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Study: Snake Oil Wildly Popular with Health Professionals

BoGardiner's picture

Truthiness and paternalism are virulent diseases that undermine every institution they infect:

50% of U.S. Doctors Secretly Dose Their Patients—With the Placebo Effect

The study found that most of the doctors who prescribe placebo treatments typically describe them to patients as “a potentially beneficial medicine or treatment not typically used for their condition.”

Doctors told the study authors they believe this is ethical, despite the AMA’s injunction against placebo treatment. Why? Because they’re not explicitly stating that a placebo is medically supported. They’re just deliberately encouraging the misunderstanding that it is. Which, technically, they say, isn’t really deception. (Got it? Me neither).

Well, you may say, if you insist on calling it deception, it’s OK because it’s compassionate deception. It’s the intention and results that really count, right? The end justifies the means. You may imagine your favorite nurturing image:

--The kindly country doctor and his sugar pills that do indeed work. “Just not in the way she thinks,” he says smiling, a twinkle in his eye.

--The holistic healer urging homeopathic remedies and the certified masseur offering “energy work.” They’ve read but don’t mention to clients that studies show these work no better than placebo. “Sometimes they do help, so what’s wrong with that? Besides, I’d rather work from my gut, not books.”

--The specialist-recommended physical therapist whose toolkit is packed with worthless modalities like craniosacral therapy (amidst many fine ones.) “I don’t read medical journals,” she says. All I know is, plenty therapists do it, and some patients say they feel better. That’s good enough for me. And it’s good enough for the doctors who refer without asking questions.”

What’s wrong with any of this, you ask? What’s wrong with health professionals violating the AMA’s ethical injunction against placebos? What’s wrong with an entire culture of health professionals unable to see an ethical breakdown in picking your pocket and earning their living by lying and defrauding you and your insurance company?

It violates my right to make informed decisions about my own health. That's what's wrong. A right I demand as long as I’m not certified incompetent. It’s paternalistic, truthy, and wrong, and it’s time good people stop defending it.

The placebo effect is real and it’s powerful – scientists agree. Let’s find out why, and how to use it without trickery. Let’s insist we redirect our dwindling health funds away from quackery, and toward research and education on developing a healthy mindset and lifestyle.

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whaleshaman's picture
Submitted by whaleshaman on

From the article:

The most common placebos the American doctors reported using were headache pills and vitamins, but a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.

Whatever happened to "first do no harm"?

splashy9's picture
Submitted by splashy9 on

Especially because of things like a possible overdose of vitamins for those that have poor kidney function, for instance. I personally wouldn't like a sedative, because I respond to those kinds of things more than others do.

I want to know exactly what I am putting into my body, what with allergies and sensitivities. No wonder so many have bad reactions.

This sounds like another reason for universal single payer health care. Cut out the profit motive, and people will only get the treatment they need, not this bogus get any money you can for nothing stuff.

"A little knowledge is a dangerous thing. So is a lot." - Albert Einstein

BoGardiner's picture
Submitted by BoGardiner on

The sedatives and especially antibiotics are particularly outrageous.

But that was only, if I recall, about 15% of the doctors; the rest were using the equivalent of sugar pills. So it's a bit of a side issue, though shocking.

The question remains: is a true (inert) placebo ethical?

And if our future single-payer government decides that placebos are effective and cheap?

bringiton's picture
Submitted by bringiton on

Couple of thoughts, Bo, on this most interesting topic. Not disputing the wisdom of being an informed consumer in medical care or anything else, and good for you in deciding to educate yourself enough to be one.

Not everyone, though, feels that way. A great many patients don’t want to be informed – they want to be treated. There is a widespread belief that for every problem there is some fix to be had, some measure to be taken that will produce a cure or an alleviation; misleading reports in the popular press as well as fictional television programs like the popular but hopelessly ungrounded and fantastical House go a long way towards driving such beliefs. Many if not most patients come to a physician with the expectation of treatment and cure, and all too frequently they are disappointed and angry when one is not available. It is in that setting, in dealing with those patients and their unrealistic expectations, that prescription of placebos plays a role.

What, for instance, should a physician do when confronted by a patient insisting on antibiotics for an upper respiratory illness that shows a negative culture for bacteria and has all the signs of being a minor viral infection just like the other fifty patients with the same thing seen over the last several days?

If after consultation and education the patient continues to insist, there are no good choices. Should the physician prescribe antibiotics even though useless and the danger of increasing antibiotic resistance is enhanced? Refuse the patient’s demands and risk that the patient will simply shop around for another physician willing to prescribe the antibiotics? Or prescribe/dispense a harmless placebo?

