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PiPS: When Less Is More

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The search for an antidote to the ills of our ailing healthcare system inevitably bumps up against the pervasive mindset that more is better. Each year we develop and prescribe more drugs, more tests, more technology. Yet, despite these investments, more treatment doesn’t always result in better outcomes. Procedures can be invasive or have unintended consequences, medications can have side effects, and tests can be unnecessary. But what is the alternative? As we look to improve quality and reduce cost, less can actually be more.

Results of recent research indicate that there is much to tap into beyond reliance on drugs and other interventions when helping patients heal. For example:

The doctor’s connection with a patient can improve clinical outcomes

In a treatment experiment where the only variable was the quality of the clinician’s engagement with the patient, those in the “higher engagement” group reported much greater relief. 1

Seeing a treatment administered increases effectiveness

Morphine injected directly by syringe has greater pain-killing effects than when added, out of view, to a patient’s IV.

Sugar pills can work as well as “real” medicine 2

In a study concerning migraine, patients reported as much relief after taking a dummy pill labeled as a proven medication as patients who took the proven medication that was labeled as a dummy pill. 3

These occurrences tend to be aggregated under the rubric of the “placebo effect.” Once pigeonholed as a nuisance factor in clinical drug trials, the placebo effect is now the subject of a promising list of studies and experiments in the fields of neurophysiology, psychology, neuroscience, molecular biology, and genetics.

Placebo research underscores what we have always known but perhaps have lost sight of; that an engaged patient-clinician relationship and the treatment context can have dramatic positive effects. Studies have demonstrated that the clinical encounter alone – without the provision of any “real” medicine – can alleviate pain, improve sleep, relieve depression, and ameliorate the symptoms of a wide variety of conditions.

Not only has the placebo effect been shown to improve health outcomes, studies also reveal it can a) be intentionally evoked, b) enhance the effects of drugs, and c) be effectively administered without deception. A dramatic demonstration of the latter point occurred in a study involving patients with chronic irritable bowel syndrome.4 They were instructed to take two placebo pills (labeled as such) twice each day. Many improved dramatically and more than one described the symptomatic relief as “a miracle”. We can only conjecture what the overall cost savings would be if we were to make greater use of such approaches to healing.

More research is needed to help doctors make the best possible use of the placebo effect. The Robert Wood Johnson Foundation has invested in a series of public seminars at Harvard University to explore the potential of the placebo effect to improve care. The initiative is engaging an international line-up of scientists, researchers, academics, clinicians, and policy-makers in this exploration. The seminars have fostered meaning dialogue between senior faculty from fields as diverse as anthropology, religious studies, and history of medicine with audiences from across the spectrums of academia, health care, and medical education. One might conclude from their popularity and attendance that placebos represent an idea whose time has come.

The human body has a remarkable network of neurochemicals that automatically respond to internal and external cues. We have been drawing on this arsenal to promote healing for thousands of years. It’s time we embrace these less invasive methods for what they are: simple and effective tools to employ in our approach to illness. It’s time we realize that when it comes to health interventions, less is often more.

By Deborah Grose, Program Administrator at The Program in Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center  Harvard Medical School

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8 replies »

  1. Dale Pennington –
    You are right. For some reason the references were omitted from the published blog piece. Thank you for asking and for your interest. Here they are. If you have difficulty locating any of them, I can probably get you the PDFs. — Deborah Grose, Program Manager PiPS

    1. Kaptchuk TJ et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008; 336:999.
    2. Colloca L et al. Overt versus covert treatment for pain, anxiety, and Parkinson’s disease. Lancet Neurol. 2004; 3:679.
    3. Kam-Hansen S et al. Altered placebo and drug labeling changes the outcome of episodic migraine attacks. Sci Transl Med 2014; 6:218
    4. Kaptchuk TJ et al. Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One 2010; 5:15591

  2. Thanks for the concise summary of placebo. There are several apparent references cited,, but I couldn’t find them in the blog. Could you supply them?

    Thanks

  3. Your way for blog post is really impressive. One thing which is most important is that you have provided all the information very deeply and in informative way. Thanks!!

  4. You have described all the points in very great way. And your blog is too informative and interesting for me. But most important part of your blog is Sugar pills can work as well as “real” medicine 2. Thanks for Sharing this information with us.

  5. As others have noted, and as Grose agrees, placebos do not work for cancer, and for hundreds or thousands of other problems. Yes, they can work for some problems, but let’s not be too quick to accept the broad brush when we need a fine pen.

  6. I could not agree more, Li-lien. Those of us who see potential for improving healthcare by applying what we have learned about placebo effects in no way see it as a panacea. To date research has identified relatively few conditions where placebos seem to produce relief. But some of them happen to be very common conditions where drugs and procedures are frequently used. Cancer itself is not one of those conditions. We are doing our best to understand the mechanisms and the best applications of placebo research. Others are working hard at improving drugs and procedures. We should all hope that providers will develop “the wisdom to know the difference”.

  7. I am normally open to many ideas and I love what RWJF does. However, as someone who has been dealing with cancer for almost 6 years, I sincerely hope they don’t spend too much money on this. If my doctors had focused on placebo effect, I would not be here or would not be able to keep my quality of life. More is not necessarily better, neither is less.

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