Interactions Make the Difference: On Placebos, Healing Environments and Integrative Medicine

What Regular Medicine Can Learn from Alternative Medicine

Last month a provocative article appeared in The AtlanticThe Triumph of New-Age Medicine by journalist David Freeman. Alternative medicine, or sham medicine depending on your view, got its day in a mainstream magazine.

Freeman presents both views, while arguing that biomedicine can and should learn from alternative medicine, particularly in the many areas where biomedicine hasn’t had the success many envisioned for it just a couple decades ago.

The back-and-forth over Freeman’s Atlantic piece provides a great entry into the big debates going onto today about how to improve medicine, how healing happens, and whether alternative medicine deserves the increasing success it has had. I’ll provide a summary of Freeman’s argument, some rebuttals (and places to find more), and then go on to make some of my own points about the direction this debate might take.

Freeman sums up his Triumph of New Age Medicine article best here (which I’ve slightly modified for readability):

The dozens of highly credentialed, highly regarded physician-researchers I interviewed at several of the world’s most renowned medical centers and academies… almost to a person agreed with my four main points:

-Most mainstream drugs don’t help most patients much with chronic, complex disease

-Alternative treatments don’t work better than placebo

-Alternative practitioners do a better job on average than mainstream physicians in investing time and effort with patients to get them to adopt healthier lifestyles and have better attitudes about health

-These lifestyle and attitude changes can significantly reduce the risk of complex, chronic disease as well as relieve the hard-to-treat pain and discomfort of many different disorders.

All of these points are backed up by mainstream studies, aren’t even all that controversial, and, as I say, are endorsed by physician-researchers [with] credentials and reputations.

This quote from fairly early in the article captures how Freeman makes the argument that biomedicine has a serious causal problem.

To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents—as the taming of the AIDS virus attests.

But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says [Nobel Laureate Elizabeth] Blackburn. “But we haven’t rethought the way we fight illness.”

Later Freeman writes on what we have learned about dealing with the increasing prevalence of these chronic diseases.

The medical community knows perfectly well what sort of patient-care model would work better against complex diseases… [It] doesn’t wait for diseases to take firm hold and then vainly try to manage them with drugs, but that rather focuses on lowering the risk that these diseases will take hold in the first place.

Aside from getting people to stop smoking, the three most effective ways, according to almost any doctor you’d care to speak with, are the promotion of a healthy diet, encouragement of more exercise, and measures to reduce stress. The evidence that these lifestyle and attitude changes have enormous impact on health is now overwhelming…. [Studies over] more than three decades that diet, exercise, and stress reduction can do a better job of preventing, slowing, and even reversing heart disease than most drugs and surgical procedures…

Medicine has long known what gets patients to make the lifestyle changes that appear to be so crucial for lowering the risk of serious disease: lavishing attention on them.

That means longer, more frequent visits; more focus on what’s going on in their lives; more effort spent easing anxieties, instilling healthy attitudes, and getting patients to take responsibility for their well-being; and concerted attempts to provide hope. Studies have shown that when a doctor speaks to a patient about quitting smoking or losing weight, the patient is more likely to do it. A 2008 study on physician-patient relationships found that physicians deemed “exemplars” based on their reputation and awards received were likely to create an emotional bond with patients; to convey to patients that their commitment to caring for them will endure over time; and to imbue patients with “trust, hope, and a sense of being known.”

And what does alternative medicine do? By Freeman’s estimation, it helps solve the problems he just outlined. Here is the list of how typical aspects of alternative medicine make a difference.

A long initial meeting covering many details of the patient’s history

A calming atmosphere

An extensive discussion of how to improve diet and exercise

A strong focus on reducing everyday stress

An explanation of how the treatment will unleash the body’s ability to heal itself

An assurance that over time the treatment will help both the problem that prompted the visit and also general health

Gentle physical contact

The establishment of frequent follow-up visits.

