July 13, 2011 -- Caring may count as much as medicine when it comes to making a sick person feel better -- even when that person really needs the medicine, a new study suggests.
The placebo effect is a well-known phenomenon in which people get better when given a fake (placebo) treatment. It sometimes works even when people aren't fooled -- when they know they're getting a sugar pill instead of a drug.
Now a study suggests that placebos can be effective in reducing symptoms in patients with asthma. The caring that comes with treatment -- even fake treatment -- is just as important, find Ted J. Kaptchuk, associate professor of medicine at Harvard Medical School, and colleagues.
"Our data give a realistic and overall optimistic perspective on the importance of understanding that the doctor-patient relationship and caring is as critical a component of medicine as the medical procedure," Kaptchuk tells WebMD.
Real Treatment vs. Placebo
In the study, 39 asthma patients stopped taking their asthma drugs and then underwent three rounds of treatment, in random order, with four different regimens:
- Active treatment with an albuterol inhaler (albuterol brand names include Accuneb, Proair, Proventil, and Ventolin)
- Placebo treatment with an inhaler that had no active drug
- Placebo treatment with "fake" acupuncture (using a device that seems to puncture the skin but does not)
- No treatment
In all four treatment regimens, patients had their lung function tested every 20 minutes for two hours.
As expected, treatment with the real albuterol inhaler improved the asthma patients' lung function by 20% -- a clinically significant effect, according to study researcher Michael E. Wechsler, MD, associate director of the asthma research center at Brigham and Women's Hospital, Boston.
Patients' lung function also got a little bit better with placebo -- about 7% better. But those getting no treatment also got 7% better. Clearly, as far as lung function was concerned, there was no placebo effect.
But when asked how much better they felt after treatment, patients said they felt 46% better after fake acupuncture and 45% better after fake inhaler treatment -- just about even with the 50% better after getting the real asthma drug. With no treatment, they felt only 21% better.
Disease vs. Illness
What's going on? Kaptchuk says there are two aspects to being unwell: disease and illness.
"Disease is what doctors search for -- the underlying physical thing they can detect with labs and imaging and can express in hard numbers," he says. "Illness is what a patient experiences. A lot of times these two things are not congruent. ...There is a difference between what doctors find and what patients experience."
What the asthma study demonstrates is that making patients better requires treating illness as well as treating disease.
"Our goal as asthma doctors is really to try to take care of the underlying problem, which is why we give the medicines we do," Wechsler tells WebMD. "But with this study we saw that part of taking care of the discomfort patient experience is being there for them. There is definitely some mind-body interaction in asthma that relates to the shortness of breath that patients feel."
Franklin G. Miller, PhD, a placebo-effect expert at the National Institutes of Health, says that the study adds to previous research showing that objective medical outcomes (in this case, lung function) are not the same as patients' subjective medical outcomes (feeling less shortness of breath).
"In the ideology of medicine, objective outcomes are seen as real and subjective outcomes are seen as not real or clinically meaningful -- and that is a mistake," Miller, who was not involved in the study, tells WebMD. "A very basic goal of medicine is relief of suffering. And suffering is subjective. I am the only one who can say I am in pain or distress. So to wash that away as merely subjective is counter to one of the real goals of medicine."
On the other hand, Miller notes, drug treatment really did make patients' lungs work better. Without drug treatment, many if not all of these patients would have had a preventable asthma attack -- no matter how much better fake treatment made them feel.
The balance, Wechsler says, is to give asthma patients both medical treatment and medical care.
"I counsel other asthma doctors to interact as much as they can with their patients," he says. "We tend to interact only during doctor visits, but certainly patients experience symptoms between visits. Perhaps some interactions by phone and by email can allay some of these symptoms."
The message from this and earlier placebo studies, Kaptchuk says, is that placebos work because of the way they are provided.
"It is the care, the ritual, the interaction, that can actually change the way people feel about their disease," he says. "We give empathy and warmth. We offer a little confidence, a little hope, a little attentive listening. We give some kind of clear statement that the doctor is in this with you, not just, 'I am going to try,' but 'I am really in your camp and am going to do everything possible to make this work.'"
One significant thing about the current study, Miller notes, is that it appears in the New England Journal of Medicine. He says this means that placebo research has moved from the fringes to the center of medical research.