Some may remember that I posted a piece called “Thinking about placebos and healing”. I thought it was just a few months ago, but it was actually in November 2018. It was stimulated by my surprise and confusion about the fact that most patients undergoing sham procedures in my EPISOD research study did remarkably well, indeed as well or even better than those who had the active treatment. How could that be?
The use of placebos/sham treatments in research studies is of course designed to see if the “real” treatment works better, with the assumption (at least by me) that placebos have little or no intrinsic therapeutic value. The falsity of that assumption and the extent of my prior ignorance was revealed and partially resolved by the writings of Dr Wayne Jonas (https://drwaynejonas.com/), including his excellent readable book “How Healing Works”.
I now organize the weekly academic lectures for the GI Division at the Medical University and was able to invite Dr Jonas to speak (virtually) last week. He carefully reviewed the scientific data on the how placebos can actually produce positive effects, and to explore the evidence about the many elements that make an effect more or less likely. An obvious one for sham pills is their appearance: red pills work better than white ones. But there are so many more factors. A very important caveat is that placebos seem to work to alleviate symptoms such as pain and nausea, but rarely change the course of diseases.
Maybe you were wondering how, when and why this relates to “worse than cats”? I will explain.
My family doctor Dad saw patients in a room in our house, called his “surgery” (as doctor’s offices in England were and are called for some odd reason; little surgery was performed). We also had a small room next to Dad’s office where a live-in young pharmacist called “Ballard” dispensed the few medicines that then existed. Her name was Miss I M Ballard. I never knew what I or M stood for. She was always called Ballard, in the same way that the woman from the village who looked after me when I was young (Mrs Pitt) was called just “Pitt”.
Students of history and Downton Abbey will know that staff “Downstairs” in earlier days were always called by their surnames (or even the surnames of their masters). Curious that now, at least where we live, we usually address people providing services by their first names, while expecting them to call us Mr (or Dr). All rather odd, and interesting.
Now for the cats part, which brings me back to Ballard. As a 5 or 6 year old, I used to stand on a chair in her “dispensary”, and watch her mix “tonics”. Not sure what else she had under her control. The tonics were mixtures of colorful liquids in the pretty containers that you now see in museums.
She would add a little of this to a little of that, but always a good dollup of the green liquid that she called “worse than cats” because it smelled really bad. Ballard must have had a traumatic cat experience to make that connection. My esteemed elder siblings may be able to add details.
That (at last) brings us back to the things that make placebos effective. Ballard said that tonics worked better if they tasted and smelled bad. Tarrah!
I am sure Wayne would agree with Ballard, but his main message, which I regurgitated in my prior blog, is that the effectiveness of sham treatments (of all sorts) is affected to a great extent by the context. Who gives it, in what environment and with what explanation and enthusiasm. The power of those aspects is illustrated by the fact that placebo pills were effective in one research study even when actually labelled as such! Note that the word placebo derives from the Latin “I shall be pleasing”.
Circling back to the science of sham-controlled studies. The whole reason to include a sham treatment is to find out (and thereby eliminate) the effects of all the factors (context, enthusiasm, belief, expectation) associated with giving the treatments. I had assumed that those effects were usually small. Wrong, wrong. They can be huge, indeed much of the world of “alternative medicine” depends on them. Plausible claims by impressive people are easily accepted, especially by those unsatisfied by traditional approaches. And why not, if not dangerous? There were many refill requests for Ballard’s tonics. Or, should there always be some evidence of “real” benefit of a proposed treatment before pulling out the promo guns? That is a big ethical question beyond my competence to discuss. And, now I’m confused again. What is “real”?
I have nothing against cats, honest
All part of life’s rich tapestry