That is precisely the distinction I am trying to make very clear and easy. There is and actual, neurophysiological, biochemical change that occurs during placebo administrations. There are defined mechanisms for it that have been demonstrated empirically. And they do make for real changes in certain disease processes. However, IMO, that is not a placebo effect – that is the effect of the active psychological intervention going on concurrently with placebo administration (active in the same way that CBT is an active therapy). That is why I have been trying to push for using “psychogenic placebo effects” to refer to those real neurophysiological changes and “placebo effect” to refer to the illusion of change via reporting error, bias, regression to the mean, etc.

Just because the magician appeared to make the elephant vanish into thin air doesn’t mean the elephant actually vanished into thin air. Just because a modality appears to work doesn’t mean it actually works.

Science, or an understanding of how magicians work, can help find the elephant.

…I hadn’t seen a dentist in about fifteen years.

You know what they say:
“Your teeth are the only problem that will go away if you ignore them.”

And I’m glad you liked your dentist. It really makes such a big difference when they seem like they enjoy what they are doing. My GF was never a huge fan, until I hooked her up with my dentist. He is so friendly and actually asks you about how your day has been, anything new since last time, etc. It makes a huge difference.

I find that when I speak with colleagues I refer to patients as their condition i.e. “the appy in 4″ – but when I am actually with a patient, that is quite different. My step father, who is a critical care doc and someone whom I admire told me his philosophy:

“There’s two kinds of doctors. Those who know what their patients do for a living, and those who don’t.”

I aim to be the former.

BTW, I often explain the lidocaine by saying it makes all the nerves fire once and then get frozen, which is why it burns and stings at first for just a little bit and then it goes completely numb. I find that is particularly helpful with children. They really have much more capacity to understand than we tend to give credit for.

Thanks for the low down on the podcast.
(I still haven’t had time to listen to it – I’ve just finished training for and completing my annual 50 km walk over the Dandenongs, and I’m now in training for the 14km City2Sea run in 6 weeks time).

I’ve listened many times to Ben Goldacre expounding on placebos but he always leaves me feeling confused. The problem, I now realise, is that he doesn’t ever get around to explaining the underlying neurophysiology so that all the examples he gives make sense.
So thanks for filling in the vacuum.

Regarding bedside manner:
I do not have any medical problems and therefore rarely attend for medical advice. However I recently had to attend a dentist urgently because one of my front teeth suddenly broke off close to the gum margin leaving a gaping hole in my smile, which subsequently disappeared. Because of my previous alienating experiences with dentists (standoffish and rude), I hadn’t seen a dentist in about fifteen years. However, my experience with this particular dentist was very different. She actually made eye contact and smiled! She seemed genuinely interested in me as a person with a broken tooth rather than just as a case of a broken tooth. And she explained everything she was doing – the topical anaesthetic to numb the pain of the injected anaesthetic (which I would still feel a little bit); and the slightly more painful injection into the hard palate etc etc. I was so impressed that I decided to let her correct fifteen years of dental neglect. She made me feel so at ease with her helpful explanations and her reassurances that I actually look forward to attending my appointments!

She was also the only dentist I’ve ever attended who seemed to actually enjoy her work.
I have a feeling you’re going to be just like her.

yes, to his advantage for piloting new ideas for research purposes, and “understanding brain pathways”…but as he said in the interview….the utility in actual clinical practice is far from clear at this point…this finding, while interesting (especially the GH part, boggled my mind) is still a far cry from useful in clinical practice I believe….but I DEFINITELY agree that clearly the bedside manner and all that jazz is important as part of “the placebo effect”….and I do find some of this stuff interesting on this basic science level…but on the clinical level I will have to see much more….

You all rock on here…learn something new every day and new perspectives – lovin’ it – good night.

I work in primary care, and the pharmacy residents and students that cycle by me…I have to work very hard to get them to stop from saying “lipid”, “hypertension”, “any change in your vitamin K intake?, “hypoglycemia”, and other such things….

