Placebo use among academic physicians in clinical practice

Placebos in Clinical Practice

REINFORCING MIND-BODY LINK

Medical dictionaries define placebo as a non-medication substance, prescribed or given to reinforce the patient's expectation to get well. Research on the effect of placebos is of great significance to healthcare professionals because of their widespread use. That widespread use draws from their effect in the improvement of a symptom or disease without specifically improving the condition under treatment. That effect, called the placebo effect, has been proven powerful and inherent in clinical work. Furthermore, the patient-practitioner relationship is an equally essential part of the psychosocial aspect of treatment. Within that context, the practitioner communicates information on recovery and wellness through words, gestures and behavior. In addition to previous studies on the wide acceptance and use of placebos, a more recent one revealed that 46% of academic physicians in the Chicago area used placebos in their everyday clinical practice. A high 96% of them believed in the therapeutic effect of placebos and the connection between the mind and the body.

No specific protocol governs the clinical use of placebos. The bioethical aspect of their use has also been questioned. Despite these issues, most academic physicians frequently use placebos in clinical practice out of a belief in their therapeutic effect and the mind-body connection.

Body

Research Findings

Placebos were already commonly used before the 19th century until displaced by modern medicine (Raz et al., 2008). Modern knowledge about the neural correlates of placebo mechanisms, however, restored the use of placebos. They soon gained popularity and hounded only by bioethical issues in evidence-based medicine. Nonetheless, some clinicians, mostly academic physicians, favor their relative usefulness and role in the body-mind connection. The worth of placebos may be questioned outside the realm of research but they are popularly used in clinical trials (Raz et al.).

Research itself provides evidence of the usefulness of placebos in clinical settings (Raz et al., 2008). A study of head nurses at a Connecticut health district said that they used placebos at that time or for the past six months at 44%. Another study conducted with house officers and registered nurses. The house officers said that 78% of respondent physicians ordered the use of placebos and 82% of the registered nurses administered them as painkillers. Doctors and nurses at the Victoria General Hospital in Canada said that 80% of the nurses administered placebos while on duty, 91% I the form of saline injections. Another research conducted with 263 respondents found that 68% administered placebos and only 12% within the previous year. A separate study among physicians and nurses in Israel showed that 53 out of the total of 89 respondents prescribed placebos. Of this total, 33 were prescribed to take once a month. And the most recent evidence comes from the study conducted with academic physicians in the Chicago area (Raz et al.).

Academic Doctors of Chicago

A survey of 231 physicians from the Internal Medicine Department of three medical schools in Chicago said that almost half of them at 45% use placebo in clinical practice.

(Sherman & Hickner, 2008). Their most common reason for the use is to calm the patient and to as a supplemental treatment. The responding physicians did not have a uniform explanation to the mechanism of action. About 96% of them believed in the probable psychological therapeutic effect of placebos on patients. Of this total, about 40% believed that create physiological benefits to cure or alleviate certain health conditions. Only 12% of those surveyed thought that its use in routine medical care should be categorically disallowed (Sherma & Hickner).

Findings of 8 earlier studies on hospital-based physicians and nurses revealed that 10 & and 80% of them, respectively, used placebos in their clinical practice (Sherma & Hickner, 2008). The use in two of the most recent studies showed that more than 50% of them used placebos. They considered the use ethical under certain circumstances. There have been concerns over informed consent and non-deceptive therapeutics in the use of placebos in medical practice. Other practitioners say the placebo effect may be pursued if there are no ethical questions. Scientists put placebos under a broad category of interventions, which affect and induce "psycho-biological functioning." Anthropologist Daniel Moerman perceived the placebo effect as a "meaning response." In his view, it encompassed the physiological and psychological effects of meaning in treatment. Goodwin and associates almost 3 decades ago reported on what the majority of academic physicians thought about placebos. They thought that these could determine the genuineness of a patient's symptoms. Large numbers of physicians believe that placebos have therapeutic effects. They help distinguish between psychogenic and merely organic symptoms. More and more physicians are taking the same position about placebos (Sherma & Hickner).

Nature and Mechanism

A placebo is an inactive substance that mimics regular medicine or treatment (ACS, 2012). It is given or prescribed to a person but he or she does not know it is not medicine. It may be a sugar pill, an injection, a liquid, a procedure or any other form of therapy. It does not directly affect the illness under treatment. It may not have direct biological effect on the illness or condition but, in out of 3 patients, they seem to assert the desired effect. An observed change in symptoms is termed as the placebo effect. This effect often lasts for a short while. In that duration, it seems to relate with the body's inherent capacity to briefly relieve pain or other symptoms. In other cases, however, it creates the opposite undesirable or worse symptoms, "side effects" collectively called nocebo effect. Headaches, nervousness, nausea and constipation are among these (ACS).

Placebo and nocebo effects are referred to together as expectation effects (ACS, 2012). Experts interpret this as the patient's experiencing what he or she expects. If he or she expects to be better, that will happen. But if he or she thinks the placebo is too strong, it may produce the undesired side effects. The placebo, in reality, does not cause these side effects directly. Rather, it is his or her belief in the placebo or the lack of it that changes his or her symptoms or perception of the symptoms. Incidental events or unrelated events may moreover be associated to the placebo by coincidence. A headache that follows the taking of a placebo may be construed by the patient as resulting from the placebo. The same goes if a good outcome occurs after taking the placebo. In other cases, a patient may actually experience the placebo effect without taking it in any form. It may occur in him or her by just visiting a doctor or doing something he or she believes in already. This unexplained type appears related to the patient's confidence or faith in something or someone (ACS).