With the latter the patient is satisfied, the placebo effect likely reduces the patient’s distress and alleviates whatever component of suffering is emotionally driven, the patient having gotten what they came for enters into an emotional contract with the physician and is more likely to follow directions for palliative treatment with fluids and rest and antihistamines, bacterial antibiotic resistance is not stimulated, the virus runs its natural course and the patient is cured by tincture of time. Under these all-to-common circumstances, is a placebo not the better decision for the benefit of the patient?

A great many conditions are poorly or not at all understood, and for many more there are no known effective treatments; in many disorders there is no actual difference in outcome between placebo and active ingredients. Since active ingredients can have side effects, would not a placebo be a better choice in these cases?

In this BMJ study, doctors were asked a question about one of these sorts of conditions; fibromyalgia. A syndrome – a spectrum of symptoms – rather than a definitive disease, fibromyalgia is poorly defined with no formal diagnostic description, no known cause and no documented standard effective treatment; in fact, no scientifically documented beneficial treatment at all.

I don’t at all discount the suffering of the afflicted patients or question the reality of their perceptions, but it is fair to say that within the range of symptoms presenting there is room to consider that some degree of patient-reported experiences are either emotionally based or emotionally enhanced – any condition with sustained pain is both emotionally and physically debilitating regardless of the organic origin.

One of the questions in this study asked physicians to choose between no treatment for fibromyalgia and treatment with a sugar pill placebo if the sugar pill treatment proved to be better. A forced and artificial decision, to be sure, and one that elicited a “likely” placebo choice from 58% of respondents.

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Critics might say that this decision would be unethical, that no placebo treatment should ever be given under any circumstances. But in treating an intractable condition such as fibromyalgia, wouldn’t choosing the better course of management be the correct choice, the choice that is in the best interest of the patient? My shock and dismay rests with the 41% of physicians who said they would not treat with a placebo even if the results were better. What could they possibly be thinking, and whose interests are they focused on?

Bo, you propose that some portion of motivation for dispensing a placebo could be avarice on the physician’s part, “an entire culture of health professionals…picking your pocket and earning their living by lying and defrauding you and your insurance company.” Human nature what it is, that could be true in part. But as the NYTimes article reported, studies on placebo use elsewhere have shown a similar incidence in Denmark, Israel, Britain, Sweden and New Zealand where a physician profit motive is not generally at work. This would suggest that some other, more universal driver is at work.

For many people, both patients and physicians, the Enlightenment decoupling of the priesthood from the practice of medicine has not yet taken hold. The importance of ritual, costume, secret language and magical thinking still holds sway and the power of expectation fulfillment remains fully in place. When the patient is the one fully invested in that world view and no scientifically-based therapeutic option is available, what is a compassionate physician to do?

[Small aside, category of personal pique: You cite “paternalism” here as an operative undermining influence; do you have data to support the idea that male physicians are more likely to provide placebos than are female physicians, or are you saying that the role of physician is inherently paternal regardless actual gender?]

Submitted by hipparchia on

the placebo effect. i've seen some of those papers that purport to be "studies" of the placebo effect. many of them are not well done.

not to mention that we have little or no idea just how many drugs there are out there that turn out to have other useful side effects that nobody ever thought to look for -- doxycycline for aneurysm? whodathunkit? how much of this has been written off as placebo effect in the past?

quibble on antibiotic resistance, we need to stop giving them to livestock, instead of rationing what we give to people.

bringiton's picture
Submitted by bringiton on

the patient does.

This BJM study doesn't require belief for the fibromyalgia question. The condition is that there are only two choices, placebo and nothing, and the placebo is better. Under those circumstances, the right thing for the patient is the placebo. There is an effect - the patients are better - it is only that the mechanism is unknown.

Dicey, but still...41% decide no? Thus the importance of a second opinion.

BoGardiner's picture
Submitted by BoGardiner on

Two replies to comments here I've made I see later have not appeared. Not sure which end the problem lies. Let's see what happens to this one.

BoGardiner's picture
Submitted by BoGardiner on

After two lengthy replies, at the moment I have no time, but I'll just say I'm surprised no commenter shares my concern with the study's core finding.

