Sally Satel says a whole lot of physicians prescribe placebos. Not actual sugar pills or saline, but things like vitamins, Tylenol, or antibiotics that don't actually treat the conditions. In the case of antibiotics, which build up resistance, this strikes me as clearly immoral. But what about the other kinds?
I was actually prescribed a placebo once, after I showed up at the emergency room with a cluster of bizarre symptoms like tingling hands and roaring blood pressure. The ER people clearly thought I was having a panic attack. (I wasn't. Before, after, and during the attack, I was perfectly calm, except for a moment when I realized that my symptoms sounded a lot like those described in the brochure on heart attacks in women that the ER had helpfully provided for me to peruse while waiting.) They told me my potassium was low and gave me some pills.
Unfortunately, I was somewhat familiar with the symptoms of potassium deficiency; mine weren't, mostly, among them. Also, the intern was an incredibly bad liar. I left the ER feeling indignant and not at all improved. Much, much later I found out that tingling hands and high blood pressure are symptoms of thyroid disease, which I do have.
But if I hadn't known, the placebo might have improved me--the mind is a marvelous thing. Here's the thing though: it really wouldn't have been a good idea for me to walk around thinking that an actual medical problem was a potassium deficiency, because then I wouldn't have gone to other doctors to get it treated. Instead, I would have walked around popping potassium pills every time I felt funny.
Doctors give placebos to people they're having a hard time diagnosing. But doctors aren't God. The reason you can't diagnose someone may be that their problem is transient, or imaginary. But it might also be that you've missed something.
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Actually, biochemical research into the placebo affect has started to yield results; it's entirely possible that soon pharmaceutical companies could deliver a placebo effect in a pill!
(Seriously. Even if it does make my head hurt...)
Megan, one time I developed a giant cyst that was rapidly expanding against my neckbone. That's nothing I could have made up; it was plainly visible and could have potentially killed or disabled me. I went to the campus clinic, and when I got to see a doctor (actually a PA), she wrote me a prescription for antibiotics, which quite predictably did nothing.
A few days later, they had to put me in the ER to have the cyst drained.
Go ahead, TRY to justify that. Just try.
The placebo effect is real, but more real is the null effect (i.e. conditions that will go away without treatment whatsoever). Doctors are wisely instructed to be conservative in their prescriptions, so scribing a placebo is usually a good idea.
On the other hand, post-surgical prescriptions tend to be excessive (14 days of morphine, 30 doses of oxycodone, plus NSAIDS for a basic orthopedic surgery?!).
Definitely strikes me as unethical in the case of antibiotics.
However, I'm also uncomfortable with the "Let's just give this person a pill, they'll THINK we're helping them, and we can send them on their way." Isn't it better for a doctor to admit, once in a while, "I don't know what's wrong with you right now."? Or for them to say, "This is a concern but we don't immediately know the best path of treatment."?
I do think it's wrong, if the doctors think there's something genuinely wrong with a person but don't know, to just pill 'em up and turn 'em out the door. And even if they thing the patient is a gibbering nutcase (which is, I suspect, a situation where a lot of placebos get used), could it be that they're a gibbering nutcase with a real medical problem?
I'd be deeply offended if I found out my doctor had given me a prescription for Tylenol or something just to "shut her up." In fact, I'd consider "firing" that doctor. Isn't the patient's right to be taken seriously somewhere in the Hippocratic Oath?
And yes, I realize, doctors see a fair share of gibbering nutcases and drama queens and people who don't get enough attention in their daily lives and they get really fed up with it but...
This is a rare case where I'd say sexism can be a factor. I certainly knew doctors who'd think of my Mom "oh she's just panicky" right-up until she'd black-out and nearly die.
Although my Mom was an odd case in that she was a Mom whose jobs were mostly part-time. Because of that women doctors were almost as bad, maybe worse. From their perspective it must be "nerves" because she wasn't well-educated or a career woman and therefore she must be screwy in the head.
The placebo scrip gives doctors an easy way out of these situations. Its their job to treat as many people who need it as quickly as possible. I'm comfortable with a conservative approach.
Note -- I'm not excusing mistakes. Doctors will make them in both directions (overscribe, underscribe). There is a system that holds them accountable.
Now if you want to talk about the effectiveness of that system, that's another conversation for another day...
Criminal defense lawyers file placebo motions all the time. I once saw one that said "The police searched Defendant's home, automobile, person, or effects."
I don't see anything wrong with prescribing a placebo. There's a reason for the term "placebo effect"--placebos often work. And if you feel better afterwards, then you took good medicine even if it's just a sugar pill.
