What I wish conventional medicine would come to see and embrace is that the mechanism of placebo is in effect 100% of the time, which is to say that regardless of the context, our beliefs - the neurological processes that interact with our cognitive perceptions - ALWAYS contribute to our health outcomes. Conventional medicine biases toward discoveries of innovative substances, but the bigger magic - by far - is the complex ability of a human body to create the chains of chemical events it needs to reach homeostasis. We should be harnessing that more. Many forms of alternative healthcare do.
The problem, I think, is that the only way to get at the pure material effectiveness, you have to limit “emergent” effects, both in interacting with the active ingredient, and also overall.
Meaning, doctors will always be faith healers, but their ability to heal is relatively weak and controlled for, with “bedside manner” and “warm” a very limp gesture in that direction.
Great point. Why is it that Western (pharmaceutical), or conventional medicine focuses so stubbornly on "pure material effectiveness"? Medicine has approached man as a holistic being for much of history, until now. Surely, this will pass and a more nuanced approach replace the pharmaceutical system.
Interesting that the placebo effect has gotten stronger over time. I wonder if that is because faith in science and medicine got stronger. If so, it would be interesting to see if there’s a drop-off after 2020 and the war on science.
There ia still the question of why the placebo effect change is less in other countries , and many EU countries and Oceania are more highly educated and probably have greater trust in science than the US
It does not surprise me that the placebo effect got stronger in the U.S. in recent years. After all, by 2016, nearly half of the voters were ready to elect a cult leader. Quack “treatments” like essential oils also nowhere sell as good as in the U.S., especially to the victims and perpetrators of home-schooling, and to Young Earth Creationists. Critical thinking is condemned from the pulpits of so many fundamentalist churches every week. Science is condemned as a “religion” (funny how preachers use that word to denote something bad), which leads good Christians astray. Even the use of the word “faith” in connection with science shows part of that problem. Science is not based on faith, it works even if you do not believe in it. In European countries, people usually trust in science, but they do not see it as just another belief system to be taken on faith.
I have participated in two drug studies in my lifetime: One was conducted by a large university (I was in college and needed the extra cash) and one was proposed by my doctor (a drug that was suppose to reduce my triglycerides). Given how the perception of the doctor's competence influences the placebo effect, it would be interesting to see if there were differences in effect sizes between those who are recruited to participate vs. those who participate as a result of a doctor's recommendation.
Very interesting article. I think the author didn't take this one step further and say that the mind actually is a powerful weapon in dealing with disease. If the placebo effect can actually be greater than the drug effect, perhaps instead of treating ailments the first thing we should do is have patients sit with a psychiatrist to help them mentally. Seems like disease certainly impacts people who are depressed more frequently than those in a good state of mind.
Solution: everyone should do yoga prior to seeing a doctor for a problem?
I completely agree with the link between the mind and the body. I also agree that working with our minds is essential to overall well being. We also have moved away from trusting our bodies’ ability to heal. However your closing question has me astounded, yoga? What do you mean by ‘do yoga’ before seeing a doctor?
There's an excellent explanation for why these gimmicks mostly work. Begin with the work of Moshe Feldenkrais (Awareness Through Movement) and the conscious activation of segments of the body. Because bringing the devices near to the pain, attention to the location excites an increased blood flow in the area. That brings fresh circulation and blood cells that relieve stress or carry away what ever might be causing the pain. More could be said about how this works and has been but is too much for a comment here. The placebo effect really works and why is only now showing up. In many cases it might be stronger than modern medicine. It can be supported with new but sound science.
Is there evidence supporting that the placebo effect is caused, even in part, by direct physiological effects of the inert substance being introduced to the body? If not, how could the means of ingestion have a direct effect, as suggested in this piece?
Far more likely is that the underlying differences in the nature and length of the patient’s interaction with the caregiver associated with each delivery method is another example of a point the article more persuasively makes: that the extent to which the patient feels genuinely cared for in the process is strongly correlated with the magnitude of the effect.
