Open Heart (24 page)

“Most of the people with AIDS whom I've seen have been intravenous drug users,” Jerry says, “and they have a reputation for being difficult, frustrating patients. They're engaged in illegal stuff, they're secretive, and they rarely have an established, ongoing relationship with a health-care provider, so they tend to elicit disapproval, and worse, from health-care workers. In turn, they become distrustful and expect judgmental treatment.

“But I've found that when you treat them with attention to their medical needs in a straightforward, clinical manner, most intravenous drug users can be disarmingly open about their lifestyle, and no more or less difficult than other patients. The essential point, as I see it, is that each person, intravenous drug user or otherwise, is unique, and does not comfortably conform to any stereotype.”

Moreover, trust itself—Jerry's “Big T”—allows many conditions, physical
and
emotional, to resolve themselves more readily than they otherwise would for the very real reason that a doctor's knowledge of who each of us is in our particularity enables the doctor to judge more exactly the ways specific diseases and conditions may be acting in any one of us—and because, as the history of the placebo effect, and of healing, reveals, such trust in the physician frequently aids and hastens healing processes.

We know that mental and emotional states brought on by trauma can affect us physically—witness the paralyses and muscular contractures of arms, legs, hands, and feet; loss of sight, speech, and hearing; palsies and tics, choreas, amnesia, catatonias, and obsessive behaviors that resulted from shell shock in World War I.
^*

We also know that patients who adhere to treatment, even when the treatment is a placebo—and adherence to treatment, as Jerry's
studies, and others, have shown, is preeminently a function of trust in the doctor—have better outcomes than patients who adhere poorly. We know, too, that placebos are effective in reducing pain and depression. When medications known to be effective against pain are paired with a variety of neutral environmental stimuli, the environmental stimuli (a pill's shape and color, for example) acquire analgesic potency equal to, or surpassing, that of the medications. In one survey of (sham) surgery for lumbar disc disease, for example, although no disc herniation was present in 346 patients (“negative surgical exploration”), complete relief of sciatica occurred in 37 percent of patients, and complete relief from back pain in 43 percent.
^*

In the relief of depression, placebo effectiveness, in a large number of studies, ranges from 30 to 50 percent, and, when compared with effective drugs, placebos are 59 percent as effective as tricyclic depressants, 62 percent as effective as lithium, 58 percent as effective as nonpharmacologic treatment of insomnia, and 54 to 56 percent as effective as injected morphine and common analgesics.
^*

In a 1999 study (“Listening to Prozac but Hearing Placebo: A Meta-Analysis of Antidepressant Medications”), researchers conclude that “75% of the response to the medications examined in these studies may have been a placebo response, and, at most, 25% might be a true drug effect.”
^*
The authors explain: “This does not mean that only 25% of patients are likely to respond to the pharmacological properties of the drug. Rather, it means that for a typical patient, 75% of the benefit obtained from the active drug would also have been obtained from an inactive placebo.”

And with regard to heart attacks, studies show that emotional conditions affect survival at least as strongly as more purely medical factors—that, for example, “the presence of major depression after acute myocardial infarction increases six-month mortality more than and independent of such clinical factors as heart failure and extent of coronary disease.”
^*
In another study, in which patients took drugs to lower their lipid levels after heart attacks, while only 15 percent of patients who took most of their prescribed medications died during the next five years, 25 percent of those who adhered less well
died during the same period, and it made no difference whether the patients took active drugs or placebos.
^*

And just as the loss of a loved one, or the end of a relationship with someone we have loved, can bring about depression and other distressing conditions of mind and body, so falling in love and being in love can enhance our well-being. Not only do we
feel
better because we are happier—appreciated, known, loved—but this state of being can help relieve preexisting conditions of mind and body (depression, impotence, headaches, gastrointenstinal disorders), and, appearances
not
being deceiving at such times, may often lead friends to tell us we
look
better too.

On the cover of the January 9, 2000, issue of the
New York Times Magazine
, above a headline in large, bold type (
“Astonishing Medical Fact: Placebos Work!”
), are four pictures, each labeled—a pill (“Antidepressant”), the top of a man's head (“Fetal-Cell Implantation”), a knee (“Arthroscopy”), and a black-capped bottle (“Cold Remedy”)—and across each picture, stamped in red ink:
FAKE
.
^*
In the accompanying article, the author, Margaret Talbot, concludes “that the placebo effect is huge—anywhere between 35 and 75 percent of patients benefit from taking a dummy pill in studies of new drugs.”

Talbot surveys a substantial body of research that demonstrates the effectiveness of placebos used in place of medications and surgery (dummy pills for depression, make-believe surgery for knees, and so on). She also reports on studies that “show actual physiological change as a result of sham treatments.” In eleven different trials, for example, not only did 52 percent of patients suffering from colitis (inflammation of the large bowel), when treated with placebos, report feeling better, but “50 percent of the inflamed intestines actually looked better when assessed with a sigmoidoscope.”

Placebo effects have been explained in many ways—they may work because of conditioning (as in Pavlov's experiments); or because of the release of endorphins that stimulate the brain's own analgesics; or because of the diminution of stress. But what all explanations have in common, Talbot writes, “is the element of expectation,
the promise of help on the way that can only be imparted by another human being.”

What is clear, too, is that without the doctor who prescribes it, the placebo is powerless.

“It may seem strange to say this of a profession regularly accused of vanity and self-importance,” Dr. Leston Havens, professor of psychiatry at Harvard Medical School, writes, but the fact is “that many professional people allow themselves to come and go among patients as if their knowledge and skills were all that counted, their persons not at all.
^*
One sees this most vividly with medical students, who cannot believe in their importance to the people they take care of. Yet we are the great placebos of our pharmacopoeia, and the power of the placebo can be measured by the results of its withdrawal.”