Apparently the negative connotation of "snake oil" and "snake oil salesman" should be rehabilitated as good people helping people by dispensing placebos. (For those selling inert or benign snake oil). Interesting.

bringiton's picture
Submitted by bringiton on

Not so much a disagreement Bo, as a different POV. When I think of snakeoil I picture an active promotion of benefits from something that does not provide them; the Paulson economic cash-for-crash proposal leaps to mind. A physician administering a placebo as a last resort does not, in my mind, fall into the same category - although I do see how it might be viewed in that way.

This is an interesting field of discussion; I do hope differences in POV will not preclude continuing the dialogue. As we move to single-payer UHC there will be a number of areas to explore where proof of efficacy requirements run smack up against belief, on the part of consumers and clinicians alike.

What, for instance, to do about established professions such as chiropractic or naturopathy or osteopathy or homeopathy or herbalists? Should the new UHC regime pay for treatments even though they fail scientific standards of credulity, simply because many people believe in them? Or should some strict standard of efficacy be employed to weed out any hint of quackery and ensure that public funds are expended only under tight controls for practices with clear and measurable benefit? If the latter, who sets those standards and how are the criteria established? What do we do about mental health, where symptoms are nebulous at best, diagnoses are uncertain and there is no standardization of treatment?

Not wanting an argument, Bo, but I would enjoy a discussion; it is in the gray zone, along the margins of things, where value lies. "Interesting" isn't always a bad thing :-)

BoGardiner's picture
Submitted by BoGardiner on

The ones that didn't get posted, for some reason. Shorte' is not my forte' either.

Sorry for the confusion; my comment was unclear. Will reply more this evening.

bringiton's picture
Submitted by bringiton on

I was poking fun at my own long-windedness*, with which some here are annoyed but do I care? Not much. If anyone was unclear in this exchange, it was I.

Whenever, Bo, no rush; look forward as always to what you have to say.

[* Biden's Disease? whaddaya think?]

Submitted by hipparchia on

thanks for taking the time to write. i can always stop reading in the middle if i have to. :)

bringiton's picture
Submitted by bringiton on

apparently

amberglow's picture
Submitted by amberglow on

it's not like most people who go to the doctor with a specific problem (say high blood pressure or allergies or whatever) are getting placebos instead of regular and appropriate medicine.

and don't we as a whole err in overmedicating using real medicines far far more than medicate or overmedicate using placebos?

bringiton's picture
Submitted by bringiton on

by inappropriate distribution/delivery of medication. Many billions of dollars are wasted every year on prescription medicines that either have minimal or no therapeutic value while millions of people go without needed medication that would definitively benefit them. Our national health care policy is somewhat like our national taxation policy; designed to deliver benefits for some who don't need it with resulting punative consequences for many others.

Depending on how placebo is defined, the practice could be seen as a major factor in ethics and funding consequence or it could be seen as just one of those societal quirks like public participation in Party primaries; charming in an antiquarian way, frustrating for those who insist on purity, but in the overall scheme of things not all that important.

The management aspect of UHC, including the question of how to define and regulate funding for "placebo" services and practices, is a discussion well worth having.

BoGardiner's picture
Submitted by BoGardiner on

Answering Bringiton:

...the placebo effect likely reduces the patient’s distress and alleviates whatever component of suffering is emotionally driven, the patient having gotten what they came for enters into an emotional contract with the physician...

What will remain of this "emotional contract" when the patient learns the doctor is lying -- a very real possibility? There are multitudes of references/resources on the Web as to how doctors can and should do a better job of addressing this emotional element of health care through better listening and better education. There are far better answers that don't involve violating AMA and other standards of medical professionalism against patient deception. As this psychology professor comments about the study, ""Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut."

There are numerous thoughtful position statements against this practice, such as that of The American Society for Pain Management Nursing:

Patients with pain, and their families, have a right to expect that the therapies provided are based
on rational, scientifically valid evidence (Wall, 1993), and delivered in a context of mutual
respect, trust, and truth-telling (ANA, 2001). Whether well-intentioned or punitively directed,
placebo use without consent compromises the therapeutic relationship between patients and
healthcare providers. It erodes the necessary environment of trust, and serves to defy the
precepts of truth-telling, informed consent, and respectful care (Coggins, 2000).

You may say:

When I think of snakeoil I picture an active promotion of benefits from something that does not provide them...

This describes exactly what the study found the doctors were doing, describing a treatment they know to be ineffective as "a potentially beneficial medicine or treatment."

What, for instance, to do about established professions such as chiropractic or naturopathy or osteopathy or homeopathy or herbalists? Should the new UHC regime pay for treatments even though they fail scientific standards of credulity, simply because many people believe in them?

Simple Answer Department: No.

...who sets those standards and how are the criteria established...

