“Healing is a ritual and drama that everyone in the world knows at least their cultural forms of. That ritual activates a neurological process that we call ‘The Placebo Effect.’”
This is the second of a two-part series; the first was launched in May 2019
Our posts for May and June were inspired by a conversation with a colleague from Beaumont Health and the Beryl Institute about the impact of compassion and belief on the economics of healthcare, and how it can play a role in enhanced outcomes as well as saving costs.
These posts are written in two parts, with related premises:
That compassion is a learned behavior, and that it can benefit the person providing care, the patient receiving care, and the organization’s bottom line in measurable ways; and
That compassion, ritual and belief play an outsized role in the healing process, the benefits of which have not yet been fully realized by the healthcare establishment.
Our point of view is that these interactions happen by design, not by default. We believe that complex healthcare cultures can change over time if leadership adopts a Systems Thinking approach, co-designing actionable steps with staff and patients to build a resilient culture focused on optimizing healthcare experiences.
Part Two: Hidden Brain
We’ve been listening to a National Public Radio Podcast Hidden Brain titled “All the World’s a Stage - Including the Doctor’s Office” with Shankar Vedantam. As always, it’s a fascinating listen. In the podcast, he uses examples from the TV Series M*A*S*H to Franz Anton Mesmer, after whom the term “Mesmerized” was coined.
He first goes into detail about a surgical study conducted by J. Bruce Moseley MD, an orthopedic surgeon in Houston, TX. It involved an arthroscopic procedure on patients suffering from arthritis in their knees.
Dr. Moseley states, “the Placebo Effect comes in many shapes and sizes: If it’s a small pill, there’s probably not as big an effect as a bigger pill. If it’s called a “new and exciting” pill, there’s more effect than a traditional pill. Many times an injection can have a bigger effect than taking a pill, and many times some other intervention (such as surgery) can have the biggest placebo effect of all.”
But testing for this isn’t built into the practice of surgery. New procedures are adopted because they’re improvements on previous surgeries; they never go through randomized trials, and almost no surgeries have a placebo control group.
So Bruce decided to run a test for 180 arthritis patients: some had the standard surgery, some only had saline solution washed through the knee, and some had no intervention aside from an incision. Every effort was made to duplicate the process of surgery, accounting for situations where a patient might not be 100% out from anesthesia. They even made sure the length of surgery was the same for each group so that neither patients or their families had an idea that the surgery was a placebo.
Not only did his patients perform identically after the surgery, they strongly recommended the surgery and its benefits to family and friends afterwards. The outcome was clear: basically all the benefit of this arthroscopic surgery was from a placebo effect. And even though Dr. Moseley is a surgeon, he’s since strongly advocated that no one should be performing this particular surgery to treat arthritic knees.
As he moves forward in his practice, Dr. Moseley has become more confident about using a power that he previously underutilized: it’s not only about what happens in the operating theatre; it’s about what comes before, what comes after. The more theatric or dramatic a placebo, the more it focuses on the rituals around treatment, this fuels the belief that the entire experience will help patients not just feel, but actually BE, better.
Implications for Healthcare Experience Design
The information and care provided before, during and after the health intervention plays a big role in the patient’s healing process, in their belief about how the surgery was conducted, and most especially their willingness to recommend the procedure/provider/facility to others. If, throughout their treatment, patients believe that they will get better through the words, actions and recommendations from both providers and peers, then their odds of doing this improve greatly.
“I find this just as astonishing as anyone else, and I’m the patient here.”
But is there a problem with the placebo effect, in that it inherently relies on deception in order to be effective? Linda Bonnano, a hairdresser from northern Massachusetts, notices that after her clients leave her chair having been listened to, they seem more at ease. Years ago, she was diagnosed with severe Irritable Bowel Syndrome (IBS). It impacted every aspect of her life: causing her to abstain from eating before an event, leave family gatherings early, even caused her to be unable to work. She organized her life around the inevitability of pain.
She’d been suffering for a decade when she found that a nearby hospital was conducting a study on intestinal patients. She made an appointment, took some tests and qualified for the study, for which her physician prescribed pills that she took twice a day. But then he told her something that dashed her hopes: the pills she’d been given were a placebo.
Why tell Linda? Wouldn’t that undermine the effectiveness of the research? Well, that was what the study was designed to test. Could a placebo help patients if they knew it was a placebo?
Eighty patients in this small clinical trial would receive this “radical honesty.” It was about an edifice of drama, rituals and the relationships between the patients and their doctors. After the forth day of taking the pills, the pain that Linda had suffered through for a decade had vanished. Many other patients reported 2x the improvement in their quality of life (similar results have been found in patients with low back pain and cancer fatigue).
After three weeks, the placebo study ended. Linda asked to continue with the pills, but the research protocols stipulated that three weeks would be the extent of the test. Four days later, her IBS returned, and Linda returned to her old ways of coping. After a lengthy period she reached out to Dr. Ted Kaptchuk, and was accepted for an extended placebo trial. It took less than a week for her IBS to disappear again. One vital factor in this relationship: her deep faith in Dr. Kaptchuk.
There are many things we don’t fully understand. We don’t know why Linda got better during the study, nor do we know if these results would translate to other patients. For some, the idea of being treated with placebos is frustrating, even infuriating. Despite growing evidence to the contrary, some patients feel demeaned and take to Facebook to air their frustrations, positing that treatment with a placebo is unethical, that it doesn’t take their pain seriously.
“The placebo effect is embodied in what patients and doctors do. It goes much deeper than simply thinking you’re going to get better.”
Research has shown that the most effective placebo trials are designed to activate the doctor-patient relationship, as well as provide the sights, sounds and rituals of clinical processes.
About a year into her second round of placebo treatment, Linda ended up in the hospital for back surgery. She couldn’t get to Ted’s office to pick up placebo pills, and was worried her IBS would return. But it didn’t.
Vedantam posits that when we go to a doctor, we require two different things.
The first is explicit and obvious: we want someone skilled and knowledgeable who can diagnose us correctly, who knows which pills or procedures are likely to help.
But we also have implicit needs: we want someone who can attend to our suffering, not just to our illness. We need someone to trust in moments of fear and vulnerability. We want more than answers; we want reassurance.
For overworked doctors and overburdened medical systems, our explicit needs can feel more urgent than our implicit needs. Surgeries and medications can seem more rigorous than the techniques to address our implicit needs: acting, and storytelling, and rituals. On top of that, these elements of performance may feel unseemly, like the behavior of snake oil salesmen. But when both kinds of needs are met, doctors and patients are more likely to get the outcome they both want: healing.
“All the World’s a Stage, Including the Doctor’s Office” - NPR Podcasts
"A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee" by J. Bruce Moseley, Kimberly O'Malley, et. al. in The New England Journal of Medicine, 2002.
"Components Of Placebo Effect: Randomized Controlled Trial In Patients With Irritable Bowel Syndrome" by Ted J. Kaptchuk, John M Kelly, et. al. in BMJ,2008.