This uniquely human fusion is in large part a learned skill attained through the hard and arduous process of real life experience. As emotionally satisfying as it can often be, this special quality of clinical practice is a realm fraught with dangers and potential pitfalls. The repercussions of ignoring the art for the science, or vice a versa can lead a professional on tangents that are not conducive to practicing solid medicine.
Among these, is the danger of succumbing to the seductive song of the placebo effect with its many manifestations. Unfortunately, many complementary and alternative modalities rely on methodologies that rely heavily on nebulous, difficult to define powers, fields, and "Elam Vitals" of varying types and origins. These ideas are based on foundations laced together more with faith and belief than with demonstrable, repeatable observations. Here one can begin to discern the elusive placebo at work.
Though, there is nothing in general fundamentally abhorrent about the concept of the placebo, doctors of medicine need to tread with great care when encountering it. Offering emotional satisfaction to a patient is very important, but it needs to be done while utilizing effective, plausible, and when possible, established evidence based methods.
At the risk of repeating a familiar theme in this blog, the inexorable, sometimes plodding- yet flexible and malleable- nature of the scientific method provides a coherent method enabling truth. It is fundamentally critical for practitioners to inherently understand the role of science in medicine and how it works in the discovery process of disease.
That said, science is indeed a human endeavor fraught with instances of egotism and bias. Even so, it has proven to be the best self correcting, objective system designed up to this point. By striving to methodologically understand the natural processes of health and disease, our own ego and assumptions can be held to the fire, and we can, as doctors, take our place within the honorable task of effectively helping others.
Important among these processes is the role that the natural history of disease plays in our understanding of how any therapeutic modality works.We should be shrewdly skeptical of “wondrous” cures attributed to our skill and maintain a healthy dose of humility of who we really are. In this context, the placebo effect becomes a comprehensible phenomenon. The elusive and mystical qualities of its action disappear and its boundaries become better defined. The dilemma of ethical doctor/client relationships is less of an issue if clinicians can avoid creating false hope.
Indeed, the ethical consideration of utilizing the placebo as any part of a therapeutic process has garnered significant discussion among the medical community. In the world of veterinary medicine, this problem seems more acute due to the fact our patients are not the decision makers for a given treatment and it is more critical for the veterinarian and client to offer appropriate care.
A retired clinician, in an editorial I read, offered an interesting twist to this ethical dilemma. Given the hypothesis that some placebo effect occurs in any doctor/patient relationship (or in other words, that the outcome experienced by a patient equals evidence based therapy plus the placebo effect) he noted; “What are we to do when a situation arises that seems to call for the use of the placebo effect? …I suggest that it is acceptable to use the placebo effect provided there is no more than a negligible risk of harm and the cost of the “therapy” is insignificant...we should not abdicate to others the utilization of the placebo effect where warranted. By virtue of our university medical education and post-graduate training, we are best positioned to understand the dynamics of illness and select optimum treatment- including the placebo effect- with the least chance of error or harm.”
He assumed a placebo effect by the very existence of the client experience and he may very well be right. I think he confuses a whole set of qualities with the placebo. These are, in large part, those human communicative skills that a clinician needs to master to "connect" with the patient or care giver- no magic placebo needed. It is important to underscore here that the placebo in and of itself is not a treatment option in the realm of modern medicine. However, we need to understand the importance and potential influence of human bonding within the context of the client/doctor/therapy interaction.
It is therefore incumbent on the guardians and care givers, especially of children, the impaired, and animals to provide evidence based methods of treatment when ever possible. This is challenging with today's misrepresentations of which standards of care are effective and which are not. The lack of solid scientific education among the general population (at least in the US) exacerbates the problem. The standard perception of the “right to choose” promulgated by many alternative medical and non-medical authorities in the human and animal fields creates a situation where the basic foundations of medical practice become fuzzy and indistinct to many. Disconcertingly, these professionals do not question the ethics of providing unproven medical therapies without caveats, representing some alternative modalities as "another" effective therapy.
The placebo effect, from this point of view, can be easily abused. It is therefore important to approach medicine using the evidence based process, under regulation, licensure, and standards. Within this framework the “right to choose” becomes a safer action and the placebo put in proper context.
The placebo effect has a variety of human to human triggers. It can originate from a touch, belief, or object. It seems to come in many forms and strengths. Ultimately, the placebo falls into the domain of the brain. When other qualities such as regression to the mean or conditioning are teased from this phenomenon it may be a uniquely human characteristic involving empathy.
The degree of empathy expressed by the medical professional increases the compliance of the patient in very direct ways. By spending a small amount of time understanding these interesting effects, the health provider can maximize the positive aspects within the art of medicine. The placing on of the hands, involving the patient in a conversation and asking questions within the context of the examination has tangible beneficial effects.These are qualities that alternative practitioners rely on, but it is not exclusively their domain. These actions are an intimate part of any doctor/patient relationship.
The evidence based approach provides a consistent formula whereby several spheres of influence can jointly impact a clinical outcome. This method takes into account many of the perceived placebo effects while focusing on science based medicine. This form of practice continues to gain popularity in the veterinary world and has made solid inroads in human medicine. As described by many human and some veterinary studies, there are three general areas in the doctor/patient relationship that work together; the clinicians experience, the clients’ perceptions, and the body of evidence based knowledge with respect to the presiding malady.
The goal of this approach is to maximize effective therapies while taking into consideration other factors that may affect the therapeutic outcome. By taking into account particularities of the clinician and client, it is possible to customize treatments to a degree. This may allow the flexibility needed to maximize compliance and allow for the best outcome for that particular case. It is not a "follow the recipe" modality as many suggest.
In essence, the evidence based approach allows room for such effects as socio cultural influences and clinician experience and reduces any dependance on hard to define entities such as the placebo effect.It takes into account many of the variables that can affect outcomes of therapy and keeps them within the bounds of solid medicine.
Evidence based medicine provides an encouraging approach to medicine that gives life and vigor to clinical practice while providing effective therapies in a flexible way. The humanity of medicine is preserved and the best medicine is offered.