Monday, October 18, 2010


We think of a “placebo” as an inert substance that acts therapeutically because the patient believes it will. Up to forty percent of post-treatment improvement, as a matter of fact, is due to placebo effect.

Placebos aren’t just pills. Doctors are also placebos.

Imagine that you, sick and vulnerable, have come to your doctor. Knowing this person is intelligent, well-trained, dedicated and experienced, you put yourself in his or her hands and expect salutary results. Even though the doctor hasn’t yet done a thing, you feel a little better already: placebo.

Unfortunately, my medical classmates and I were absent the day they taught Placebo 101. Had we been there, we’d know better how to use placebo power skillfully. Indigenous shamans, on the other hand, receive intense placebo training. They have time for it because they’re not required to take microbiology and biochemistry. Like much else in life, it’s a tradeoff: they wind up lacking scientific background, and we lack healing magic.

Of course, nothing prevents us docs from learning how to play our placebo role effectively. For example, we could decide to see our examining room as a sacred space. That means getting quiet and centered before we enter it, and then, once inside, treating its intimacy and potential power with serious respect. It means converting its atmosphere from mundane to transcendent, from despair to hope, with ritual.

The traditional medical ritual is the physical exam, with its four major components, observation, auscultation, palpation, and percussion. The amount of diagnostic information this can reveal is staggering. All this staring and listening, feeling and tapping can also be mystifying to the patient; in the benign disorientation the ritual engenders, it begins to create a wider reality, one richer in possibility.

Despite its medical and spiritual value, though, the physical exam is dying. As often as not, the doc relies more on a quick history and abundant testing to reach the grail of diagnosis. Just as today’s psychiatrists are taught psychopharmacology but very little psychotherapy, too many young docs learn to practice without the sublime contact skills that both reveal and comfort.

A century ago, Dr. Edward Livingston Trudeau opened America’s first tuberculosis sanitarium. The disease was considered medically incurable then, but Dr. Trudeau achieved great success simply by offering his patients rest, fresh air, good food, and abundant attention. His motto, preserved on a plaque near the shore of Lake Saranac, New York, was,

“Cure sometimes,
Relieve often,
Comfort always.”

In those days, diagnosis wasn’t everything. Relief and comfort were and remain our most profound goals. One of today’s proponents of reviving the physical exam is physician-author Dr. Abraham Verghese. In a recent NY Times interview, he said that performing the exam tells the patient, “‘I will never leave you. I will not let you die in pain or alone.’ There’s not a test you can offer that does that.”

1 comment:

  1. I utterly adored the article in the Times about Dr. Verghese, and he reminded me of a select few doctors I met briefly in nursing school...alas, I am not at liberty to comment on my current situation, since in this recession I desperately need to keep my job, and it is hard not to go into a laundry list of how sad and deplorable so much of what we experience is (I only write from home on my personal computer on my personal time off under a pseudonym, but apparently not even that is safe from the prying eyes of employers, as we learned only this week regarding what a patient said about us nurses on her blog, resulting in major policy changes at work)...which is why this blog is so TRUE!
    If ONLY each and everyone of us could deliver HEALING...I am currently suffering from one of the worst colds I have had, and I so rarely get sick....but for a week now, I keep thinking, ah, this is the agony before the storm passes, and then the next night I am up all night breathing through my mouth with my head throbbing, my nose and eyes dripping like a sieve, and my throat a burning coal, because I am too stubborn to take over-the-counter medicines...
    today, at last, I called my doctor to ask if he could call me back...I wanted to see if he thinks it's most likely viral, which is pretty much what happens every time I feel this abjectly miserable...but he didn't call me back, and at last, it seems to be "breaking," and the congestion is moving from a preoccupation to a background annoyance, because I can, for the most part, somewhat breathe again....
    But the problem is, my doctor is NOT much of a placebo for me...this is hard to explain to my mother, for whom doctors ARE placebos, and who is adamant that I should rush myself and my daughter to the doctor for the slightest ailment. I tell her I KNOW what the doctor is going to say...and what is unspoken is, I know HOW he is going to say it, in that dreadful office with the blaring fluorescent lights in a high rise building I don't connect with anyway.

    I honestly think people can get all the technical info they need off the internet, and they are probably better off seeking shamans or traditional, mystical healers, if they are open to it...if they are freaked out by the thought, then obviously, it's not going to help them...but I have had an alarming number (5 in five years) of colleagues die, all between the ages of 42 and 52, all of cancer...and they all got treatment quickly and all died so quickly...each passed within 6 months of diagnosis...and that just cinches it for me... I would so rather go outside our medical system to a shaman, or just collect my friends and not even pretend I have to "battle" cancer or any disease.
    Because doctors as they exist today are trained to be all brain and no heart, with Dr. Kane and Dr. Verghese being remarkable exceptions. I think society has always been such that it makes it easy for people to mechanize themselves, and if they conform, it is just easier for the whole system to just sort of blindly tumble along, whether it makes sense or not (look at the mechanization of greed, legalized robbery, in our banking system, and the incapacity of even well-meaning government regulators or media watchdogs to stop it) people who don't conform, who question things and feel deeply...they aren't going to fit in as well, they are going to be a monkey wrench in the system...but they are the ones that really achieve the most genuine healing for the people who find them, and find each other...