On the other hand, telling you they think you have something when in truth they don't know what you have, that sounds like malpractice to me.
"Instead, I would have walked around popping potassium pills every time I felt funny."
Either that, or you couldn't eaten a lot of bananas. They have lots of potassium.....and besides, guys like girls that like bananas....
i'm kind of fascinated with this story. as a doctor i cannot remember one time in my career purposefully giving someone a placebo. tylenol and opioids are pain killers they have a purpose and an effect. And no physician would give anyone potassium pills just for the heck of it. that's dangerous. we talk about the placebo effect in medical school but we do not learn to just give someone a placebo. we may try a therapy to see if it works. but we just don't prescribe people medicine with the thought, "haha they don't know that i've just given them a placebo." i haven't read the study but i'd be interested in seeing how they defined placebo.
One of the (few) great weaknesses of the US heath care system is that nowhere near enough time is spent on diagnosis.
The reason is understandable. Drugs are cheap (and largely subsidized) in the West, while health care worker hours are fantastically expensive.
One almost wonder if, instead of an M.D. spending 7 minutes (the current average doctor-visit length) with me, somebody with less academic qualifications and access to a good database spent considerably longer.
This is the information age. Does me GP really need a Doctorate degree simply to evaluate if I have a diabetes, high blood pressure, or pneumonia? Shouldn't nearly anybody with the right testing equipment and the knowledge to use it properly be able to figure such things out?
Perhaps it's time to push "routine" medicine down the food chain, to nurses, lab techs, pharmacists, and even (*gasp*) self-diagnosis resources. Then we could free up the well-schooled doctors to play "Doctor House" with the genuinely difficult questions (such as figuring out than Megan has a thyroid problem.)
It is not that "Doctors give placebos to people they're having a hard time diagnosing", but that doctors give things to people they are having a hard time treating.
The posted article did not include the text of the questionnaire, but it is clear from the description that they led the respondents towards conclusions. They started with asking about a diagnosis, fibromyalgia, that is notoriously subjective and difficult to treat. Many doctors (not me among them) truly believe fibromyalgia is "all in your head" to begin with. They they asked if they would give a sugar pill "if trials had shown such treatment to be superior to no treatment". Well, duh! Clinically proven in (implied) published and vetted clinical trials...and no side-effects expected... and no other better treatments out there?
They then asked if they would give other treatments "primarily because you believe it will enhance the patient’s expectation of getting better". Under the principles of consistency, one could expect most doctors to agree. And so on, they led the respondents into defining giving analgesics and vitamins as placebos simply because they couldn't find a better treatment, but believed the patient might feel better.
The thing that amazes me is that 45% of the docs said they wouldn't give something innocuous even when they believed the patient would be better off. It is an established principle in medicine that if you are not sure what is going on, but are convinced that there is no urgent need to intervene, you should "watch and wait" to see if the condition reveals itself. There is nothing wrong with giving the patient something that might make him feel better while you are letting time take its course.
I was actually prescribed a placebo once, after I showed up at the emergency room with a cluster of bizarre symptoms like tingling hands and roaring blood pressure.
The ER took a look at you, realized that you weren't dying of anything and told you to watch and wait. The ER isn't there to diagnose and cure you, it's there to stabilize you.
"The ER isn't there to diagnose and cure you, it's there to stabilize you."
Then they shouldn't have diagnosed her.
Rather than give her useless pills base on a false diagnosis, they should have, at most, given her something to relieve her symptoms and then urged her to see her GP (and possibly a specialist based on her GP's recommendation) at her earliest convenience.
It's always immoral if it's done without informed consent. (Informed consent as if you are participating in a medical study and are aware you may be part of the control group getting the placebo.) If I go spend my money to hire a doctor, and (s)he gives me a fake treatment, that's fraud. If they are at a loss on how to treat me, they should just say so. If I'm too difficult to deal with, drop me as a patient. But don't play games with something as important as my health.
It's not that you are too hard to deal with, if the "cure" can be mental so can the cause. Telling a crazy person that they are crazy doesn't help. If a doctor says its only in your head you won't believe him. The problem with medical conditions is that they sometimes have these symptoms, sometimes some other symptoms and every once in a while something entirely different. Diagnosing a patient can be impossible sometimes and down right hard on others. I spent 3 years thinking I was crazy because my subsidized school medical center didn't know how to properly diagnose asthma. Since I don't have attacks, no one knew. Thank God I eventually went to a really good GP and then really good specialist.
I also don't know that longer diagnosis would produce better results. We could study that but we might find out that more information makes it harder to diagnose or we could find that it doesn't change results at all.
