Wednesday, January 23, 2008

Beyond the placebo

….notes from the front

The concept of utilizing a placebo in the clinical setting is a topic of considerable interest to many practitioners who are genuinely concerned about today’s modern take on the sacred doctor/patient relationship. This issue plays a crucial role with many of the concerns practitioners have regarding the rise of Complementary and Alternative therapies and their heavy use of unsubstantiated therapeutics.

In this context, the clinical use of a placebo is -intentionally or not- utilized as a real entity represented as an object, treatment, or unit of some therapy. The evolving nature of modern medicine has been steadily peeling away at many of the fuzzier aspects of clinical placebo use. For instance, whether they suggestively cause the mind to change the course of a disease- they don’t, or if doctors can represent them as deceptive objects (pills, needles, or whatever) as a means to an end- they can’t.

This increasingly important distinction has become an important stumbling block for non-science based CAM medicine. In the same vein, modern science based medicine has had its own historical and current struggles with aspects of clinical placebo use.

However, where CAM is basically checkmated –no placebo means no CAM for the most part- scientific medicine is able to face this issue on various fronts and begin to genuinely understand the placebos illusive properties as well as delve deeper into the all important “human condition” that are its origins.

If you take a step back from a focus on clinical placebos and consider broader human characteristics that include deception, empathy, communication, and cultural biases the doors open for a more nuanced, fruitful, and effective doctor/patient relationship. Dr Ness at Science Based Medicine has a nice piece emphasizing the “grey scale” that occurs even in science based doctor/client relationships- especially in the area of communication and how these variables can challenge doctor/patient relationships.

For example, he notes that it is not always advisable to go through every single little detail of why a certain medication is prescribed or the exact probabilities for expecting some therapeutic outcome. In addition, patients help determine -to a degree- how the doctor communicates these details to them. This is true. The huge caveat here –the gorilla in the room for many CAM practitioners- is that unlike CAM this relationship is built upon an infrastructure of science and reason.

What makes this situation truly meaningful, accurate, and effective is that the necessarily shifting demands between the needs of the patient and the doctors’ own opinions and experience are threaded together with the “real world” tapestry of science and this defines the essence of evidence based medicine.

This is not always an easy task and the current health care crisis hinders this type of doctor/patient relationship while opening the doors for the superficial gratification CAM is only too willing to provide. That said, the benefits still far outweigh the hardships and hopefully dialogues such as these will add to the goal all proper doctors have- that of being effective and human healers.

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