We have a system already of peer review, medical boards, certifications, and laws determining standards of care; it is of course complex, but the mechanisms are largely in place, though they can and should continue to be improved to insure science-based medicine.

You cite “paternalism” here as an operative undermining influence; do you have data to support the idea that male physicians are more likely to provide placebos...

Google the words paternalism in medicine. It's a well-known concept that we're supposed to be moving away from; the term is even used in AMA policy papers. Marcus Welby, MD, aka Father Knows Best, bless his heart, rests with the dinosaurs.

The doctor doesn't need to believe, the patient does.

I have little doubt that alternative medicine, which works largely on the placebo effect, is more effective at use of placebos than doctors because of the enthusiastic belief of the practitioners.

Amberglow asks,

...don’t we as a whole err in overmedicating using real medicines far far more than medicate or overmedicate using placebos?

Don't know. Got a link with data supporting that? In any case, why can't we address both overmedication AND placebos? Seems a different topic.

Hipparchia hypothesizes:

Maybe 41% of physicians don't believe in the placebo effect.

Unlikely. A simpler answer to me is that only 41% care to honor their professional ethics codes, with the rest taking shortcuts.

Submitted by hipparchia on

i sort of agree with bio, having been a lifelog patient with multiple, um, conditions. but i'm just not up for getting into all the ins and outs, other than to say that i personally do not want any of my doctors outright lying to me, though i haven't got a problem with them offering me a drug that 'might or might not help, but probably won't hurt' [usually as an off-label prescription].

amberglow's picture
Submitted by amberglow on

and so many believe that there is a pill or treatment for all our ills, no matter what.

“when something is the matter with you, you will not get better unless you swallow pills.” (from the article)-- this is the underlying cause of overprescription -- of both real medicine and placebos.

BoGardiner's picture
Submitted by BoGardiner on

Handing out pills is so much quicker than discussing stress, exercise, diet, etc. I don't know the answer to doctors not taking enough time for patients, or whether UHC would relieve that at all.

Placebos only drive further expectations for pills. It's a vicious circle. It's definitely all connected.

Sarah's picture
Submitted by Sarah on

of a placebo.

What we're learning is that the mind and body are more integrated and interrelated than we've been lead to believe in the past.

Doesn't mean I want to be fed bear-gall, rhino-horn or tiger-bone when what I need is Clavamox or Keflex.
We can admit that we’re killers … but we’re not going to kill today. That’s all it takes! Knowing that we’re not going to kill today! ~ Captain James T. Kirk, Stardate 3193.0
1 John 4:18


We can admit that we’re killers … but we’re not going to kill today. That’s all it takes! ~ Captain James T. Kirk, Stardate 3193.0

1 John 4:18

BoGardiner's picture
Submitted by BoGardiner on

The power of placebos is profound indeed. But that was the old model of medicine; the new model is based on honest and open cooperation, not fraudulent claims.

There's something very important we need to learn about how to think healthfully, the power of our minds over our bodies. It's critical that we research and understand this better.

But I INSIST I not be tricked by Marcus Welby into doing it. It's my right -- and my responsibility, I might even add -- to learn how to do it for myself.

bringiton's picture
Submitted by bringiton on

and then again I sort of don't. (Thanks hipparchia, for that construct; so useful in so many settings, must remember to employ it :-)]

As you say, it shouldn't ever happen and, as you say, better education and more time spent with patients would certainly help reduce the incidence and, as you say, there are a great many pronouncements by many prestigious organizations and learned respected authorities that caution against the practice. All true, exactly so, and yet....

Everywhere we look we find that about half of physicians - MD physicians, to be clear - prescribe placebos with some regularity. What you haven't addressed, Bo, is the why of that fact. Something must be driving it, it must serve some useful purpose for someone, or in the face of such formidable criticism by the guild it would be far less common - don't you think?

It can't be because of avarice, as you first posited; the frequency is the same in countries where no practitioner financial incentive exists. And surely it isn't callousness or malice, or are we to conclude that 50% of docs who are Danes and Kiwis and Brits are mean and awful people who get their jollies from deceiving the gullible and credulous? Well, OK, maybe the Brits, but not the others, and that leaves us searching for a reason. I note you walked right past that question, and really I think it is the heart of the matter - Why does it happen?

I don't know. But I do feel that until that gets a decent answer then all the proscription in the world won't put an end to it - or sort out when it may be actually the right thing to do as with the study's artificial question regarding fibromyalgia.

