Posts tagged "primary-care"

Those of us on the industry side of healthcare may dismiss today’s news as another headline doing damage to an industry that delivers benefit to millions. But in claiming “The difference in improvement between patients taking placebos and patients taking anti-depressants is not very great”, lead researcher Professor Irving Kirsch raises some undeniably challenging questions.

For one thing, the “effect” is not limited to mental health trials. One RCT in patients with acute duodenal ulcer (Lanza et al. 1994) consisted of three treatment arms: the then-new drug lansoprazole (Zoton/ Pravacid), an older drug, ranitidine (Zantac) and placebo. As per experimental law, the 44 patients receiving placebo had the same diagnosis as the other patients and were examined alongside them. After two weeks about a third of the placebo patients were healed, and after four weeks just under half of them were healed.

Here’s another in angina: (Boissel et al 1986) 35 patients with severely limited functional status were treated for 6 months only with placebo and short-acting nitroglycerin. The placebo dosage was blindly titrated over this time until an “optimal” response was seen. Twenty seven of the 35 patients showed substantial improvements over this period. Overall the number of angina attacks dropped from 10.3 to 2.4 a week with a corresponding decrease in nitroglycerin tablets used. It seems unlikely that these people would have simply gotten better had they stayed at home and had no treatment. But, with inert treatment in a clinical trial, they did get better.

Let’s not forget that a placebo isn’t necessarily a tablet. In two studies (Cobb et al, NEJM 1959. Dimond et al, J of Cardio. 1960) surgeons were only informed once in the operating room which patients were to have a complete internal-mammary artery operation, and which were to receive sham surgery. Both studies showed that most of the patients were much better after “surgery” regardless of whether they had actually received it or not.

These examples of a high response rate in a placebo arm are not uncommon. For centuries, it has been known that sick people frequently get better when administered an inert intervention by a healer or medicine man. It’s hard to account for the substantial improvement in these patients.

Increasingly, the term “placebo effect” has been a dismissive one, given to justify a response that cannot really be understood. To me, it seems that at some point the role of the patient’s ‘mind-over-illness’ must be considered. Indeed, the word “placebo” is being challenged by medical anthropologists, who ask how placebos, an inert substance by definition, can have any effect at all. If it does something, it is not inert. There must be something else at play driving this change.

Daniel Moerman in his excellent book Meaning, medicine, and the “placebo effect”, suggests a very different approach to this problem. He uses the term “Meaning response” and defines this as “the psychological and physiological effects of meaning in the treatment of illness”. The meaning response can be applied to most of the results traditionally attributed to placebo effect. As a definition it gathers the elements of the non-physiological into treatment success, aiming at a better understanding of this phenomenon.

Once you acknowledge that treatment ‘meaning’ exists alongside mode of action and plays a role, it’s only a short distance to another important realisation. This is directly relevant to us: by understanding meaning in the eyes of the end user, we can feed this insight into the HCP strategy. Adapting and optimising our communications can only help drive a better brand experience, a better consultation and perhaps better outcomes.

What do you think?

A recent post about the rise of the informed patient attracted some insightful comments. Dr J got me thinking about knowledge, responsibility and a few things in between.

Patient education is a good thing and we need more of it. The EMEA roadmap for 2010 promises more access to accredited medical information. Ideally this will help override the reams of flimsy information that, as Dr J points out, are in abundance.

I think the EMEA have their work cut out for them. How much information do people need for a start? Is it OK to broadcast an advert simply telling people to be more active, or do we need a clearer link to the real consequences of obesity? And what if we overload people with information - will we scare them into doing the wrong thing? Will they just stop listening?

What really alarmed me was Dr J’s comment that, even when patients know their onions, they often balk at decision time. Perhaps we know enough, but we’d still like to blame someone else if things don’t work out. Or is it the other way round - are we being urged to take more responsibility for our treatment, but don’t have enough insight to make decisions?

There’s a great take-out from this: We must be on the ball if our minds are boggling with the same question that patients’ are. What we all want to know is: how do we embrace patient empowerment without compromising medical integrity?

Looking forward to your thoughts on this one.

A few years ago, the rest of this consultation would have been relatively straightforward. I would ask some questions, run a couple of tests, recommend a treatment and the patient would feel reassured. Nowadays however, it tends to go rather differently.The patient will, more than likely, have already been on various websites looking for a diagnosis. They may also have looked into the different treatments available, even compiled a folder of information for discussion. They want and expect to be actively involved in their diagnosis and treatment plan. And if they aren’t completely satisfied with my opinion, they’ll get someone else’s. In short, “trust me, I’m a doctor” no longer holds much water.

Never before have patients been so well informed, so involved and influential in their healthcare. With a finger on the public pulse, the government is planning for personal healthcare budgets so that each patient can choose their hospital, consultant and treatment. Since I graduated 10 years ago, the face of medicine has become almost unrecognisable. It’s more like going shopping than to the doctor.

How does this make us healthcare professionals feel? I’ll be honest; a little mixed. The quality of information available to patients varies enormously and can sometimes do more to confuse than to clarify the situation. On the other hand it’s likely that a patient who feels invested and in control of their wellbeing will live a healthier lifestyle and engage with the required treatment. Isn’t that the aim?

Whatever the implications, the NHS claims to hold the needs and wishes of the patient at its core. This makes sense ethically and politically. The question is, why are healthcare communications agencies still servicing healthcare professionals before satisfying the public interest?