This is also why it’s reasonable in double-blind trials to assume the magnitude of the placebo effect is the same for both groups. What’s not well known is how to determine whether a given drug’s effects are absolute - independent of caregiver interaction - or incremental to any effects of it.
One interesting study was done at the University of Toronto, many decades ago, where my father was a professor of medicine. Somebody put up signs looking for volunteers for a study to test the effectiveness of ingesting something odd -- I think bee jelly -- in promoting healing of wounds. So they would give you a small wound and measure how quickly it healed.
My father and many of his friends were really annoyed by the idea of the study. They predicted that any positive result found would be entirely due to the placebo effect, and that the study would only encourage people to waste money on expensive useless quack remedies. So they decided to all enroll in the study, 'to balance against the credulous'. Ha! This is precisely what the researchers wanted, which is why they recruited in the medical building. Through some questionaires they identified a cohort who strongly didn't believe in the healing power of bee jelly. And then they ran their real experiment, which didn't use any bee jelly at all. Nothing but placebos here. The real experiment was to see if the placebo effect worked on people who didn't believe in the therapy.
And the interesting result was that it _did_ have a statistically significant effect. No matter how much the conscious mind might decry quack medicine .... in many people, the unconscious mind lapped it all up and the placebo promoted healing. Which annoyed certain people even more when they discovered that it worked for them. :)
I suspect if we understood how hypnosis worked better we might understand more about how the placebo effect does its stuff.
Great article! So many interesting implications here.
When it comes to testing pain relievers, ideally there would be an objective way to measure pain. (The scale of smiley-frowny faces has always struck me as the most childish thing in medicine.) This 2022 study from UC Boulder suggests that might actually be possible. https://www.nejm.org/doi/full/10.1056/nejmoa1204471
Granted, we can't run thousands of patients thru an MRI machines on a frequent basis AND that this study only focused on heat as a pain source, but at least it suggests there are objective markers which could counter "placebo creep".
Oct 7, 2023·edited Oct 7, 2023Liked by Seeds of Science
Fascinating article. Do I take it then that people are today more gullible / persuadable? This would align with a few other studies about human behavior that are not medical related. The belief that just because someone is in a perceived "better/higher" position than we are that they are to be wholly trusted is apparently much more true today.
Along with the term placebo there is also a term called “nocebo”. If I say something will have negative side effects, you will start to exhibit those negative side effects, but in reality all I gave you was a sugar pill and there should be 0 side effects. We tend to gravitate towards expectations from what we have seen and read about a particular subject. An interesting topic is the whole CBD cream. I’m sure everyone has heard of it and its effects of helping joints, muscles, pains and aches. However, the over the counter active ingredient in these CBD creams is no where near the actual therapeutic effect it needs to cause a physiological change. So when people buy these creams they have these expectations of something working when in reality all they are experiencing is a placebo
I've long played around the with idea of starting a supplement company that would ethically sell placebos to its customers. Our marketing would make this very clear, customers could get their money back immediately if they suspected they received a placebo. And our prices would be half that of our competition.
The graph labelled “Interaction Effect between Expectations and Physician Characteristics” is a typical example of how to lie with graphs. The y-axis does not start at zero, but at four millimetres, wildly exaggerating the impact of the physician’s characteristics on the size of the wheal. Please watch out for things like that!
There are many and huge factors when it comes to placebo effect. Check out the story of the guy who runs the placebo branch in the NIH. His interest started when he studied Chinese herb medicine and found and was told that patients need to feel better before they leave the office!
In the histamine study above, you and researchers ignore the more important nocebo effects of negative expectations causing consistently higher reactions. I’m not sure the differences are significantly different in the positive/competent components. The difference between 4.3 and 5 mm is quite small and I would challenge you to measure accurately on a skin reaction. Cheers!
Interesting article.