There is a lot more to Freeman’s piece, so I recommend readers follow up with the original:

The Triumph of New-Age Medicine

Critics Strike Back

Steven Salzberg, professor at the University of Maryland and author of the blog Genomics, Evolution and Pseudoscience, pens a strong critique at The Atlantic, A ‘Triumph’ of Hype over Reality. Salzberg was interviewed as part of Freeman’s reporting, and took on the role of critic of “sham medicine” in the journalistic formula of getting opposing viewpoints. In his rebuttal, he can get directly to his points.

The triumph of new age medicine is really the triumph of marketing over science, of hype over reality… It’s true that modern medicine has many failings, but alternative medicine is not the answer. We do need to find ways to fix what’s wrong with the practice of medicine, but not by turning to fairy tales.

David Freedman is right in pointing out that study after study shows alternative medicine to be no better than placebo. What he neglects to mention is the real possibility, however small, of serious harm. Perhaps the greatest “triumph” of alternative medicine is the multi-billion dollar industry that now flourishes around it, offering ineffective treatments at a handsome profit…

Acupuncture, homeopathy, Reiki, Ayurveda, healing touch, and other “energy” therapies have all failed their scientific tests. Alternative medicine proponents like Brian Berman make excuses for these failures, claiming that the benefits of their so-called medicine somehow cannot be measured, and insisting on more studies. Real science is all about admitting our mistakes and moving on.

Steve Novella, a doctor also interviewed as part of Freeman’s reporting, writes his critique as Alt Med Apologetics at the Atlantic over at his Neurologica blog.

Here is [Freeman’s] premise in a nutshell: Mainstream medicine has “lost that loving feeling”, the “touchy feely” side of medicine. Meanwhile, now that we have conquered many life-threatening illnesses, the population is aging, and health care is shifting to more chronic illness…

This [chronic illness “failure”] is largely a false premise. First, the medical system has had decades to slowly adapt to the slowly changing face of health care – and we have. Of course it has not been fast enough, and there are many flaws in the system (just like every complex human system). But our resources have shifted to managing these chronic illnesses.

And it is completely a false charge to say that mainstream medicine waits for illness to happen (the “preventive medicine” gambit of CAM). Preventive care is a core part of primary care and many other specialties as well. There is tons of research looking into ways to reduce risks of heart attack, stroke, cancer, and other diseases. Further, physical-therapy type interventions, lifestyle changes, as well as legitimate (not pseudoscientific) nutritional interventions are part of mainstream medicine. The “drugs and surgery” claim is patently false…

The solution absolutely is not discarding all of the principles of science in medicine (even common sense) and wrapping some kind of practitioner attention and maybe some basic common sense lifestyle advice around an elaborate pseudoscientific ritual. But that is exactly what Freedman concludes.

Other Reactions

Besides general interest, I think this debate could be a useful addition to medical anthropology courses or to other classes on social science and health. So here are more materials to explore, whether for yourself, for students, or something else.

The Atlantic – Fix or Fraud? A Debate on Alternative Medicine. Here you get a range of reactions from very prominent figures in this debate. Definitely the place to start.

David Freeman’s blog post, Angry Responses to My Piece On Alternative Medicine. Quick links to some of the major critiques (including the two above), and some response from Freeman.

Orac at Respectful Insolence – The “triumph” of New Age medicine? The Atlantic strikes again. Besides the critique, where else can you get 600 comments?

And over at the blog Fon Therapeutics: Advancing Integrative Medcine, Glenn Sabin argues that integrative medicine and alternative medicine are not the same thing. Integrative medicine is where the action is at, says Sabin in a series of points about this debate.

I also suggest you see the previous post on mental illness, drugs, and placebos: Chemical Imbalances and Mental Illness? Go for the Placebo with Side Effects

The Debate Falls Short

I agree with the critics – the framing of the debate falls short. But in this, both sides are at fault. It’s consistently mainstream medicine versus alternative medicine. This approach limits both how we understand chronic health conditions and how we understand how people get better. To use Freeman’s terms, we either use drugs or surgery, or we lavish attention. Or, to use Novella’s approach, mainstream medicine already gets chronic health problems, so what’s the big deal?

