Ted Kaptchuk on the Placebo Effect | Harvard Medical School

[00:00:00][Music] the simple answer is that a placebo is a fake treatment a fake a sugar pill a saline injection or a fake dummy procedure surgery even uh that's used to control um an active intervention in a randomized control trial and you say a placebo effect is the effect that you see in a randomized control trial in the placebo arm that's probably accurate enough but actually that's not what I studying what I I think Placebo is a surrogate marker or a um it's not the sugar pill that does anything it's everything that envelops the sugar pill and the sugar pill is embedded in the provision of care it's study of placebo effects is what does the provision of care give patients if there's no active pharmacology or active procedures it's what does the ritual of medicine provide people and in a broad sense it's the doctor patient relationship it's the um it's compassion trust and hope it's all the things that we say are non-specific in Placebo studies we make them specific and say let's look at things in healthcare that are not just the drugs not just the procedures not just the surgery and uh that's what Placebo studies is Placebo studies is also means it's not it's not it's a it's a field it's a mer mergent field it's not many people do this um and it means and we use the word Placebo studies because we study the clinical phenomena what what does the ritual medicine do for people uh what is just taking care of someone do we study the scientific basic science questions what's the neurobiology what's the neuro circuitry of of of people getting benefits from the ritual of treatment we also study um the anthropology the sociology we study uh history study philosophic questions it's um we Define placebo studies as a multi-is disciplinary initiative and try to understand what usually is considered intangible in medicine to make it [Music] tangible well I you know we've done several studies we try to tease apart U what what the components of the placebo effect are but clearly they're things like uh in terms of the doctor patient relationship it's attentive listening repeating the words the patient has it's looking at the patient it's making connections expressing empathy uh feeling connected to the patient's um serious questions in their lives um it's um it's uh expressions of confidence knowledge all those things are it's touch it's also sometimes thoughtful silence I mean it's very hard to uh list a complete category of what the um what's the social context that's one level another level is going into a Sacred Space or special space that's different the hospital is different Clinic is different um it's a place that um where people go that are how do you say we're when we're sick we're not part of our normal world we get ostracized it's a special place to bring us back to our normal world uh it's it's a very complex social place it's a place that social context has profound impacts on people it's a place where you talk about things you might not tell your husband or wife it's a place where um no matter what you say you're usually treated with absolute respect hopefully and people um are there to help you uh it's it's a very charged place there are very few places that have as much um charge and persuasive forces as the clinical encounter I think we're in a obviously we're in a crisis place in healthcare in the United States and maybe all the Western World um and I think that all the medical schools I know Harvard Medical School uh also is trying to put humanism back into medicine there's um the new exams for medical students are going to uh next two years are going to switch to have more social science and psychology there is an attempt to I think I'm part of a wave of how do we humanize medicine how do we put the patient in the center of care I think historically it's really hard for uh medicine to put the patient in there in the center uh we think about medicine as a science and science puts numbers and X-rays and blood tests in the center but I think that uh tends to at least ideologically make that important part of what they do and I think um Placebo studies is a uh part of uh a trend a movement to put the patient in the center and not only are we dealing with um drugs and procedures we're also dealing with a human being that just being taken care of has a profound and dramatic potentially dramatic effect on how they experience themselves how they feel their symptoms how they feel the well-being in general um I would say the evidence suggests that placebos are for self-appraisal symptoms that have to do with chronic pain headache back pain um knee pain um osteoartic pain what um um migraine headaches the these are not inconsequential aspects of Health in fact that's what brings our patients to the uh the healthc care provider um I think the evidence that Placebo shrink tumors doesn't exist I think there's been an important study in the journal National Institute of of National Institute of uh National Cancer Institute 2003 that made it pretty clear they've never seen any tumors shrinking with Placebo controls um except it in situations where there'd be spontaneous remission anyways uh but does do does the of taking care of people reduce nausea reduce pain reduce fatigue um help alleviate anxiety and depression I think that the evidence suggests that's really there and is that important absolutely is it the only thing in healthcare no we need powerful drugs we need reliable procedures um but part of the transformation of medicine going on now in general is how do we humanize the situation of drugs where where where is the patient in all this and and my work is saying the patients in the middle of very compelling ritual a very compelling