The Placebo

A mother recently complained about her frustrations with current medical treatment:

“The doctors are just experimenting and treating us like guinea pigs.”

She had taken her child, with a skin rash, to a pediatrician who after evaluating the child and the rash, appropriately prescribed an ointment, booked a follow-up in one week and requested the child return if the rash got worse or if the child had problems with the ointment.

The mother continued:  “Why can’t they just order the correct treatment at the first go around rather than waiting to see what happens?”

I tried to explain how most medical symptoms are managed on an algorithm or a flow chart basis, starting with simple and safe methods. Yes, starting on a trial and error basis before using more complex and potentially complicated methods.

I said, “If you have a headache, the universal management is to drink more water, take an Aspirin, get more sleep and so on.” And if the headache worsens and persists, return to follow-up and proceed down the flow chart sequentially to the ultimate MRI that may unfortunately demonstrate a serious and severe pathology—it would be most unusual to get a

MRI on the first review.

Similarly, if you have chest pain considered to be from indigestion, you are given an antacid and advised to monitor your diet, not sent for cardiac enzymes or an esophagoscopy.

I went on to explain the treatment response graph in general and specifically for most viral and self-limiting conditions.

The bell-shaped graph plots severity of symptoms with time, showing a rising upslope as the symptoms worsen, followed by a falling downslope depicting symptoms improving over time, as our autoimmune system triumphs. Now consider, if a placebo or sugar pill is taken during the period of worsening symptoms (the upslope of the graph) then it would be deemed a failure. If, however the same placebo was given during the period of decreasing symptoms (the downslope of the graph) then it could be deemed a success even though it had nothing to do with symptom improvement.

Our humility and honesty should remind us doctors that at times our patients get better despite our treatments and not because of them, as they would have gotten better anyway with the tincture of time.

 

-Anthony Dwyer, M.D.

(The opinions stated in this blog are those of the author Dr. Anthony Dwyer and not necessarily those of the American College of Spine Surgery).

 

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