In talking with my friends about placebos, they make a helpful distinction between illness and disease.
^*
For most doctors, they explain,
disease
is what the doctor sees and finds, whereas
illness
is what the patient feels and suffers. Given that what most doctors see most of the time is illness, the distinction is not insignificant. Although the two terms are, in general, used synonymously, disease can occur in the absence of illness (as in a person with hypertension—or heart disease!—who is asymptomatic), and illness can occur in the absence of disease (all those debilitating conditions of mind and body—stomach disorders, headaches, back pain, hives—that have no discernible physiological causes).

Because we have, since the end of the nineteenth century, been able to successfully treat many previously intractable diseases, we sometimes lose sight of the fact that, as Arthur Shapiro puts it, “the history of medical treatment until relatively recently is essentially the history of the placebo effect.”

Some researchers contend that the placebo effect is a myth, and many, like Shapiro, are keenly aware of “faddish exaggerations about the extent of placebo power.”
^*
Still others, like Dr. Howard Spiro, professor of medicine at Yale, while finding “no evidence that placebos helped disease or that they changed the objective, visible, measurable aspects that we doctors regard as important,” believe that
placebos do “help patients with the pain and suffering that the disease brings.”

Yet clinicians, Spiro writes, “have a hard time accepting the idea that mental events may affect physical events, that faith can ‘heal.' That is why placebos embarrass modern doctors, for they call attention to the persistent dualism of medicine and our so recent climb out of the prescientific swamp.”

Although Spiro accepts the existence of the placebo phenomenon, he insists on the “difference between treating cancer with placebos and treating the pain that comes from cancer with them.” Nonetheless, he cautions physicians to “be humble before our ignorance of how one person can relieve the suffering of another,” and “to remember that the placebo is only a symbol of all that we do that we cannot measure.”

How measure, then, the degree to which my own attitudes and responses, before and after surgery (my persistence in pursuing the cause of symptoms, my skepticism about preliminary diagnoses, my swift recovery, the absence of common complications such as infection, memory loss, and depression), were made possible and enhanced because of the trust I placed in my friends, and in the doctors they trusted?

10

In Friends We Trust

I
N
REVIEWING
THE
HISTORY
of healing practices that have been used from ancient times to our own—in China, Babylon, Egypt, and India, and in the Western world for more than two millennia—Arthur Shapiro reports that “the astonishing total of these remedies is about 4785 drugs and 16,842 prescriptions.
^*
Even more startling is that with only a few possible but unlikely speculative exceptions, all were placebos.”

He quotes Galen—a Greek philosopher of the second century A.
D
. and physician to the Roman emperor Marcus Aurelius—whose pharmacopoeia dominated treatment in the Western world for 1,500 years, and disappeared fully only near the end of the nineteenth century, as saying that “he cures most successfully in whom the people have the most confidence.” (This from a physician not lacking in self-esteem: “Never as yet have I gone astray,” Galen proclaimed, “whether in treatment or in prognosis, as have so many other physicians of great reputation.”)

In
Care of the Psyche
, a history of healing practices through the centuries, Stanley Jackson describes measures that people in ancient Greece and Rome developed to aid them when they found themselves helpless in the face of disease and illness—in particular, their reliance upon magicians, sorcerers, priests, and physicians. “The healer's experience and reputation,” he writes, “his status in the particular
culture, his knowledge of the proper ritual, his use of the proper words with the proper tone and in the proper manner, and his belief in the efficacy of his words and actions all came together to calm and reassure sufferers, to soothe and comfort them, and to mitigate any sense of helplessness or hopelessness. Sufferers in need, and their willingness to believe and cooperate, completed the potentially healing situation.”

While delineating the ways a healer was urged to be considerate and compassionate so as to maintain the patient's morale and thereby increase the patient's confidence in the physician and his treatments, Jackson, professor emeritus of psychiatry and the history of medicine at Yale, also remarks on something that reminds me of the place my friends hold in my life: “these issues were apparently addressed as aspects of being a good person and an effective physician rather than as an aspect of psychological therapeutics.”
^*

Philia
, or friendship, was to the Greeks, in fact, the very basis of the doctor-patient relationship. For the doctor, friendship with the patient consisted of a correct combination of
philanthropia
(love of man) and
philotechnia
(love of the art of healing); the Hippocratic
Precepts
(c. 400
B
.
C
.), in discussing the physician's approach to the patient, state that “where there is love of man, there is also love of the art of healing.”
^*

But what about trust in doctors who, like my friends, have a good deal more than placebos to offer? The Roper Center for Public Opinion Research, having conducted polls on this issue since 1945, reports that confidence in “the leaders of medicine has declined from 73 percent in 1966 to 44 percent in 2000.” (The lowest public confidence rate, 22 percent, occurred in 1993, during the debate over national health-care reform.) In a series of recent essays on trust in medical care, David Mechanic, René Dubos professor of behavioral sciences, and director of the Institute for Health, Health Care Policy, and Aging Research at Rutgers University, suggests that patients have become increasingly distrustful mainly because they cannot freely choose their own physicians, or depend upon continuity of care from their health-care providers. In addition, aware that their
physicians do not control some decisions concerning their care, they become less certain they will receive the care they need.

For their part, doctors, too, are disenchanted with recent changes in health-care policies; witness the following, from an editorial in the
New England Journal of Medicine: