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In Praise of the Placebo Effect
One of the Eight Skills of Clinician Healers promoted by the Institute for Functional Medicine is “Share Authority.” This came to mind when I reviewed an article dropped in my inbox by the American Congress of Obstetricians and Gynecologist.  The article, “You Can’t Always Get What you Want: The Influence of Choice on Nocebo and Placebo Responding,” was published in the June 2016 issue of The Annals of Behavioral Medicine.  In this study, university students were given a choice between two different medications and were then given a placebo which they were told was an active drug.  Some were given their pill of choice others received a randomly assigned pill. Twenty four hours after starting the medication side effects were significantly lower in those individuals who received their pill of choice.   In addition, the choice group showed a stronger placebo response to the pill. What is interesting here is that nobody received an active pill. The presence of side effects from a placebo is known as a nocebo effect – a negative response to a non-active intervention.  The presence of an expected response to an inactive agent is known as the placebo effect.
The important take-home message of this study is that context matters.  If we believe something is going to help us, it is more likely to help us.  If we are skeptical or afraid of side effects, we are more likely to suffer from side effects. This isn’t to say we should all start popping sugar pills in anticipation of unrealistic benefit but it does support the notion that the doctor-patient relationship may be more important than which drug is dispensed.  More and more studies in the medical literature support the notion that a strong doctor-patient relationship helps to promote healing and improve outcomes.  A Study published in Family Medicine in the 2009 July-August issue demonstrated decreased symptom severity and duration of common cold symptoms in patients approached with a high level of empathy compared to those who had a minimal empathy encounter with health care staff. This speaks volumes to me as a physician and I try to remember the words of Dr. David Rakel which I paraphrase here:  The ritual surrounding the writing and handing of the prescription may have more relevance to the success of therapy than what is written on the paper.
As a patient, how can you participate in this ritual so that you can get full benefit?   I would recommend that you start by communicating clearly and openly with your provider.  If you’re not going to follow recommendations, let her know.  If you’re concerned about the side effects of an intervention – speak up!  Ask about alternatives – and there are always alternatives.  The alternative may be between two pills, or between two procedures, or between a pill and a procedure.  Sometimes, the alternative is doing nothing.  If you are afraid of the risks of action (surgery, medication, procedures) ASK what you can expect if you take no action. I try to remind my patients that declining intervention today does not mean they can’t opt for intervention later, but it’s important to know what the risks of delaying intervention might be. We in the medical field often forget how frightening and overwhelming these decisions can be.  When we prescribe a certain medication or perform a certain procedure many times per month, or even per day, it is easy to lose sight of the fact that this is a novel experience for the person sitting in front of us.  Don’t be shy about calling us out on this.  Once reminded, we can step back and remove the nonchalance that accompanies our own familiarity.  If you find that the provider you are working with isn’t willing to address your concerns or involve you in the sharing of authority, you need to remind yourself that your body belongs to you.  No one else knows what you know about yourself.  If you aren’t able to get the full benefit of the doctor-patient placebo effect – seek out a second opinion.
Finally, don’t diminish the importance of the placebo effect.  If something is working for you, just because you believe it should – go with it.   Physiology is complicated, but relationships can be ever more so.  If I can make you feel better just by being nice to you or improve the efficacy of a drug by having you trust me – hey, that’s likely to be the safest intervention I have in my little black bag!

---Robyn Jacobs MD
Copyright © 2016 Hygeia Optimal Health through Functional Medicine, All rights reserved.

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