um social Dynamic and those Dynamics have consequences in terms of and some illnesses very big consequences like depression and chronic pain and some illnesses they deal with the complaints associated with dramatic illnesses like cancer ama's uh American Medical association's Council um Council what do you call it Council um has passed a resolution saying it's unethical to give placebos uh with deception uh to patients you it's obviously legal to do it in a randomized control trial you inform the person say you may get a placebo you may not you may get the active ingredient but deceit is considered unethical but in fact um it looks like uh one of my postdocs did a a a national survey and and uh was published in bmj in 2008 and 50% of a national survey of us Physicians reported using placebos in the last year that was much higher than we expected um and what it's most of those placebos were what we call impure placebos they weren't necessarily uh saline injections or sugar pills they were vitamins that had no effect on the illness that the physician probably we don't know why they did it we just didn't ask that question in the survey a physician gave them knowingly because we asked did you know this would have only a psychological benefit or what we call placebo effect and people said yes so the question is complex because historically from about 1772 that's the first example we have Physicians routinely gave patients in our culture placebos but they thought they had no effect um all the big hospitals in the Boston area had different kinds of sugar pills different kinds of color saline injections for injectables and people were routinely given placebos but they said it had no effect it was really to deal with malingerers and nuisances and get people out of your office uh they didn't talk about it much but it's called the pious fraud or the humble humbel what happens after World War II when people start doing randomized control trials and needing to talk about a placebo control is that P the medical community starts talking about something it calls a powerful Placebo but also is unethical to give people that that that um these things without informing the patient so it's a complicated thing I think in general um I would say it's unethical to use deception in any clinical encounter so I would say the ethical Norm is one that we should probably uphold which is uh deception is inappropriate [Music] behavior until very recently um the prevailing wisdom in health care has been that um if you give a person a placebo and tell them it's a sugar pill it won't make uh they won't they won't get a placebo effect um I had reasons to think that may not be true and because you know I do research I want my research to be relevant I want to make sure that it's going to contribute to improvements in healthcare so in uh 2010 only two years ago um I organized a clinical trial giving people Placebo pills uh in people with EOB bow syndrome which is a really difficult condition and I randomized half of them to receive Placebo pills and they were told it was Placebo the bottom said it was Placebo we explained to them it was Placebo um had to sign the informed consent and say it was Placebo and we gave them a rationale we said you know we don't we know that people get better with placebos but we don't know if they get better with placebos if they know but we think it works maybe like have lost dogs um if you give um when paav lost dogs hurt a bell they would salivate so we think that even if you don't believe it's going to work we think it might work and all we ask you is take two pills twice a day for the next few weeks and the other half of the people randomize to no treatment stay their regime the way constant so they had we had a comparison a small study and we got this very big placebo effect we have to replicate it we have to replicate it in other illnesses to find out if it's true but right now um the prevailing wisdom has been shaken it hasn't been overthrown and we would call that a study a small study a proof of concept so and part of the reason I did that study was um because I wanted to see is there a way of ethically harnessing placebos uh without deception what do you think was the mechanism that was at play in that study I think that you know if you if you keep singing a song um to yourself that of a certain kind you eventually Bec part of you and you know you go to hear music it becomes part of you you go to church synagogue mosque it becomes you know even if you don't believe it becomes part of you I think we were I think that our gastrointestinal doctor Dr limbo who's a great doctor when he gave that Placebo pill and said you're going to take it it might work let's see what happens they they they saw Dr limbo twice a day and um I think that this the repetition and the uh almost the craziness of it had a positive fact people were amazed and people say I can't believe it you know I'm getting better and uh so these people were going to the hospital to to get the pill and we follow them and and and uh I think the mechanism is very complex I think there probably many many mechanisms and I'm conjecturing we didn't do a mechanistic study I will do a mechanistic study we move forward with that kind of model um I conjecture it's related to repetition um a the combination of Hope and uncertainty and just and then people probably saying oh maybe I'm a little better and you know maybe and then they start focusing more on they're getting a little better selective attention um it's unclear for me what the mechanism was but I was really happy it was positive outcome because I would have hate to wasted all that time and got nothing but it was so but again I'm going saying that's actually not a very strong study yet