If a person is having a panic attack, rather than a heart attack, a placebo might be a good treatment. It might be good to tell the person to see a GP the next day to evaluate further treatment.
Not funny, those placebos. I got one recently -- don't know if it was a placebo or prescribed with good intent for helping migraines -- magnesium oxide. Come to find out, I have an allergic reaction to it; which also may explain why I've never been able to tolerate sea food or most multi-vitamins. Made me feel very, very sick on top of the very very sick I already had.
Life's a bit better without it in my system.
But as every mom knows, a placebo -- a band-aid for the scrape almost imagined scrape -- can work wonders. But so can chicken soup.
Doctors give placebos to people they're having a hard time diagnosing.
And also to patients that have no real complaint, but want to see a doctor. My late father was a podiatrist and had a number of regular patients, all older widows, that had vague foot problems that couldn't be diagnosed. My dad gave them a corn and callus trimming, a short foot massage from the nurse, and if nothing else worked, a prescription for a placebo. They came back as soon as Medicare would allow it.
What these women wanted was an excuse to get dressed, leave the house, and talk to someone. The foot pains provided that. I'm sure they had similar complaints that sent them to their internists.
RIght, but how often do perfectly calm 35 year old women with no history of visiting the hospital for anything but bacterial infections show up in the ER with either a panic attack, or hypochondria?
Megan, the docs in the ER must not read your blog; that's they only justification I have for them not realizing how calm you are even in a financial world run amok, the only justification for mistreating you so.
But doctors mistreat and misdiagnose patients all the time. They just don't like to admit it, because it means admitting they don't know too much of the time; and knowing would require taking more time to talk with their patients -- the one luxury they don't typically have.
Patients get blamed all the time, is the point; even if the patient doesn't know they're being blamed, for a doctor's ignorance of illness. I had to teach my doctor about the food sources of estrogen -- one of the primary triggers of menopausal migraines, which are pretty much destroying all my quality of life now. He didn't know why certain foods were triggers, just that they were, and I should avoid them. He'll be a better doctor just because he had me as a patient; even if he runs over on his time with me.
I don't normally watch much TV, during the election my watching increased to include several hours/week of nightly news. I was amazed at how many random drugs I could have been prescribed, based on my symptoms, for migraines (had I not already known they were migraines.) Not a medical world of a proper diagnoses, but a world of a marketing niches; particularly when it comes to the brain-altering drugs for pain/depression/anxiety. Pain in the neck/head, sadness, inability to function in work -- lets try this drug. Never get to the work part is because of bad lighting; etc. It's not depression, it's migraine; but hey, some pharma company's closed another sale, and some poor schumck's got a migraine, but at least she's not depressed about it.
It's like putting together a jig saw puzzle where it doesn't matter if the edges aren't straight, the corner's aren't square.
I hope you're well. I wish, above all, you'd get off the pop. It's gonna kill you; worse the tobacco.
I agree with Lara -
"if, instead of an M.D. spending 7 minutes (the current average doctor-visit length) with me, somebody with less academic qualifications and access to a good database spent considerably longer"
Several years ago, I was having an allergic reaction to something my doctor (ENT) gave me. I told him that something was wrong, that I'd been having ear and sinus infections for more than a decade and that this was completely different from any symptoms I'd had before, but he just told me to come back in a week. I knew that I literally didn't have a week left (I was drilling my young children daily on how to call 911 and what to do if they found mommy lying on the floor 'asleep' and turning blue), so I Googled my symptoms and figured it out on my own.
The bacitracin my doctor told me to put on my septal perforation was later named contact allergen of the year. Thanks to Google, I was able to figure out what was causing my symptoms. Either my doctor or else a nurse with a good database should have spent a little more time trying to figure things out, rather than gambling that it was probably nothing.
Megan, I don't think your experience at the ER was a case of prescribing a placebo. More likely it was a case of treating a lab result, which is far too prevalent in medicine today. ERs generally follow standard protocols, which are designed to stabilize and separate those people who need to be hospitalized from those who can be safely sent home for later follow-up. They are not places to go for diagnosis of unusual medical conditions.
My guess is that they did a standard panel of blood laboratory tests, found that your potassium was low, and having nothing else to offer gave you some potassium pills. It doesn't sound like you needed to be hospitalized, and you survived, so the ER performed its basic function. Ideally, they should have referred you to a good internist for follow-up and diagnosis, but that would depend on the ER staff knowing a good internist and that internist having enough time to properly evaluate you. Unfortunately, neither of these are very high probability.