B: There are multitudes of references/resources on the Web as to how doctors can and should do a better job of addressing this emotional element of health care through better listening and better education. and “Doctors may be under a lot of pressure to help their patients, but this is not an acceptable shortcut.”
Acceptable to whom? I laid out a scenario that is not hypothetical but actually typical, of the patient with a mild upper respiratory viral infection who demands antibiotics. It happens frequently, multiple times a week in an average general practice and more often during cold and flu season. I asked, what under these circumstances is a compassionate and responsible physician to do?

Take more time; do a better job at education? Easy to say, difficult to implement; 15 minutes is too long to spend with such a patient and still be able to sustain a practice. There are no community resources available for referral to treat a patient's need to demand that which does not exist, and advice to seek psychotherapy will surely go unheeded. Time spent with a sniffly nose from a rhinovirus is time that cannot be spent with a patient having vague symptoms of unspecified discomfort and tiredness and general depression that may be organic or may be early signs of cardiac disease and impending heart attack or maybe shower TIAs that untreated will lead to a stroke or death. A bottle of sugar pills for the sniffles buys another five minutes to look a little harder at the atypical patient and perhaps avert real disaster. These are the realities of a modern medical practice, here and abroad, and we should perhaps be just a little less severe in how we judge those who have to make such decisions. If you have a better set of choices, practical and not didactic theoreticals, I'd very much like to hear them.

Placebo effect. Here we can agree in part, that the effect whatever it may be is real. How much is due to the patient's belief and how much to the sales job by the practitioner is, I suppose, open to argument. My belief, and that is the correct word, is that it is all about the patient and what is happening in their mind. From a practitioner's side it is easier to sell something you believe in but one of the desirable arts, much sought after by the patients themselves, is a manner of assurance and confidence expressed by the physician. If you have that manner, you can sell fake ice to Eskimos.

To a large degree, patients who have the need to hand over their care to another will seek out such caregivers. It is a feedback loop of dominance and dependency that can in some unscrupulous or delusional practitioner’s hands become pathological co-dependency, and again the caring physician will not want to refuse a demanding patient only to see them fall into the hands of charlatans. Is not a sugar pill the lesser of the evils?

What happens if a patient discovers the fraud? A rare occurrence, assuredly, when the patient is the one entirely invested in the deception; I give you the prevalence of organized religion as proof of that concept.

You're a tough one, you are. The interesting part, for me anyway, is that you are of course right on a certain moral level - we all of us ought not to lie to each other about important matters. On the other hand there is a morality that deals with the necessity of the practical, and where the two diverge lays a dichotomy that fascinates. I hope we can continue to talk about it.

BoGardiner's picture
Submitted by BoGardiner on

I never "walk past" a thing! Not in my head, anyway. Not my style. I don't mind dealing with a fly in the ointment if it's there. The problem is time. I hit head-on the issue raised of doctors in countries with socialized health care... in one of my initial long replies that somehow failed to post, then I had to run to work. Like I do now, yet here I am...

The time crunch is a global issue for doctors: see my new comment above. It drives much of this. In these other countries, doctors still need to court success to get ahead, and the ones who make the most patients happy in the shortest amount of time win the game. You simply can't pretend there's no self-interest when a rushed doctor convinces herself she's being noble in doing what parties without self-interest unequivocably find unethical. Not "caution against," as you dilute the statements of bioethicists, but FIND UNETHICAL.

Why do they do it? Because PLACEBOS WORK and it's easy. That's the whole point. The motives I'm describing are far more nuanced than simple avarice, as you keep claiming erroneously I'm positing. One has to draw upon cognitive dissonance theory to learn why they take these lazy, lying shortcuts.

Sorry, gotta run.

herb the verb's picture
Submitted by herb the verb on

The "fibromialgia" question here is a dishonest construct. It asks the doctor to suspend their disbelief of whether or not placebo effect is real (i.e. trust the questions premise) in order to get a statistic on whether or not a doctor would prescribe a placebo. It's circular. I have a better, related question I will ask later.

There are more dangers of placebos. First take the case of BIO's (not so?) mythical doctor presented with someone with a mild viral cold who refuses to take "you don't need pills and none will help you" for an answer. Prescribing a placebo to make them go away happy reinforces the perception to not only them, but their family and friends that pills cure everything when they don't. So what if that patient doctor shops? That has the same strength of argument as "everyone else is doing it, why not me?". I think it is a good thing, not bad, if they doctor shop. If every other doctor says the same thing (i.e. that no pill will help your rhinovirus cold), that will either end the doctor shopping, or the cold will be over with by the time they get worn out.