What I wish conventional medicine would come to see and embrace is that the mechanism of placebo is in effect 100% of the time, which is to say that regardless of the context, our beliefs - the neurological processes that interact with our cognitive perceptions - ALWAYS contribute to our health outcomes. Conventional medicine biases toward discoveries of innovative substances, but the bigger magic - by far - is the complex ability of a human body to create the chains of chemical events it needs to reach homeostasis. We should be harnessing that more. Many forms of alternative healthcare do.
Love this comment.
The problem, I think, is that the only way to get at the pure material effectiveness, you have to limit “emergent” effects, both in interacting with the active ingredient, and also overall.
Meaning, doctors will always be faith healers, but their ability to heal is relatively weak and controlled for, with “bedside manner” and “warm” a very limp gesture in that direction.
Very interesting problem.
Great point. Why is it that Western (pharmaceutical), or conventional medicine focuses so stubbornly on "pure material effectiveness"? Medicine has approached man as a holistic being for much of history, until now. Surely, this will pass and a more nuanced approach replace the pharmaceutical system.
Interesting that the placebo effect has gotten stronger over time. I wonder if that is because faith in science and medicine got stronger. If so, it would be interesting to see if there’s a drop-off after 2020 and the war on science.
Hi Matt
There ia still the question of why the placebo effect change is less in other countries , and many EU countries and Oceania are more highly educated and probably have greater trust in science than the US
It does not surprise me that the placebo effect got stronger in the U.S. in recent years. After all, by 2016, nearly half of the voters were ready to elect a cult leader. Quack “treatments” like essential oils also nowhere sell as good as in the U.S., especially to the victims and perpetrators of home-schooling, and to Young Earth Creationists. Critical thinking is condemned from the pulpits of so many fundamentalist churches every week. Science is condemned as a “religion” (funny how preachers use that word to denote something bad), which leads good Christians astray. Even the use of the word “faith” in connection with science shows part of that problem. Science is not based on faith, it works even if you do not believe in it. In European countries, people usually trust in science, but they do not see it as just another belief system to be taken on faith.
I have participated in two drug studies in my lifetime: One was conducted by a large university (I was in college and needed the extra cash) and one was proposed by my doctor (a drug that was suppose to reduce my triglycerides). Given how the perception of the doctor's competence influences the placebo effect, it would be interesting to see if there were differences in effect sizes between those who are recruited to participate vs. those who participate as a result of a doctor's recommendation.
Very interesting article. I think the author didn't take this one step further and say that the mind actually is a powerful weapon in dealing with disease. If the placebo effect can actually be greater than the drug effect, perhaps instead of treating ailments the first thing we should do is have patients sit with a psychiatrist to help them mentally. Seems like disease certainly impacts people who are depressed more frequently than those in a good state of mind.
Solution: everyone should do yoga prior to seeing a doctor for a problem?
I completely agree with the link between the mind and the body. I also agree that working with our minds is essential to overall well being. We also have moved away from trusting our bodies’ ability to heal. However your closing question has me astounded, yoga? What do you mean by ‘do yoga’ before seeing a doctor?
Very nice summary. Thanks!
Nice short though piece. Fascinating subject. Thank you.
There's an excellent explanation for why these gimmicks mostly work. Begin with the work of Moshe Feldenkrais (Awareness Through Movement) and the conscious activation of segments of the body. Because bringing the devices near to the pain, attention to the location excites an increased blood flow in the area. That brings fresh circulation and blood cells that relieve stress or carry away what ever might be causing the pain. More could be said about how this works and has been but is too much for a comment here. The placebo effect really works and why is only now showing up. In many cases it might be stronger than modern medicine. It can be supported with new but sound science.
Is there evidence supporting that the placebo effect is caused, even in part, by direct physiological effects of the inert substance being introduced to the body? If not, how could the means of ingestion have a direct effect, as suggested in this piece?