Both approaches privilege medical systems as the primary way to deal with chronic health problems and as the best way to deal with pathologies and/or help a person heal. Let me say upfront that I like biomedicine and public health, and go to the doctor to deal with my medical problems. But health problems are not necessarily the same as medical problems. Biomedicine and public health have been greedy – violence and drug use and sexual behavior are now often medicalized. And alternative medicine is marked by the same greed – if biomedicine can’t deal with it, we can…

Chronic health conditions generally have complex patterns of causation related to social and psychological dynamics, not just biological dynamics. Moreover, effective maintenance of health requires much more than medical intervention and attention. As Freeman says himself, a healthy diet, more exercise, and reducing stress all help with chronic illnesses. What we eat, how much energy we spend, and patterns of adversity and how we cope with that adversity are all things that extend well beyond medicine. Drugs and surgeries and more patient attention can all help with that. But thinking any of these will solve these chronic health problems is simply foolish.

On how we are healthy, the debate reverses cause and effect. Either mainstream medicine or alternative medicine is the cause of us being healthy, either through drugs, surgery, and preventive medicine, or through attention, productive relationships, and taking an integrative approach. This reversal of cause-and-effect is not surprising. After all, medical systems of all sorts emphasize their ability to heal, their specific approach to dealing with the problems we inevitably face in life.

In both cases, biomedicine and alternative medicine emphasize what they do, and how that makes a difference, with an accompanying explanatory framework over which practitioners of various stripes argue vehemently. But health is much more than either biomedicine or alternative medicine. Health is something onto itself, not what each approach’s explanatory system makes it into.

Moving beyond Techniques and Beliefs

Western biomedicine has privileged surgeries and drugs, of doctors doing things or giving things to patients. Even with preventive medicine, the emphasis is on finding the right set of recommendations, the right intervention, that will make a difference. Biomedicine focuses almost exclusively on finding and evaluating techniques of intervention, rather than on factors like environments, relationships, and meanings.

Patients’ own recovery is also an assumed part of the process. It is taken-for-granted, which heightens the focus on finding what techniques make the difference. And those techniques have made a tremendous difference in millions of people lives, especially when coupled with our increasing understanding of the basic biological processes involved in a specific health problem. But it is now clear that both health problems and recovery, especially with chronic health problems, involve more than just a set of techniques and understanding of biology.

The placebo effect is often what is contrasted to drug interventions, a stand-in for the effects of patient’s own recovery, doctor-patient relations, and so forth. Whatever a specific technique does above and beyond all that other stuff, that is its efficacy. But leaving all the rest unanalyzed is no longer a tenable position. And here Freeman is right in showing how integrative medicine, mainstream scientists and doctors, and patients themselves are all getting at how to harness the rest of what contributes to healing and recovery, or at the least, in improving a person’s ability to cope with a chronic disease and carry on with his or her life.

However, the placebo effect doesn’t specify these other elements. Rather, the placebo is often cast as how patients’ irrational beliefs make a difference – their emotions, their preferences, their need to hang onto some system of authority. It is what is thrown away in efforts to find out what “really works.” Doctors and researchers want that above-and-beyond effect, and that then becomes evidence-based medicine.

If patients find bigger pills more effective than smaller pills, respond well to the touch of a doctor’s hand, and believe surgery makes a difference even when no surgery is done, that is all just quackery, in the eyes of many. All of these effects have been demonstrated through research on the placebo effect. But what is getting lost in this framing is one simple point.

People who do NOT believe in the treatment they are getting do not do as well. If they don’t think it will make a difference, generally the effect of any intervention is lessened. Understanding how people come to accept a particular medical system is thus an important area of research. As decades of research in medical anthropology has shown, patients need to buy into the local treatment system for them even to want to access it. Medical systems often have elaborate belief systems to heighten their perceived authority and to be able to provide compelling explanations for patients’ illnesses and also to explain away treatment failures.

