MEDICAL MATTERS:Longer consultations give patients a better outcome, writes MUIRIS HOUSTON.
"A miracle is an event that creates faith" -George Bernard Shaw
THE WORD placebo comes from the Latin meaning "I shall please". The first words of a prayer for the dead are "Placebo Domino - I shall please the Lord". By the early 19th century, placebo had acquired its modern medical meaning as something "given more to please than benefit the patient".
But the placebo effect is more complex than giving a sham treatment to patients. Nor is it necessary to give a tablet or injection to produce a placebo effect. A recent study even showed the price of treatment influenced a drug's effectiveness. Published in the Journal of the American Medical Association(JAMA), the study tested pain relief in a group of people who were told they were receiving a brand new form of codeine.
In fact they were given a placebo; some 85 per cent of those who were told the drug cost $2.50 (€1.58) reported pain relief whereas 61 per cent of those told the cost of the drug was 10 cents said it was effective. When the price of the placebo was reduced, so was the pain relief.
I have written before of my personal experience of and belief in the "doctor as drug". Earlier this month, a groundbreaking paper in the British Medical Journal(BMJ) rather elegantly demonstrated different components of the placebo effect.
In some 262 adults with irritable bowel syndrome, the researchers from Harvard University looked at the effects of placebo acupuncture in three different circumstances. One group of patients were placed on a waiting list and simply observed; another cohort received "sham" acupuncture alone; and a third group received the "sham" acupuncture as well as 45 minutes of "quality time" with the doctor.
Some 3 per cent of the observation group reported a significant improvement in their symptoms, while 20 per cent who got sham acupuncture alone said they benefited. But four in 10 of those given both sham acupuncture and an extended patient-focused consultation reported the greatest relief of symptoms.
The doctors in this group inquired about the patients' symptoms and their beliefs about them. They were asked to be "warm and friendly", show empathy and communicate their positive expectations about the proposed treatment to the patient.
The doctors in the brief sham acupuncture group told patients they had been asked not to talk about the experiment. The idea in this group was to try to replicate a medical consultation carried out under strict time limitations.
The fact that the extended consultation approach provided the greatest improvement in irritable bowel symptoms raises some interesting questions. Has the reduced time that doctors are able to spend with patients resulted in poorer outcomes?
Does an over-reliance on the prescription pad and a culture of "a pill for every ill" reduce the likelihood of a person getting better?
Patients may well respond better to both real and placebo treatments if they are associated with a good doctor-
patient relationship that deepened the consultation experience for both parties.
Certainly, in the case of chronic and disabling conditions such as irritable bowel syndrome, a deeper and more meaningful engagement by the doctor produces better results. People with symptoms that affect their quality of life want to be able to tell their stories in a way that reflects their personal suffering.
Allowing them the time to reshape their narrative clearly adds to the benefits of pills and other medical interventions.
There is a place for a different style of medical practice. If I require emergency surgery, I want a calm but decisive surgeon who weighs up the situation quickly and accurately before bringing me to the operating theatre without delay. I don't want a long chat about how I am feeling; a forthright discussion of what he plans to do and some indication of my chances of recovery will do fine.
Back in 1985, The Lancetstressed the importance of doctors as human placebos: "The doctor who fails to have a placebo effect on his patients should be a pathologist . . . In simple English, if the patient does not feel better for your consultation, you are in the wrong game."
But clearly doctors need time to exert a placebo effect: now that we have firm evidence for this, how long will we have to wait for the health system to facilitate longer consultations with patients? Despite the potential economic benefits it is almost certainly a case of don't hold your breath.
Dr Houston is pleased to hear from readers by e-mail at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries