response?
What does all of this new information mean for us as care dispensers? I think it means that caring is important and can make a critical difference if we have chosen a patient with the favorable genome. Of course, how are we to know whether we are working with such a patient? All the caring in the world may not change the outcome if we have selected incorrectly.
And then there is the other side of the practitioner-patient relationship and the definition and quantification of “caring.” Are there practitioners who are so inept and/or devoid of caring that even patients with the most favorable genome are not going to respond to their attempts at dispensing placebos?
Are there some practitioners who are born with a knack for caring? Can it be taught? Do we select for the quality of caring with the Medical College Admission Test (MCAT)? Do we weed out those who obviously don’t have it during their training?
Dr. William G. Wilkoff
Is caring a finite resource that can be exhausted? Is it affected by sleep deprivation or marital troubles at home? Or hours sitting in front of a computer screen? I suspect I know the answers to some of these questions. But what I do know for sure is that the placebo effect is real and is just another example that practicing medicine is more of an art than a science.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@mdedge.com.