Heroes Not Zombies

The placebo effect is much misunderstood, seriously under-researched and full of peculiarities. I must admit I’ve assumed that the placebo effect is the body’s self-healing effect. I’ve always thought that’s an important point to make because otherwise people tend to think of the placebo effect as some kind of trick. Whatever it is, it’s real. Symptoms can be modified or even removed, and the “nocebo” effect (that’s the one where harm is caused) can cause real illness. It’s not a pretend effect, even if the intervention is deliberately a pretend one!

However, I’ve just read a short article on the Edge, where a psychologist muses about the placebo effect and raises an issue I hadn’t considered. If the placebo effect is the self-healing effect, why doesn’t the body just get on and do it without the placebo? That’s a good point. Where’s the advantage in waiting for a push? In the article, Nick Humphrey considers the phenomenon from an evolutionary biology perspective and there’s something in what he says, but I’m left with the nagging doubt that whatever the placebo effect is, it IS NOT the self-healing effect. It might be related to the self-healing effect. It might even have its impact by provoking the same, or similar pathways to the self-healing effect. But maybe it’s distinct and different from the placebo effect, not least in it kicking in and getting to work without the need for an external push.

We tend to use such concepts in un-thinking ways. One of the tricks we use to stop our thought processes is to name something and in so doing convince ourselves that we now KNOW it. It’s not true though. Sadly, often when we name something, that naming stops us from thinking – especially if the naming is judgemental. (I think it was Wendell Johnston, the General Semanticist, who said “Judgement stops thought”) After all, what exactlly IS the placebo effect? Spontaneous healing? The natural capacity to recover? A statistical trick? And what IS the self-healing response? How DO people get well? We know some of the components and pathways eg inflammatory responses, the immune system, various hormones and so on, but can all these components be considered together to constitute something called the “self-healing response”?

The answer is…….we don’t know. But don’t you think it would be a good thing if we did? (fields of research such as psychoneuroimmunology and psychoneuroendocrinology are exploring these questions – google them and see what comes up!) If we understood the self-healing system then we could develop the healthcare interventions which were not only designed to promote healing but which actually did stimulate and support it. Why do we concentrate on “disease management” and “symptom control” instead?

One of the things that frustrates me about clinical epidemiology (which goes by the name “evidence based medicine”) is how often it seems detached from the real world. Whilst researchers and statisticians pore over reviews of randomised clinical trials, real people with real problems turn up each day in the doctors’ consulting rooms. In the British Medical Journal there’s a regular column entitled “From the Frontline” and it’s written by a Glasgow GP called Des Spence. I always read his column because so often it reflects the daily reality I used to experience as a GP and which I still experience as a Glasgow hospital doctor. This week his column was particulary good – a healthy, realistic alternative view of the government’s “Quality Outcomes Framework” within which all UK GPs now practice.

It is not just the huge financial opportunity cost, nor the well made unwell, but the wanton consumption of our medical energies that I take issue with. Our energy has been spent bean counting the measurable while dismissing the most valuable aspect of medical care, the immeasurable. Perhaps I am wrong. But I will stand my ground of absolute scepticism until some redcoat finds real evidence to run through my Jacobean heart.

Well said, Des!

I especially appreciate your succinct “Our energy has been spent bean counting the measurable while dismissing the most valuable aspect of medical care, the immeasurable.” It’s a daily sadness to me that we increasingly pay attention to the measurable while dismissing the immeasurable in health care.

Researchers at Ohio State University have just published a randomised clinical trial of pyschological interventions in women with breast cancer. Here’s the summary conclusion –

breast cancer patients who participate in intervention sessions focusing on improving mood, coping effectively, and altering health behaviors live longer than patients who do not receive such psychological support. The study indicates that reducing the stress that can accompany cancer diagnosis and treatment can have a significant impact on patients’ survival.

This was a study of 227 women who had been treated for breast cancer for an average of 11 years. Half of them were given an intervention designed to address stress and help them cope better psychologically (I can’t find the actual detail of the intervention yet!). The intervention group experienced about half the recurrence rate of the others and that group also had about half the risk of death from breast cancer.

Two things interest me about this trial. Firstly, it shows that non-drug, non-surgical interventions in serious conditions like cancer can both positively influence the course of the disease and even reduce the chance of dying from the cancer. Secondly, by reporting improved mood, and healthy behavioural changes, the researchers highlight the value of interventions which make living better. I recently wrote about death avoidance and made a plea for health care which is focused on living. This little trial is a piece of that jigsaw. It not only shows the potential for such interventions but it begins to make the case for such approaches to become routine.

A few years ago I stumbled across the works of the “General Semanticists“. I won’t go into detail about this school of thought here, but it originated with a man called Alfred Korzybski in the early years of the 20th century. He wrote and taught about the way in which human beings reacted as whole organisms to their environment. One of the most interesting features of this way of thinking is the emphasis it gives to not only environment, but to what Korzybski called the “meaning environment” – in other words both symbols and the symbolic power of the environment itself. This focus raises all kinds of issues including change, transience, and context. The book which made this whole way of thinking clear to me was Samuel Bois’ Art of Awareness (ISBN 978-0965103701).

One of the ways of thinking they highlighted for me was “two value thinking” – we do this a lot. It’s the process by which we classify experience into one of two categories – us and them; black or white; and so on. Although generalisation and categorisation can be useful tools they are dangerous and frequently stop us seeing reality. You’ll come across this a lot in medicine. I’m sure you’ll have heard people talk about treatments as either “proven” or “unproven”; “evidence-based” or “not evidence-based”; “drugs which work” and “drugs which don’t”. But this is a silly and unhelpful way to think about treatments because all treatments need to be considered within the inescapable context of the individual. And you can’t even say a treatment “works” or “doesn’t work” for an individual – the same treatment can work at some point for a person, but then not work at another.

Think about painkillers as a simple example. Is there a “proven” painkiller which will kill pain for all individuals on all occasions? No. And, actually, it’s the same with all medical treatments. The only person who can tell you whether or not a treatment is beneficial for them, is that person – doctors have to listen to their patients and hear what their experience is. It’s very frustrating for patients to be told by a doctor that their lack of benefit they’ve received from a particular treatment is their own failure – because the treatment is “proven”. Similarly, it’s very frustrating for a patient to be denied a treatment which brought them benefit because somebody has ruled, on the basis of clinical epidemiology, that that particular treatment is “not evidence-based” or “does not work”.

The world is more complex than that. See if you can spot any two-value thinking today, and consider different contexts to see the weakness of this type of thought.