PostScript saw this in the Wall Street Journal Health Blog, and maybe you did too: A new study published in the Journal of General Internal Medicine says that nearly half of physicians surveyed have given a patient a placebo. According to the Healthblog, calming the patient was among the most popular reasons that a physician had prescribed a placebo, though 6 percent of docs checked yes in the “to get the patient to stop complaining” category.
On one hand, this is So What stuff. The word placebo comes from the Latin placare, to please or calm. So the reasons docs cited for using placebos line up with the purpose of the faux therapies to the letter.
On the other hand, it raises eyebrows. When we talk about doctors tuning out the pharma detailers, we talk about wanting them instead to rely on evidence-based prescribing, but is there something deeper we need to account for? If, as this study suggests, a statistically significant number of prescriptions are being written to calm a patient or get a patient to stop complaining, that adds another variable (where PS stands for patient satisfaction) to the already complex prescribing picture of Americans’ trip to the pharmacy. To us, it seems such considerations have a piling on effect to pill-requests spurred by direct-to-consumer ads and the lunch-bearing supply-side pressures coming from pharmaceutical sales reps.
First, it’s important to acknowledge a couple of things: the JGIM survey was a small sample size – 466 internists at Chicago-area med schools — and only half of those MDs canvassed replied. Recall bias, science-speak for the fallibility of the human memory, may be at play. Moreover, numerous studies have shown placebos to be effective in treating clinical ailments, an effect that is often attributed to the “mind-body connection,” and the brain’s significant role in how we are sick and how we are made well.
Still, as the Healthblog points out, the practice of prescribing placebos – whether it be a straight sugar-pill, an antibiotic for something a doctor suspects is viral, or a drug for an indication that drug has not been approved for (off-label) – brings up some sticky ethical questions. Off-label prescribing is appropriate in many cases, and inappropriate and dangerous in many others. Antibiotics have been so overprescribed that the CDC set up a task force in the late 90s which is working to prevent anti-microbial resistance. Wal-mart and other mega-pharmacies began to sell $4 generics last year, effectively removing another barrier to prescribing a medicine that may not be needed, but sure won’t hurt. If a patient feels better, then gets better, is prescribing something he or she thought was something else unethical, or merely medicine by different means?
Let’s face it: doctors are practicing in a Hot-or-Not world – a world where they are being rated by patients like restaurants a la Zagat on trust, communication, availability and office environment, and where managed care has privileged formularies over behavioral health treatment, and placed time constraints on office visits, especially for primary care physicians.
To lower cholesterol, a doctor may write a script for a simvastatin for a patient who has been uncooperative to dietary changes or exercise, even if the doctor believes lifestyle adjustments, adhered to, would do the trick. And by prescribing an antibiotic for a most-certainly viral malady, doctors protect themselves from the slim chance of leaving a lethal case of bacterial pneumonia untreated. The lines between the unnecessary, the supplemental, and the just-in-case are thin and in places all but unreadable.
Taken alone, this survey is a coin in the fountain of issues around the ethics and practice of health care in this country. But it does break the surface, and send a ripple of questions through practitioners’ and patients’ minds: if some of us get better by thinking we are being treated, does that justify the use of placebos? And if it does, then what are the rules for using them? Certainly patients ongoing work to win an audible consumer voice has improved health care dramatically, but how far does the patient-as–consumer model take us before the practice of scientific medicine takes a hit?
And with so many participants, consumers, and profiters in the prescribing picture, how much wiggle room is there to move physicians toward evidence-based prescribing?