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A placebo, yes, but not harmless

Every day on the front lines of medicine, doctors quietly weigh treatments. They consider which ones might help patients and which ones might harm them. And sometimes, rightly or wrongly, which ones might simply please or appease them.

I'm a pleaser at heart. My family and friends know it, and so do most of my patients. However, when I think about doctors dispensing prescriptions merely to please, I feel my gut wrench.

I first witnessed placebo medicine in the 1970s. Back then, a few doctors at my university hospital treated patients with saline injections and little blue sugar pills. To add insult to injury, some of their prescriptions read "obecalp." Even though I was only a medical student at the time, I remember my wide-eyed amazement. Did they imagine patients would never gaze at the slip of paper in their hand and read the word backward?

Times and ethics have changed. No colleague of mine would dare prescribe "obecalp" if he or she wanted to keep a medical license, and many (like me) consider the covert use of placebos a frank deceit. But even traditional drugs can be used as placebos. Take, for instance, the truckloads of antibiotics given every year for viral flus and colds (viruses, unlike common disease-causing bacteria, live inside cells and do not respond to conventional antibiotics).

As an infectious-diseases doctor, I know antibiotic overuse is a serious problem. But even though I'm worried about its ultimate upshot — the creation of drug-resistant superbugs — I also understand the patient perspective.

Consider two people with the same lousy sore throat and congested cough who end up in a doctor's office. One comes seeking antibiotics and is brusquely told, "You're OK — go home, get some rest and drink fluids." The other is examined, reassured and given a handwritten note with the name and dose of a standard cold remedy. Most important, the second patient is asked to call back. Which patient is more likely to go somewhere else and demand antibiotics a day or two later, or when the next cold hits?

The truth is: Many seasoned pros can distinguish a routine viral illness from, say, a bacterial pneumonia before they ever pick up the stethoscope. However, when the bottom line is blurted out too fast, the doctor is, in effect, saying: "There's nothing I can do for you — goodbye." And that equals a lost opportunity to help, with or without the latest wonder drug.

Harried, unsympathetic doctors are not the only problem. In my outpatient practice, I sometimes face an even stickier dilemma. Because I specialize in tropical medicine, every year I see a few folks who are convinced they harbor an exotic parasite — and don't. By the time they reach me, some have consulted a dozen other doctors, examined bodily specimens under microscopes and scoured the Internet for rare remedies. They practically have their prescriptions written out before the receptionist checks them in.

After performing a history and physical examination, I won't pretend it isn't tempting to relent "just this once" and dispense the desired panacea. But I don't, because I know from experience there is long-term harm in validating and treating false diagnoses.

After a while, the placebo magic wears off, and patients are more desperate than ever. And so I simply tell the truth and prepare for the fallout. Some patients are grateful for my opinion; others storm out angry and disappointed.

Of course other people might handle this situation differently, including a number of doctors and patients who have recently re-joined the placebo camp. They believe that a positive placebo response equals a self-healing force. To me, this notion comes dangerously close to the claim that positive thinking cures illness. Most serious illnesses are not so easily trumped.

Plus, placebo medicine creates pitfalls.

First, science tells us that placebo responses are strongest in patients who are anxious, dependent and non-analytical. Especially in these cases, blind surrender to a practitioner's "secret art" worsens the imbalance of knowledge and power that already dogs the doctor-patient relationship.

By blurring the line between legitimate and mock treatments, placebo medicine also opens the doors to charlatans and counterfeits. These predators are just waiting for folks who are frustrated with everyday docs and their failings.

As a result, there is one common turf on which legitimate placebo supporters and opponents can meet. We all agree that a healthy doctor-patient encounter involves far more than handing out pills. Its bedrock is solid medical knowledge and a decent amount of time devoted to thoughtful evaluation and communication.

In the old days, placebos made up for our lack of facts and treatments. Perhaps, today, they are regaining popularity because we simply take too little time to talk.


Claire Panosian Dunavan is an infectious diseases specialist and professor of medicine at the David Geffen School of Medicine at UCLA.

Copyright © 2014, Los Angeles Times
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