Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, October 24, 2008

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: 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."



At Fri Oct 24, 08:50:00 AM, Blogger mark's tails said...

Touche Dino. I wish I could put that little accent thingy above my e.

At Fri Oct 24, 10:47:00 AM, Blogger Lisa G said...

Classic case of the media manipulating a study to bash healthcare. Great post!

At Fri Oct 24, 12:43:00 PM, Anonymous Anonymous said...

I'm not sure I understand why you have your Joe Boxers in such a twist.

If it looks like a duck and talks like a duck and walks like a duck... then it's a duck, yes? Regardless of whether the survey used the actual word "placebo" or not. Euphemisms don't change the truth, after all; they just make it sound nicer.

The more compelling point of the study is that the respondents only rarely explicitly told their patients that the treatment was mostly ineffective. The word "sneaky" is emotionally loaded, of course, but what else would you call it to make it more palatable? Dishonest? Failure to provide complete disclosure? Paternalistic? Looks like a duck, walks like a duck, talks like a duck...

At Fri Oct 24, 01:10:00 PM, Blogger Resident Anesthesiologist Guy (RAG) said...

Anytime the media makes some effort to discuss healthcare or medical concerns I tune out - they don't what they're talking about most of the time and clearly have desires to make doctors sound greedy and manipulative.

At Fri Oct 24, 01:39:00 PM, Blogger Angry Professor said...

I'm not certain why Prof. Kirsch is averse to using placebos. The placebo effect is an amazing, positive thing, and if all it takes to get it to kick in is for a doctor to recommend it, then I'm all for it. (After, of course, other treatment options have failed.)

Way back when I was a healthcare professional, I witnessed physicians prescribing placebos all the time. My favorite was an injection of normal saline for a woman with "10/10" pain. I know that doesn't happen much any more, but that woman in pain slept peacefully the rest of the night.

Am I missing something here?

At Fri Oct 24, 01:48:00 PM, Anonymous Anonymous said...

Given the attitude expressed above by RAG, why should the media like you or want to tell your side of the story?

It's a two-way street here, guys.

I'm not trying to start an argument; I just get really tired of the contempt that doctors often display toward anyone who hasn't been to medical school.

On the one hand you want us to respect how hard you work and how much you know and how special you are. On the other hand you disrespect us because we don't have your special qualifications.

Your education and training *do* set you apart from everyone else. So I don't understand why you would expect reporters or any other lay person to have precisely the same level of knowledge and experience that you do - and then snark about it because they don't.

At Fri Oct 24, 06:54:00 PM, Anonymous Anonymous said...

What? There is a reason they have come up with the idea of the "health reporter". You do not have to have gone to medical school just to be able to read a paper and write a reasonable article about it. We practice medicine for a living, not read the NEJM; there is no reason someone whose primary job is reading the medical literature can't write a fair summary without bashing doctors.

At Sat Oct 25, 01:34:00 PM, Blogger Lynn Price said...

I'm not certain why Prof. Kirsch is averse to using placebos. The placebo effect is an amazing, positive thing, and if all it takes to get it to kick in is for a doctor to recommend it, then I'm all for it. (After, of course, other treatment options have failed.)

Really good point. When I was doing research for my book, I encountered a doc over at CHOC who's young patient had Type 3 Neurofibromatosis. Poor little spud had zippers from his many surgeries. They'd reached the end of the line with him, medically speaking. He was on meds, on top of med. Most he took were to counter the side effects from other meds.

The doc recommended his parents take him to the accupuncturist who was heading up their new alternative care clinic. The mom, skeptical as all get out, did so, and the kid ended up going off all his meds. She told me there was no way she would have EVER taken her kid to an acupuncturist had her doc not recommended it. I won't bother going into the "is it placebo or real" aspects...

At Sat Oct 25, 10:22:00 PM, Anonymous Anonymous said...

Ooohhh yes. Let's be frank. Homeopathy et al is bunk relieving the hip pockets of the gullible. Don't get me started on the rort that is 'alternative medicine'. Especially when they blame us for their bad outcome when they don't take sensible advice....


At Sun Oct 26, 10:14:00 AM, Anonymous Anonymous said...

I'd prefer my doctor just say, "look, there's no real medical treatment for this; the problem is probably "x," you'll get better on your own." Then I'd go home and go about my business. A lot of that has to do with trusting my doctor's judgment, and knowing if the problem gets worse, she'll reevaluate.

I understand the reason behind giving placebos, but find the idea of having one prescribed for me somewhat insulting. Anything I pay to fill at the pharmacy better have some medically active -- and useful -- ingredient.

At Sun Oct 26, 02:03:00 PM, Anonymous Anonymous said...

Oh for heaven's sake.

Any medication for fibromyalgia other than antidepressants: placebo.

Antibiotics for a cold/sore throat/cough: placebo.

Diazepam and tylenol for benign febrile seizures: placebo (for the parents).

Vitamin E for scars: placebo.

Glucosamine: uber placebo.

X-rays for broken toes: utmost placebo.

And don't get me started on homeopathy.

Physicians generally try to say to patients: this is a benign and self-limited condition: it will go away on its own, eventually. Most reasonable people are happy enough to accept that (with more specific explanation and follow-up), but there are some people who will not leave without a prescription, and who get very demanding and belligerent about it.


At Sun Oct 26, 05:42:00 PM, Anonymous Anonymous said...

Okay, I guess I didn't really understand the reason behind giving placebos after all, and never would have thought of the examples you mentioned. Makes more sense now, thanks.

I do think "consumerism" in medicine has gone a little too far. I'm guilty of looking stuff up on the internet and self-diagnosing, but when I see my doctor I'm quite aware which of us has been to medical school and has developed the clinical judgment and experience.

I hate the thought of demanding and belligerent patients. Sigh.

At Mon Oct 27, 02:03:00 PM, Anonymous Anonymous said...

Haven't there been a few studies recently that show the placebo effect works?

Assuming that a doctor wants to take advantage of the placebo effect, wouldn't the doctor have to by definition deceive the patient in order for it to work. Therefore, the doctors could not tell the patient the treatment was not going to be effective because the it would not be effective.

At Tue Oct 28, 08:48:00 AM, Blogger Cycledoc said...

Medicine's little secret is that most problems will resolve whether they are treated or not. In a sense the majority of what we do is to provide reassurance (and placebos) until the issue resolves by itself.

At the other extreme there are those problems that no matter what we do will continue and perhaps worsen. Similarly our treatment there is placebo-esque.

It's the 20% (my estimate, what's yours?) of issues that are medically treatable and whose disease course is positively altered that are the medical success stories.



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