Medical Journalism -- "Gotcha" Style

Today's alarming headline:

Doctors Sneaking in Placebos

Turns out that when 1200 American internists and rheumatologists were surveyed, of the 57% who responded, anywhere from 46 to 58% of those "reported prescribing placebo treatments on a regular basis."

Whoa! That sounds bad. Indeed, one of the authors responded:

"Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut," said Irving Kirsch, a professor of psychology at the University of Hull in Britain who has studied the use of placebos.

Oh, the shame!

Turns out when you actually look at the paper in question, THE WORD PLACEBO WAS NEVER USED IN THE SURVEY!!! In fact,

Because the term "placebo" and behaviors surrounding its use can be contentious, we devised a series of non-judgmental questions beginning with broad questions that avoided the term "placebo" and then gradually gained more specificity, culminating in items whose responses used a clear definition of a "placebo treatment."

The way the concept was phrased in the survey instrument:

...how often they recommend a therapy "primarily because you believe it will enhance the patient’s expectation of getting better"

They set their respondents up even more:

When asked if they would recommend a dextrose tablet for a patient with fibromyalgia if trials had shown such treatment to be superior to no treatment, most respondents (58%, 381/654) said they would be very likely or moderately likely to recommend it.

They actually phrased their hypothetical scenarios to include studies showing positive responses to placebos. When put in those terms, wouldn't someone sound like an idiot for refusing to use a "proven treatment"?

I read the entire article very carefully and discovered that the investigators never asked WHY the respondents recommended the "placebo" treatments that they did. That would have been illuminating. I'll bet my annual income (ok; big spender I ain't) that "placebo" prescribing is a response to patient demands to "do something." I know, I know; we're supposed to spend whatever time it takes (never fully compensated) to explain to the patient why there is no effective pharmaceutical intervention for their condition (usually after the patient has refused non-pharmacologic modalities like exercise, diet, physical therapy, etc.) Guess what: the patient then goes next door, to one of the 46% of the 57% of the 1200, who will suggest that they take OTC vitamins or other innocuous compounds, typically describing them not as "placebos" but as "a medicine not typically used for your condition but might benefit you." Adding insult to injury, the patient usually considers that "placebo prescriber" (the one being unacceptably dishonest) to be a better doctor than the first; the one who follows "advice from the American Medical Association, which recommends doctors use treatments with the full knowledge of their patients," by refusing to "prescribe placebos" as described in the journal article.

One last thing: If you use "physician beliefs" instead of scientific evidence to define "placebo", then all the homeopaths naturopaths purveyors of vitamins and other supplements quacks who really believe that the water and sugar pills and vitamins they sell are doing something, then by the standards of this article, they are the virtuous ones who never prescribe placebos. As it happens, the questions about placebos described in this paper were actually part of a survey about complementary and alternative medicine.

So the bottom line is a survey that sets up respondents by specifically avoiding the word "placebo" (although they do state that they re-phrase some of their questions to include it, after carefully defining it); leading respondents on to answer favorably, and then blasting them in headlines over the Associated Press about "sneaking in placebos."

Gotcha!