Pure and Impure Placebos

Empirical studies on their current use in clinical practice remain inadequate ((Fassler et al., 2010). But the prevalent use of both types outside clinical trials is ample. Moreover, attitudes towards the use of placebos differ among practitioners and among patients. The use of pure placebos should be confined to exceptional situations on account of their deceptive nature. Practitioners will tend to continue using certain interventions considered impure placebos. They should be aware of the tendency to resorting to problematic options in settling dilemmas of uncertainty. These include perceived patient expectations of prescriptions, unjustified trust in the effectiveness of a particular intervention, and the use of a prescription as a substitute of time. Future research may add knowledge on the development of a more open, honest and effective patient-practitioner relationship (Frassler et al.).

Psychiatrists Favor

A review of attitudes and beliefs on placebos outside clinical research compared those of academic psychiatrists and those of physicians in other specialties in 17 Canadian medical schools (Raz et al., 2008). The anonymous survey was conducted with 600 respondents in these medical schools and 257 of them were psychiatrists. Results showed that psychiatrists prescribed much larger amounts of placebos than did the physicians in other specialties. About 20% of both psychiatrists and non-psychiatrists prescribed them. Only 2% of psychiatrists perceived placebos as possessing no clinical benefit. Of the total number of respondent-psychiatrists, 60% simply or strongly agreed that placebos have therapeutic effects. In comparison, fewer than 45% among other practitioners shared the same view. This means that psychiatrists, more than other physicians, attribute greater value to placebos in enhancing the mind-body link. They also relish more favorable attitudes and beliefs towards placebos (Raz et al.).

While most physicians agree to the beneficial effects of placebos, they do not as yet have a common description for these substances (Raz et al., 2008). Psychiatrists, more than non-psychiatrists do, view placebos as therapeutic. Thus, they prescribe or administer these in much larger sub-therapeutic doses of medication according to their belief in their efficacy. Prescribing unwarranted treatments can cause clinicians both legal and ethical troubles (Gianola, 2009). One situation, which leads to prescribing sub-therapeutic doses, is the practice of starting low and going slow on an ineffective dose. The physician actually intends to gradually increase the dose. But it is possible for the patient's symptoms to show improvement at a far below the accepted threshold. The other situation is where the physician continues to prescribe the low doses to a patient already on sub-therapeutic regimen, which seems to work in him or her (Gianola, Raz et al.).

No Place in Pain Management

The use of placebos in this case is considered sub-standard care (Arnstein et al., 2011). As such, it violates the patient's rights to proper assessment and appropriate treatment. Sub-standard care exposes healthcare providers and facilities to legal trouble. For almost two decades, the use of placebos in clinical practice has been denounced by professional organizations, federal practice guidelines, State boards of nursing, and civil courts. Despite this formal position, a large and still-growing number of healthcare providers regularly give or prescribe placeboes to relieve pain. Worse, some medical students are instructed that prescribing or administering placebos is clinically approved. Those who prescribe placebos may be doing so in the belief that these will improve symptoms of a given illness. But there are patients who receive placebos develop undesirable or even harmful effect after taking them. This nocebo effect ranges fro mild discomforts to fatal complications. The problem is that a patient's response cannot be reliably predicted. Some of those who prescribe believe that placebos will assess pain. But an alert and oriented patient, who can well understand the pain assessment scale and describe his or her own pain experience, is more reliable than an objective diagnostic study. Objective tests do not measure the activity of pain-signaling nerves or other inner factors, which influence the intensity and expression of pain. Giving or administering a placebo deceives the patient into determining his or her truthfulness is unprofessional and unethical. This activity will expose the nurse to legal complications and a loss of practice license (Arnstein et al.).

Consequences of Nocebo Effect

The range of consequences in the use of placebo includes nocebo effect; physical and mental problems connected to the still-unrelieved but severe pain; and the patient's loss of faith and trust in the healthcare team (Arnstein et al., 2011). The nurse or provider's reputation will suffer or result in lower patient satisfaction, liability, and loss of credentials, license or accreditation status (Arnstein et al.).

The Role of Placebos

They may work only for a while or thought to cure illness, but they do not (ACS, 2012). But placebos play a significant role in relieving symptoms that are more real to the patient. They do away with pain, anxiety and sleep troubles. Doctors in earlier years gave placebos to deal with the frustration and desperation of patients when nothing else could. Doctors in recent years admitted to doing the same to make patients feel better. When placebos clear up or improve symptoms, the patient is better able and willing to cooperate in his treatment and his chances of a cure improve (ACS).

Conclusion

For many years, many practitioners have used placebos to make patients feel better. Modern practitioners, especially academic physicians, continue to do so in their clinical practice despite bioethical questions posed against the use. They do so because of the belief in the mind-body connection in therapy and the unique role of placebos in it. #