Evidence-based medicine, which has its scientific and practical merits, also happens to be a system that does exactly these things. Doing the research increases the authority behind treatments; having evidence for effectiveness helps to explain away failures, which can be attributed to the patient or to random factors. Other medical systems, not having the evidence-based approach, are simply discarded as being ineffective.

By setting it up as techniques versus placebos, evidence-based medicine puts on a set of blinders. It is a very effective set of blinders in one domain – showing better than random effects, using effective controls so the evidence backs up a specific intervention. But it blinds itself to many things. One that deserves immediate mention is that evidence-based medicine often assumes a homogeneity to people that is at a far distance from human variation. Drugs, psychosocial interventions, surgeries – these all come face-to-face with incredible human variation around the world.

That problem can be largely solved by repeated studies that address that human variability. But that belief matters, and environment can make a difference – the double-blind study focused on techniques is not a scientific approach built to test these ideas. But we have learned that these things do make a difference.

How we can build research designs that effectively incorporate environmental factors and patients’ meanings is a crucial next step in building better medicine. One point here – an idea that integrative medicine gets at – is that it is often not one simple factor working on its own that makes the difference (that’s just a return to the idea of finding one technique that is controllable). Rather, it is the conjunction of factors that make a difference. This sort of design – testing sets of factors working together – is more challenging, but equally needed.

But so is an approach that looks beyond what medicine does, to people themselves and the environments in which they live and the things that they do and experience there. Rather than writing off the placebo effect as irrational belief, and not recognizing that lack of engagement cuts into health seeking and recovery, the medical establishment needs to see how many chronic health problems flow from environment to brain to body and back out again. Recovery is not simply a matter of fixing the body, correcting the pathology with evidence-based techniques. The whole needs to be addressed. This also happens to require more than “lavish attention.”

My fellow plogger Steve Silberman captures how placebo research has actually opened the door to these sorts of ideas in his post, Meet the Ethical Placebo.

The emerging field of placebo research has revealed that the body’s repertoire of resilience contains a powerful self-healing network that can help reduce pain and inflammation, lower the production of stress chemicals like cortisol, and even tame high blood pressure and the tremors of Parkinson’s disease.

Jumpstarting this network requires nothing more or less than a belief that one is receiving effective treatment — in the form of a pill, a capsule, talk therapy, injection, IV, or acupuncture needle. The activation of this self-healing network is what we really mean when we talk about the placebo effect. Though inert in themselves, placebos act as passwords between the domain of the mind and the domain of the body, enabling the expectation of healing to be translated into cascades of neurotransmitters and altered patterns of brain activity that engender health.

I want to end by saying that even this framing of the placebo misses what is really making a difference. It sets up placebos as beliefs – as a password for the mind to do its effect, and thus activate the body.

But the really interesting thing about the research that Steve describes is that doctors consciously giving sugar pills to patients who knew what they were getting still showed an increased effect. These patients reported less symptoms weeks later than those patients who got nothing.

What really made a difference in this study is the interaction between doctors, patients, and techniques. Interacting with a doctor, focused on getting a sugar pill and being told that can help harness healing, was the difference maker compared to not getting anything; this interaction was comparable to getting the standard drug used to the medical condition in the study.

Placebos as beliefs misses that point. It is the overall interaction – which includes ingesting a substance, feeling drug effects, speaking with a doctor, and being in a convincing medical setting – which helps with a chronic condition.

And if that type of interaction makes a difference in the clinic, imagine what all our interactions out in the real world are doing. Things like our diet, our ability to exercise, our levels of stress… Yes, these too are interactive phenomena. Giving patients a right set of beliefs (follow this diet, you need to exercise more, here are common stressors and try to reduce them) is not going to be effective. It’s just repeating the same techniques/belief combination. Diet, exercise, and stress are interactive, are part of people’s lives. We need a new approach that gets at these things within people’s lives, alongside what the medical profession can do in the clinic.

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