Reclaiming the placebo

Alternative medicine is bunk, but makes good use of the placebo effect. Orthodox practitioners should be allowed to do the same
March 22, 2007

I am one of a breed of doctors who is as happy to recommend the "herbal remedy" St John's Wort for depression (as good as the SSRI class of antidepressant for moderate to severe depression, and biochemically similar to "normal" antidepressants) as I am to prescribe aspirin after a heart attack (not only is it proven to prevent further heart damage, it is also an extract of willow-bark). It is evidence that leads me to this conclusion; if the evidence finds favour for a treatment as doing more good than harm, I should offer it to my patient.

Contrary to popular belief, there is lots of evidence about complementary and alternative medicine (CAM), and most of it—the bulk is on homeopathy—shows that it is scientifically bunk; no better than placebo. When alternative medicine does work, it ceases to become alternative and becomes orthodox. Despite this, most medical schools offer training in alternative medicines and many—some estimate half—GP surgeries offer some kind of CAM. The NHS funds five homeopathic hospitals, one of which, the Royal London, recently underwent a £20m refurbishment. Meanwhile, the National Institute for Clinical Excellence strains to resist wasting money on all kinds of unproven or minimally effective interventions.

Yet the placebo effect on offer by many CAM interventions is important. Misunderstood and often derided, placebos need active consideration, not least because new medicines often offer only marginal gains in effectiveness. In research terms the placebo effect is a nuisance, but in clinical practice, the placebo effect is one of the most useful, consistent, cheap, side-effect-free and convincing things that medicine has to offer.



Take, for example, a famous experiment reported by the Lancet in 1972, in which medical students were given a red or a blue tablet, one of which they were told was a stimulant, the other a tranquiliser. The students were asked for their reports on the effects of the tablets with a questionnaire: they reported the red tablets to be arousing, while the blue tablets were found to be calming. Additionally, two tablets rather than one resulted in a more potent effect. But both colours of tablet were actually chemically inert placebo pills. In another study, people given a branded variety of aspirin for headache reported a better effect than people given the same chemical aspirin but in a plain package.

But a "placebo effect," regarded rather more widely, extends beyond tablets or operations. It is about the doctor-patient relationship. Homeopaths know this, and many speak of the "holistic" detailed personal, dietary and emotional notes which they say helps guide them to the right "treatment." We know the diluted tinctures they prescribe are ineffective, and many doctors, including me, think that to use placebos is fraught with problems, not least the deceit of the patient.

Yet there is a raft of advantage to be gained, and entirely honestly, in the way the patient and doctor interact. For example, we know that seeing the same doctor repeatedly, rather than being passed from clinician to clinician, results in better outcomes for the patient. Longer consultations result in less stressed doctors and more satisfying consultations. Confident, empathetic nurses and mental health professionals result in patients feeling more enabled to cope with ongoing illness. Patients value a good relationship and continuity of care with their doctor.

Compare this to the demands placed on current primary care in the NHS. A consultation with a GP will typically be ten minutes long, given the balance between pressure for appointments and enough time to get the job done. It is hardly enough, and indeed many people attend with more than one problem to be addressed. The GP, however, is paid on the basis of a contract which expects them only to ask patients if they smoke, to check their blood pressure and to take cervical smears. People with chronic diseases are "screened" for depression using a tick-box questionnaire. There are influenza vaccination and child health surveillance targets, patient satisfaction questionnaires, audits and significant event analysis to be done. Then there are walk-in centres and NHS telephone lines, neither of which will have notes on your past history and neither of which are designed for long-term relationships. In the meantime, alternative practitioners have only your agenda and an hour, and will see you personally as often as you wish.

Good, evidence-based medical care should mean keeping what works and ridding ourselves of what doesn't. In CAM, there is no apparent ambition to improve and evolve as good medicine should. Frustratingly, in orthodox medicine—which prides itself on being evidence-based—we seem to have stalled, knowing what we should do to provide better care yet being unable or unwilling to do it.

The core values of care and continuity need to be valued in NHS primary care; currently they are voiceless in a contract agenda which de-professionalises doctors and reduces patients' concerns to the margins of the consultation. It is scandalous that the one place on the NHS where patients are given the time and space they need is a homeopathic hospital. Why should one have to leave science behind in order to gain the time and perception of care which should be accessible to all?

Evidence-based doctors should be reclaiming caring, holistic healthcare as their own. Otherwise it will be seized by doctors who dare into these hinterlands and think that by rebranding medicine "integrated" they can pick and choose between orthodox and alternative medicine. To "integrate" my practice with things that don't work sends us straight back to sugar pills, platitudes and the era of paternalistic medicine.

Worse, alternative and "integrated" practitioners threaten to take what rightfully belongs to ordinary doctors and their patients away while dressing medicine in the rags of pseudoscience. It is not merely possible to be a doctor who applies the best of evidence-based medicine with honesty, compassion and humanity; it is necessary. Doctors should reclaim the time and compassion that they need to deliver good medicine, and it is in patients' interests that they demand that the government leaves them, as professionals, to do it.