As for the fibromialgia case, I prefer this question, "Provided that it could be proven that a placebo works better than no treatment, and as there is currently no known treatment for fibromialgia, would you prescribe a placebo knowing it may dissuade a patient from accepting a future proven treatment with uncomfortable side effects?
The real plus side to placebos is no side effects. Who wouldn't want to cure cancer with a sugar pill rather than those awful chemotherapies, radiations, surguries? This is where the placebo business really thrives, selling patients on a no-lose cure. "We don't know how it works, but many people find that it makes them feel better."

Indeed.

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Around these parts we call cucumber slices circle bites

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I'm not such a bad guy once you get to know me.

herb the verb's picture
Submitted by herb the verb on

Any doctor who doesn't have the strength of character to tell a patient they aren't getting useless drugs is not a doctor I want treating me. Any doctor who is in too much of a hurry and cares so little about their patients that they can't bother to take the time to educate them is not a doctor I want treating me. Any doctor who prescribes placebos because they "have seen them work" probably also believes in Magical Thinking and the great spaghetti monster's noodly appendage and I don't want them treating me (Think the Honorable Dr. John Cornyn, or Honorable Dr. Bill Frith). Any doctor who prescribes a placebo because they are too lazy to educate themselves on the ethics of the practice is not a doctor I want treating me. I could go on, especially regarding that sometimes it is also a good thing when patients doctor shop because they are doing something called "seeking a second opinion". This is a feature, not a bug of the current ethical practice of medicine. Prescribing a placebo ensures that a patient never seeks a second opinion. What if the placebo prescribing physician is wrong in their diagnosis? What if that patient has something serious (and treatable) wrong? It is possible that doctors are wrong occasionally, that is why second opinions are vital and a placebo short-circuits that process.

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Around these parts we call cucumber slices circle bites

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I'm not such a bad guy once you get to know me.

BoGardiner's picture
Submitted by BoGardiner on

Herb makes a crucial point:

[S]ometimes it is also a good thing when patients doctor shop because they are doing something called “seeking a second opinion”. This is a feature, not a bug of the current ethical practice of medicine. Prescribing a placebo ensures that a patient never seeks a second opinion. What if the placebo prescribing physician is wrong in their diagnosis? What if that patient has something serious (and treatable) wrong? It is possible that doctors are wrong occasionally, that is why second opinions are vital and a placebo short-circuits that process.

I've been in the scenario Herb describes several times, where stumped doctors proposed what I knew to be sham therapies, which I ignored and then got more useful second opinions. The dishonest, lazy ones impeded my healing. Those who aren't knowledgeable enough to do this should be able to trust in their doctor's respect for professional ethics codes.

May the FSM's noodly appendage touch and bless the fine, honest doctors I've known.

BoGardiner's picture
Submitted by BoGardiner on

I've seen the Denialism blog, whaleshaman -- it is a good one. Today he's urging people over to another great blog, a new discovery for me, NeuroLogica, to read a post by a long-time hero of mine, Dr. Steven Novella.

It's a huge topic:

The New Scientist has recently discovered what readers of this blog have known for a while - that the denial of materialist neuroscience is the “new creationism.”

I feel another post brewing...

bringiton's picture
Submitted by bringiton on

Possibly not the term you're looking for.

Second opinions are not only fine, but advisable in many cases. If there is uncertainty or conflicting advice as to the best course of treatment, a third would not be unjustified.

But for an uncomplicated rhinovirus or similar conditions? Either of you want to take a whack at what that would to to health care costs under single-pay UHC, not to mention the effect on wait times for more serious conditions?

There also seems to be a bit of confusion here on the makeup of the physician population. If half of the doctors out there are as Bo characterizes them frequently taking "lazy, lying shortcuts" then the unwitting patient has a chance of finding a not-lazy not-lying practitioner with the same odds as a coin-flip. At 50-50 the odds do not improve simply by tossing more coins, so how exactly does seeking a second opinion - granting these circumstances - ever help anyone? Which doctors are the lazy liars and which are not? Seeking multiple opinions is only of benefit if most doctors are competent and ethical; if it is true that half are not, then the typical uninformed patient might as well stick with whoever they get first.