Most of us know how hard it is to find a good car mechanic. For simple things, like oil changes, there are chain stores that are cheap and quick. For somewhat more complicated issues the dealer has specialized diagnostic equipment. But woe to the person with an annoying noise, an electrical problem, or who owns an unusual car. Then you need someone who really understands the car, and is willing to spend a lot of time messing around with it.
In medicine, many problems are require a good bit of 'cognitive' time and most of us are 'unique'. On top of that our bodies are several orders of magnitude more complicated, don't have manual, and we can't just junk it and go buy a Toyota.
The problem is that cognitive time is expensive, especially if the doctor is truly gifted. There would undoubtedly be more such time and people available if the system paid more (right now it is very much underpaid), but society cannot afford to pay for everyone, and there seems to be a consensus among Americans (at least those who support 'universal health care') that medical care is a right, and if a specific medical service is not made available for everyone, no one should be able to get it.
"...because then I wouldn't have gone to other doctors to get it treated."
I guarantee the ER doctor told you to follow up with your regular doctor within 72 hours, and they would have referred you to one if you had none.
ER's are designed to rule out life-threatening illnesses,and they seem to have done that well. You may very well have had a low potassium which could have been related to your thyroid disease. The most important things are:
1) You didn't die.
2) You saw another doctor later.
3) The ER doctor didn't waste precious time and resources on you and he/she was fresh for the sucking chest wound that came through the door 45 minutes after you left.
Success.
Things that are NOT important:
1) Your perception that you were mistreated.
2) Everything else
I knew a woman who, paranoid about heart disease and potassium defficiency in particular, killed herself with too many potassium supplements. As pb already noted, that's not something to screw around with. Unless it was Moron Night at that particular ER, I highly doubt they handed you the supplements unless they had good reason to believe that you were potassium defficient at the time, even if it wasn't the primary cause of your symptoms.
If they wanted to give you a placebo, for those particular symptoms it would have been much easier and more practical to sell you on the idea that your sodium and blood sugar might be low.
As a medical student, I would never, ever, prescribe a placebo (except in the case of a research study, for which the participant provided consent). Even if placebos do work, there are other imperatives, other than besides for simply allowing the patient to feel better. Like telling people the truth, and allowing them to make their own decisions, based on information or guidance that the doctor has provided.
"I guarantee the ER doctor told you to follow up with your regular doctor within 72 hours, and they would have referred you to one if you had none."
Tony, Read Megan's IKEA post. She has a hard time following instructions.
I guess her time's too valuable. (Yet she spends hours writing this blog, go figure.)
Economists.
I have worked in an ER for eight years. No one has ever recieved a placebo. I'm with Tony on this one.
Just wanted to note that the anecdotes provided here are not cases of MDs prescribing "placebos."
Megan's case: As has been pointed out, too much K+ will kill you. If a doc is going to prescribe a placebo, it would NOT be K+, as that is potentially lethal. More likely is that Megan's K+ was low (it's part of the standard blood chemistry panel run on almost every patient who checks into an ER) and they were treating a lab value. Misdiagnosis? Yes. Placebo? No.
Silas Barta: PA probably thought rapidly enlarging lump in neck was an acutely infected cervical lymph node, which is the most common cause of a rapidly enlarging lump in neck. Or may have thought it was an infected cyst. Either way, antibiotic was appropriate first-line therapy for most common cause of presenting symptom. Sounds like more needed to be done. But in this case--misdiagnosis/mismanagement? Yes. Placebo? No.
Zic: Magnesium is a second-line therapy for migraines. Not much evidence that it will help, but every now and again it does. Not a placebo.
And I agree with SteveSC: the questionnaire used in the study--especially the first 3 questions--are not as clear cut as Satel presents. The first question asks, "How likely are you to recommend sugar pill PROVED to be better than no treatment for fibromyalgia," the second "How often do you recommend treatment primarily to enhance patient expectation," and the third, "Is it appropriate to recommend treatment primarily to promote patient expectation?" The problem with the first is that the pill is promoted as a clinically proven effective therapy, the problem with the second is that "treatment" is not defined as a drug and the questions don't exclude the possibility that the treatments may be expected to do more than promote patient expectation (Tylenol for instance could moderate physical discomfort as well as acting as a "placebo.") And when physicians describe the use of antibiotics and sedatives as "placebos," as opposed to non-biologically active agents such as saline and sugar pills, I think there might be some confusion as to the definition of "placebo" in the study, which the authors discuss. Anyway, I'm not convinced the study can conclude what the study authors claim it concludes.