In the second week of March a bout of the flu left me with a cough that simply wouldn't go away. I was miserable. Not only was speaking difficult—I would start hacking in mid-sentence—but the cough woke me up throughout the night, ruining my sleep. I tried the cough syrup in my medicine cabinet, but it didn't help. As the cough persisted into the first weeks of April, the uncertainty as to how long it would last added to my misery.
Finally, discouraged and now a little worried, I called my internist. And as soon as I picked up the phone, I began to feel better. My internist—I'll call him Dr. Stevens—was, as usual, thorough, upbeat, and authoritative. After asking about my symptoms, Dr. Stevens told me that persistent coughing was common following the recent flu strain and that in most cases it gradually cleared within six weeks. He prescribed a cough suppressant, told me I should feel much better within a week, and added that if I didn't I should call him back.
When I put down the phone, my cough was not yet better, but I was. Relief was a possibility; for the first time in a month I was in charge of my cough, not the other way around. For the rest of the day the cough seemed less troublesome, even though I probably coughed as often as I had for the past few weeks. Certainly I brooded about it less. That night I slept better than I had in a month. Within three days the cough was barely noticeable, and in a week it was gone.
I don't know if the suppressant helped heal my cough or if the cough would have healed just as quickly on its own. But as a psychiatrist, I do know that the mere fact of seeking and receiving medical care—the "treatment situation"—made me feel better: less disabled, less distressed, more hopeful.
The benefit I received from the treatment situation is called, often derisively, a placebo effect. Although the placebo effect is frequently disparaged by doctors, it is a powerful part of healing. In fact, the history of medicine is largely the history of placebos. When subjected to scientific scrutiny, the overwhelming majority of treatments, old and new, turn out to derive their benefits from the placebo effect.
It is easy for us to accept that the treatments of antiquity—potions, brews, and incantations—did not provide the benefits attributed to them. After all, truly effective treatments were in short supply; the healers of the past cannot be faulted for offering something they and their patients believed might be helpful. But it is less widely acknowledged that much of today's medicine—the treatments offered in technologically sophisticated hospitals and doctor's offices—continues to be an amalgam of faith, magic, and ritual. Yes, medical treatment is more scientific today. New treatments often undergo rigorous testing to prove their effectiveness. And both the healing professions and managed care providers are demanding that treatment be based on evidence. Even so, some experts estimate that as few as 20 percent of the treatments routinely used by physicians today have actually been proven effective in careful studies. Doctors and their patients continue to ascribe healing powers to pills, psychotherapies, and surgical procedures that may be essentially inert.
It isn't that these treatments don't work; most do. Patients benefit from them. The catch is, like most treatments of the past, the treatment itself is of no particular value. The healing comes from the placebo effect.
Unfortunately, placebos are all too often ignored by the healing professions. I say unfortunately because the placebo effect—a more accurate (though unwieldy) term is "response to the treatment situation"—contributes to the benefit of every treatment. And often it is the only benefit. But as you'll see, savvy patients can take steps to ensure that their doctor takes advantage of this remarkably effective healing tool.
Pills Are Just The Beginning
But what exactly are placebos? When many people hear the term, they think of a sugar pill, a pharmacologically inactive capsule. More broadly, though, a placebo can be thought of as those components of medical care that have no intrinsic therapeutic value for the condition being treated but that nonetheless make people feel better. This might include the act of getting a medical exam, receiving a diagnosis or an explanation for one's symptoms, being given a plausible treatment, and leaving the office expecting to feel better. Depending on a doctor's personal style, the treatment situation may also include the healer's enthusiasm and commitment, an opportunity for the patient to talk about the illness, and any encouragement and attention the patient receives. The placebo effect is simply the improvement that occurs as a result of these components of care.
Placebo treatment can be extraordinarily effective. For example, in the late 1950s thousands of patients with angina pectoris—chest pain caused by insufficient blood supply to the heart—underwent internal mammary artery ligation, a surgical procedure believed to increase the heart's blood supply. The results were impressive: As many as 90 percent of patients enjoyed relief from their symptoms. But some cardiac surgeons were skeptical and decided to take a closer look. As an experiment, they did internal mammary artery ligation in one group of patients and in another group performed a "sham" operation—they made a chest incision but did no further surgery. With the artery surgery 76 percent of patients improved; with the sham (placebo) surgery 100 percent improved. Internal mammary artery ligation turned out to be merely a rather effective placebo.
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