For the hypothetical patient with a headcold I proposed, I'll tell you what happens. Refused treatment beyond palliation by Doctor #1, they run across the street to Doctor #2 who also tells them fluids, rest, antihistimines and analgesics but no to antibiotics. Convinced now that they are being mistreated by a conspiracy of white coats who simply do not understand, they go to Doctor #3 and so on. Eventually, over time, they will come under the "care" of someone unscrupulous, phsyician or otherwise, who will exploit their fixation and manipulate their misplaced trust. The patient will be happy, having found someone who "believes" them - read "Tells me what I want to hear" - and the practitioner will be happy having found someone to victimize with a plethora of sham treatments.

This scenario is not far-fetched, and while hypothetical it is certainly not mythical - happens all the time. Any general practitioner will deal with a dozen of these patients or more a week and the difficulty of the decision is never lessened. If they are refused - the patient's world view - they will likely go elsewhere with uncertain outcome. If they are palliated, given a placebo with no harm done, they may return and possibly over time they can be re-educated; think of it under basketball rules - No Harm, No Foul.

Some patients never will learn; they have settled into a mindset and nothing anyone can say or do will shake them from their convictions. The medical profession is about evenly divided on what to do about that. Some feel that it is always the right thing to refuse to employ a placebo, while an equal number believe that in some circumstances use of a placebo is the right thing to do for the overall benefit of the patient. "Ethics" being entirely situational, and in this circumstance a matter of personal choice rather than law, it would seem we have a draw. Having two conflicting opinions, rather a pity there is nowhere to go for a third.

If all patients were informed and open and desirous of full disclosure and detailed explanation, the practice of medicine would be much more straightforward than it is. Unfortunately, a great many patients come to consultation with an agenda, having already diagnosed themselves based on something they've seen on TV or read about or heard from Cousin Molly or their good buddy Fred, and have a treatment plan already mapped out. That would be a great time-saver if they were right, but they so seldom are.

These are the patients who will, in fact, "doctor shop" until they find someone who will tell them what they want to hear. There are a great many of them, they are driven by unshakeable conviction, and the ubiquitousness of television advertising and doctor shows is only making the frequency worse. I argue that for them a placebo treatment is not the worst possible outcome. If I were to have to choose, I would damn sure rather be treated by Dr. Welby than by Dr. House.

Bo, I am sorry to hear that you've had difficulty with incorrect treatment; medicine is still an art, and the number of puzzling diseases and conditions is growing rather than shrinking. If you are unlucky enough to have one of those sorts of problems, it may take a few tries to find someone who recognizes what's going on. That, I'm afraid, is just life as things are today and yes, I am only offering cold comfort; I wish there was more. Not wanting to get into either your details or mine, let me just say that I understand completely what it is like to have a difficult to diagnose disease and to live with one that has no known treatment. Not something for the faint of heart, and frustrating in the extreme. I wish you well.

One of the great benefits of true single-payer UHC will be the ability to set up decision-tree networks to help guide diagnosis and treatment. Today that happens informally, and a correct diagnosis may depend on your doctor first noticing you're unusual and accurate identification and treatment depending on who they know for referral. It is haphazard now, and we can do much better. Some of us who are concerned with government having too much information will have an interesting time balancing the pros and cons of that advancement.

Bo, about that "avarice" thing I keep bringing up. Perhaps I am being unfair or inaccurate, but these are the words that drew my attention - "an entire culture of health professionals unable to see an ethical breakdown in picking your pocket and earning their living by lying and defrauding you and your insurance company" - stated in bold, no less. Maybe you could suggest another term to use that covers such behavior, so we don't get bogged down by my word choices.

BoGardiner's picture
Submitted by BoGardiner on

Yes, you've done a good job pointing to potential advantages of a return to the Victorian, paternalistic Doctor Knows Best system. Each point deserves debate. And it's been done: the results are the recent international and longstanding US standards for professional medical ethics. These were borne of countless hours of debate by countless physicians, psychologists and philosophers. I believe the cons of ignoring these standards outweigh the pros.

As for the "avarice thing," mine were strong words indeed and I stand by them. The quote of mine you've italicized, actually doesn't speak to motives, only to actions and outcomes.

I carefully designed the three examples in my post to demonstrate my awareness of some of the nuanced motives that drive placabo-pushers. Yet whatever fine motives they convince themselves are behind their deception, my pocket has still been picked, and I and my insurance company have still been deceived.

Thanks for the sympathy, BIO. But my lot is incredibly fortunate compared to most, and my health is now great. Thanks to insurance, I was able to keep battling, until one by one found cures or good solutions for each issue. I hope you're able to do the same and wish you much luck. I came away with awe for medical science and its true practitioners -- they produce the closest to miracles we'll ever see. I support your desire to extend them to far more (Go HRC!)

bringiton's picture
Submitted by bringiton on

Now if we can just define each of them better....