Far more likely is that the underlying differences in the nature and length of the patient’s interaction with the caregiver associated with each delivery method is another example of a point the article more persuasively makes: that the extent to which the patient feels genuinely cared for in the process is strongly correlated with the magnitude of the effect.
This is also why it’s reasonable in double-blind trials to assume the magnitude of the placebo effect is the same for both groups. What’s not well known is how to determine whether a given drug’s effects are absolute - independent of caregiver interaction - or incremental to any effects of it.
One interesting study was done at the University of Toronto, many decades ago, where my father was a professor of medicine. Somebody put up signs looking for volunteers for a study to test the effectiveness of ingesting something odd -- I think bee jelly -- in promoting healing of wounds. So they would give you a small wound and measure how quickly it healed.
My father and many of his friends were really annoyed by the idea of the study. They predicted that any positive result found would be entirely due to the placebo effect, and that the study would only encourage people to waste money on expensive useless quack remedies. So they decided to all enroll in the study, 'to balance against the credulous'. Ha! This is precisely what the researchers wanted, which is why they recruited in the medical building. Through some questionaires they identified a cohort who strongly didn't believe in the healing power of bee jelly. And then they ran their real experiment, which didn't use any bee jelly at all. Nothing but placebos here. The real experiment was to see if the placebo effect worked on people who didn't believe in the therapy.
And the interesting result was that it _did_ have a statistically significant effect. No matter how much the conscious mind might decry quack medicine .... in many people, the unconscious mind lapped it all up and the placebo promoted healing. Which annoyed certain people even more when they discovered that it worked for them. :)
I suspect if we understood how hypnosis worked better we might understand more about how the placebo effect does its stuff.
Great article! So many interesting implications here.
When it comes to testing pain relievers, ideally there would be an objective way to measure pain. (The scale of smiley-frowny faces has always struck me as the most childish thing in medicine.) This 2022 study from UC Boulder suggests that might actually be possible. https://www.nejm.org/doi/full/10.1056/nejmoa1204471
Granted, we can't run thousands of patients thru an MRI machines on a frequent basis AND that this study only focused on heat as a pain source, but at least it suggests there are objective markers which could counter "placebo creep".
Fascinating article. Do I take it then that people are today more gullible / persuadable? This would align with a few other studies about human behavior that are not medical related. The belief that just because someone is in a perceived "better/higher" position than we are that they are to be wholly trusted is apparently much more true today.
Along with the term placebo there is also a term called “nocebo”. If I say something will have negative side effects, you will start to exhibit those negative side effects, but in reality all I gave you was a sugar pill and there should be 0 side effects. We tend to gravitate towards expectations from what we have seen and read about a particular subject. An interesting topic is the whole CBD cream. I’m sure everyone has heard of it and its effects of helping joints, muscles, pains and aches. However, the over the counter active ingredient in these CBD creams is no where near the actual therapeutic effect it needs to cause a physiological change. So when people buy these creams they have these expectations of something working when in reality all they are experiencing is a placebo
I've long played around the with idea of starting a supplement company that would ethically sell placebos to its customers. Our marketing would make this very clear, customers could get their money back immediately if they suspected they received a placebo. And our prices would be half that of our competition.
I'm amazed these scientists can waste their time or mine on effects this small.
The graph labelled “Interaction Effect between Expectations and Physician Characteristics” is a typical example of how to lie with graphs. The y-axis does not start at zero, but at four millimetres, wildly exaggerating the impact of the physician’s characteristics on the size of the wheal. Please watch out for things like that!
There are many and huge factors when it comes to placebo effect. Check out the story of the guy who runs the placebo branch in the NIH. His interest started when he studied Chinese herb medicine and found and was told that patients need to feel better before they leave the office!
In the histamine study above, you and researchers ignore the more important nocebo effects of negative expectations causing consistently higher reactions. I’m not sure the differences are significantly different in the positive/competent components. The difference between 4.3 and 5 mm is quite small and I would challenge you to measure accurately on a skin reaction. Cheers!