Monday, October 27, 2008

I Will Please (or Not)

I thought I'd weigh in on the doctors-prescribing-placebos story that caused some media stir at the end of last week. While some might view this issue as yet more evidence of the conspiratorial perfidy of the medical profession, I find it a fascinating window onto the dynamics of the clinical encounter, based on converging expectations of both physician and patient. It does, granted, reflect the persistent ethical naivete of doctors as well as an attitude carried over from a millenia-old tradition of paternalism.

The phenomenon is most relevant to the vast and--somewhat like the deep ocean, insufficiently explored--symptom pool of vague and recalcitrant complaints, unassignable to definite diagnosis, that constitutes much of primary care. No, I do not do primary care, but I live in close domestic proximity to an ER physician, and a good deal of ER practice these days is de facto primary care.

As the linked article implies, doctors are not generally prescribing true placebos, i.e. substances known to have no therapeutic activity such as sugar pills or IV saline solution. Rather, they are offering drugs, ranging from vitamins to antibiotics, that they themselves are skeptical will have a direct physiological (as opposed to psychological) effect.

I'm guessing that these interventions are not being made for clear-cut diagnoses with clearly indicated treatments, but rather for amorphous and mercurial syndromes for which no definitive clinical path is clear. If you're hopelessly lost in the woods and feel that you have nothing to guide you--no cell phone, no compass, no stars even--then you feel a need to pick some direction and start walking. Just step carefully and make sure you watch out for cliffs.

At some point in this age of technological overstretch, someone came up with the medical saying "Don't just do something, stand there." That is, sometimes inaction--watchful waiting--really is the best strategy. But it is one thing to do this in risky, high-tech, and acute situations and quite another to do it with chronic relapsing conditions in which people keep coming back again and again in search of relief. Paradoxically, "There is nothing more I can do for you" may be easier to say in cases of terminal illness than in cases of fibromyalgia, chronic back pain, or other long-term afflictions. In some particularly tough cases doctors desperately want to do something, and patients desperately want to get something, such that these expectations are mutually reinforcing.

I think there is no excuse for using non-indicated drugs that could have significant side effects, including antibiotics which could increase bacterial resistance in general. But consider the speculative case of a doctor prescribing a multivitamin for, say, chronic pain or fatigue. If pressed on whether the pill specifically targets the pathophysiology in question he would have to say, "I don't know" (if only because in many of these conditions the pathophysiology isn't really known). But he could honestly say that the pill has been helpful for others he has given it to (if only due to the placebo effect, a classic and potentially virtuous case of the self-fulfilling prophecy), and he could honestly say that a vitamin could decrease pain or fatigue by virtue of its overall effects on health or the immune system.

As some have mentioned, this practice, even when it does not (as in the case of multivitamins) involve significant side effects, does promote the general "pill culture" as a response to distress. But in this many bear culpability: doctors, patients, drug companies, marketers, the list goes on. Doctors need to be much more willing in general to say, "I don't know."

I don't know that this placebo trend has a counterpart in psychiatry, although it might if one includes it in the general category of the longshot. That is, with particularly chronic and refractory cases, I think a psychiatrist will sometimes resort to psychotropic medications that are not inappropriate, per se, but that he deep down has little confidence in, particularly in the difficult case in question. The side effects of this type of drug are generally quite minor, and seem a small price to pay to keep hope of relief alive. And the latter is not impossible--as with all hail Mary passes, "miracles" can happen.

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