The patient-doctor relationship is entirely transactional, not imposed; it is the patient who in almost all circumstances has choice and ultimate control whether they realize it or not, and the physician must be both an authority figure and a supplicant. Sounds all rather D/s I'll grant, but it is about human emotion and so there you go, similarities everywhere.

I don't see paternalism in this the same way you do; POV, perhaps. I've had the experience of meeting and working with and coming to know thousands of physicians and other clinicians over the years, all over the world, and by and large they are I think no different than any other human beings. The vast majority of them (MDs and RNs, to be sure) have good intent and in my view high integrity; they nearly all want to do right, even if they may sometimes be clumsy in the pursuit. The paternalism you describe is, in my view, artifact of the role of men in society in general and not specific to the healing arts. Those arts, on the other hand, require a certain distance be maintained between the participants that likely will continue even when gender equality is achieved. More than one thing is going on.

And more Edwardian rather than Victorian in tone, I should think; most physicians are well past the artifice of prudery. Please exercise a bit more precision when putting me down. One last link for now, if only to show that I am not alone.

BoGardiner's picture
Submitted by BoGardiner on

Your link provides an attempt very similar to that reported in the study to suggest some verbal contortions a doctor might go through to not TECHNICALLY lie, but as I said in my post, speak in such a veiled manner that the patient is deliberately misled. Lovely. She even admits that the less "astute" the patient, the greater the effect:

I think an astute patient presented with this statement could figure out that she was being offered a placebo.

Now that's progressive medicine, one that benefits most from ignorant, rather than educated, patients.

Sarah's picture
Submitted by Sarah on

the other night.

"Snake Oil" is not the same thing as placebo treatment.
Medications -- particularly in cases where a patient is taking more than 7 separate prescriptions -- are often NOT carefully screened by docs.
A doc who tells you "I'll put you on an antibiotic" isn't doing you any favors. You need to know WHICH one and what it's for (e.g. an antibiotic for a fungal infection will be pricier than an antifungal and may not work as well).

ALWAYS take a copy of your current dose of all meds -- including OTC remedies and vitamins and any natural/herbal supplements like Vit. E or saw palmetto -- with you when you go to the Dr. If you are given a prescription check that new drug with a registered pharmacist against your list of other meds to be sure there's no contraindications in the mix.

(E.G. certain antibiotics are defeated when your diet includes dairy products)


We can admit that we’re killers … but we’re not going to kill today. That’s all it takes! Knowing that we’re not going to kill today! ~ Captain James T. Kirk, Stardate 3193.0
1 John 4:18


We can admit that we’re killers … but we’re not going to kill today. That’s all it takes! ~ Captain James T. Kirk, Stardate 3193.0

1 John 4:18

BoGardiner's picture
Submitted by BoGardiner on

While the terms "snake oil" and placebo are not synonymous, as the former is commonly used they certainly share the concept of a medicine recommended to help someone by another who knows it is largely ineffective and makes deceptive claims about it.

Obviously this discussion does not include placebos given to patients in drug trials who are fully informed they may be receiving either a placebo or the drug being tested.

I'm unclear how the rest of your comment relates to the discussion.

Sarah's picture
Submitted by Sarah on

arising from the ordinary everyday lack of communication and/or comprehension inherent in the medical practice (and they call it PRACTICE for a reason).

I'm not so much on about the "cheating out of money" or the "useless prescriptions" aspect of this issue as I am about people being given the WRONG medicine, or the right medicine in the WRONG dose, or being afraid to seek a second opinion instead of taking the first practitioner's word as gospel.

You see it more in older people, yes. But the current financial situation makes it harder to get a second opinion (if you're able to afford the first one, or the co-pay).

Lots of flaws in the way medicine "works" in this country. Not all of them are based in greed or patriarchy, although admittedly those systemic problems play right into the mix to the detriment of all concerned.

The key to getting well is the same as the key to voting well -- KNOW what's going on. Pay attention. Talk. Listen.
Dr. Siefert went on for days about how hard it is to read the labels on prescriptions, and the directions. (Take a look at a magazine ad for something relatively benign like Claritin sometime. A picture, a couple dozen easily-readable words, maybe a catchy slogan. "Ask your doctor." Then six pages of four-point type with half-inch margins about what could go wrong.)


We can admit that we’re killers … but we’re not going to kill today. That’s all it takes! ~ Captain James T. Kirk, Stardate 3193.0

1 John 4:18