Sometimes you really do wonder how much of what we say, really sinks at all….

I make it a very very important point to speak in the simplest of terms in every respect within my practice, and I am glad to hear others strive to do the same!

One thing I definitely value about this placebo discussion is the whole bedside manner, therapeutic ritual piece. For the psychogenic aspect perhaps in its smaller way, but also just that how many times do we see COPD’ers having an exacerbation because they mistakingly take their scheduled dry powder inhalers PRN….or how many seizure patients have a seizure because they are non-compliant…etc..etc…etc…that therapeutic ritual is quite important…if it is one thing the CAM community does criticize us right in one aspect it is that we are failing in this regard many times – although their criticism is from an ivory tower, not in the trenches of the difficult realities of modern medicine.

But reducing things down to better understand how they work is fundamentally different from divorcing them out of the treatment of a patient. That is why I hate that old adage that people seem to think is so profound “Treat the patient, not the lab value.” No! You must always treat the patient AND the lab value. The sCAMsters are claiming we divorce the two and ignore the patient. But they are at the same time divorcing the two and ignoring the medicine. Neither way is right.

So yes, use those psychogenic placebo effects in concert with actual medicine and yield much better results. I have seen this in my own work in the ER. Talking to patients, explaining how and why something will work, giving them an expectation of benefit, and being kind and empowering them with knowledge is so vastly useful that I can’t imagine treating patients without doing so.

An anecdote from my experience I love to relate:

Last year I did a month long surgical elective. Mostly general surg but I covered trauma call and did some ortho as well. In this case I was doing call and we got called over to evaluate a pt with abdo pain as to whether she needed her gallbladder removed. The relevant studies all demonstrated clearly that was not the cause of her pain and that it was in fact a gastroparesis (her stomach just wasn’t churning and moving like it should). The surgeon came in, briefly told the pt and family that and called it a day. The pt and family were in distress – the pt was getting intense waves of pain every 10-15 minutes and couldn’t understand why it wasn’t the gallbladder or what it all really meant. While the surgeon was dictating, the mother of the pt came over and snagged me and asked me if she could ask the surgeon a question. I said he was busy at the moment, but if she wanted to hang out for 5 minutes I would flag him down after he was done. In the meantime, I was happy to answer whatever I could, making it very clear that I was just a medical student and not a doctor. She asked if the gallbladder tests could be wrong. I explained to her how the test worked and why they couldn’t be. She then asked why her daughter got pain every 10-15 minutes. I then explained the migratory motor complex and how it causes the intestines to contract in a wave from top to bottom every 10-15 mins as a way of keeping our guts clean. I also explained that guts can’t feel pain like the rest of our body – they only hurt when the get stretched. So since her stomach was paralyzed the MMC caused that pain. I explained it in reasonably basic terms, but I did use the technical jargon from time to time, explaining what it was each time. After just 5 minutes, she was very relieved and said she not only understood why the results were what they were and why her daughter was having that pain, but also thanked me for taking the time and not treating her like some stupid person who wouldn’t be able to understand.

I think that most people not only can but want to hear some technojargon and have it explained to them to really understand what is going on. But we are taught in med school never to use big words around patients and to make matters worse many doctors don’t know how to describe something without using our latin based obfuscatory language that is pounded into our heads all through med school. So they are left with no middle ground – either really technical language or so basic as to not really explain much and make the patient feel like we are talking down to them.

The middle ground is hard to find, but I think very important and I advocate for it at every single chance I get. I’ve even had my clinical comm skills tutors chastise me for using big words in role plays (yes, we do those) and I’ve stopped the session and explained clearly my rationale and advocated people follow suit. Writing constantly on these fora helps me develop those skills (as I’d said to Tmac57) as does leading my weekly tutorials for 1st year students. Teaching effectively is a skill that must be practiced – not a gift that some people just don’t have.

One thing I do need to work on though, is being less long winded! haha