Worlds & Time

Monday, November 23, 2009

Placebos and Patient Care

I've had a single article open in my browser for a few days now: "The Cost Conundrum" by Atul Gawande in the New Yorker. I think it makes an important case for a certain kind of health care reform and I would like to discuss it for a minute, and the use of placebos below.

There are a lot of great New Yorker articles and this is clearly one of them. It is written from the perspective of a medical professional but is clear, concise and compelling to read. It's an examination of the health care system of McAllen, Texas. McAllen has the second highest health care costs in the country, per capita, after only Miami.

The article points out that despite high costs McAllen doesn't have particularly good health care, scoring below average on 23 out of 25 items, and wonders what the difference is between McAllen and a place with well recognized excellence but low cost such as Rochester, MN.

My only criticism of the piece is that it buries it's conclusion a bit. What Dr. Gawande found is that there is a difference between doctors in high cost and low cost areas. In low cost/high quality areas, the doctors were more likely to focus on patient care above profits. They worked in systems designed to reward patient health and satisfaction and the ability to work with other doctors instead of maximizing doctor's profits.

In high cost/low quality areas, the doctors were more likely to share what is euphemistically called in one section of the article "entrepreneurial spirit." Instead of focusing on patient care they were more likely to focus on the bottom line. In one hospital doctors owned shares of the company and thus reaped the rewards of higher profits. They have a direct incentive to increase the costs for patients and by extension the health care costs for the entire region.

Increased costs for patients means higher taxes for Medicare/Medicaid, longer waits in emergency rooms and more wasteful bureaucracy. In order words, it basically costs all of us more money in the form of taxes.

This isn't something that can be controlled by the free market because health care costs are basically uncontrollable. It's difficult to choose what hospital an ambulance will take you too or what the general "patient care vs. profit" climate of a regional health care system is. Since the need for health care exists anywhere there are people and the ability to choose the best option is limited there has to be an outside influence to prevent the sort of behavior that drives up costs and good care down. As Dr. Gawande quotes Dr. Lester Dyke: "Any plan that relies on the sheep to negotiate with the wolves is doomed to failure."

I think that the reaction to the above issues for most humans is obvious: people want good health care and they understand the need for some sort of governmental intrusion into their lives to make sure that they get it. Because that conclusion is so obvious, I want to take a bit of a tangent for a moment.

There's another name for the behavior by doctors that results in high cost, low quality care. Some Christians that I know would call it greed. As much as greed is a problem for the deeply religious, it's also held up as an enshrined right by the libertarian segment of our population.

It's a weird divide, but it's a very clear cut one. You can't both believe in letting the market solve all problems and taking care of the poor. You can't believe that capitalism solves all problems while believing that greed is a bad thing.

I think that a lot of the current accusations of socialism and communism toward anyone who wants to impose limitations on a capitalism are a sort of fearful reaction to admitting that there is anything wrong with the acquisition of as much money as possible. If everything else is worse than what you're doing then you don't have to admit that what you are doing is bad. Since socialism and communism are bogeymen, any nuanced position has to be equated with them in order to prop up one's moral stance.

This leaves the libertarians in the Republican party with a clear and simple position: Anything interferes with the quick and vast accumulation of money is a bad thing. The sheep must negotiate with the wolves or else the world will end. Greed has to be good and pure and necessary.

Still, it seems clear that doctors that go into the business of health care with the primary goal of making money actually harm the people that are in their care. If, as a patient, you want to get better then you want a system that focuses on rewarding the doctor for the best outcome while restricting the direct profit that your doctors can make charging you for tests. Overall, that's going to mean that doctors are going to have to give up the lure of massive quick profits on the patients that they treat. That's going to require a major social shift though, because I can't imagine that greed is an easy habit to give up.

Speaking of cheap health care, there is another issue that I've been thinking about recently that is on the opposite moral spectrum but relates to the same issue of patient care.

This is something that most people have been taught not to do from a young age and the Bible specifically repudiates but may provide a basis for better health care: Lying.

I think that we need to establish medical guidelines for lying to patients in the form of prescribing placebos.

A recent article in Wired examines placebos from a perspective that challenges the view that most people have held since the discovery of placebos: not as something to be avoided during the testing phase of a scientific study but rather as a powerful effect in it's own right that can be used to help people.

Let's be clear, I'm not suggesting that doctors should lie to patients about their conditions or the possible outcomes of their diseases, but I do think that there should be ethical guidelines for doctors to prescribe placebos to patients that may help millions of people recover from their ailments.

There are two kinds of possible placebos; those that contain no medications whatsoever--the proverbial sugar pill--and real medications that are given in doses too low to have proper chemical affect. I can see some argument for the former as less harmful due to the decreased likeliness of side effects but I actually see the latter as more likely to be prescribed by doctors. With medications given below the indicated dose the doctors themselves can feel that they are giving the patient something that does actually clinically do something and decreases the chances that the patient may figure out that the medication that they're on isn't chemically relevant to their recovery.

It doesn't change the fact that the doctors would in some sense have to lie to the patients about the drugs that they are being prescribed. Just the phrase "studies have shown that patients that take this substance report less continuing pain" is a lie of omission. Some patients may force doctors into positions where they need to both be trusted and still prescribe a placebo, requiring a more direct lie.

Until there are ethical guidelines recognized by the wider medical community doctors may be at risk prescribing placebos for malpractice suits. Lawyers, not understanding the nuances of patient care, would probably seize any confirmed placebo prescription as evidence that the doctor didn't care enough about a patient to prescribe something "real." We'd see class action lawsuits against hospitals that didn't prescribe high enough doses of painkillers and psychiatric drugs. But placebos can help patients with a minimum of side effects and complications and generally recognized standards will prevent doctors from getting in trouble when they try to help their patients.

In this current climate of reduced spending and high pressure to cut costs there is a great incentive to get that placebo improvement with minimal production costs. Even using drugs at the subeffective dosing, that can mean substantially reduced costs to the patients and to the clinics and hospitals while improving the standard of care. I will say that personally I think that using the most expensive chemicals in doses that are not effective is unethical because it creates both a cost to the patient without a substantial enough gain. Any placebo medication should be on the ultra low end of the drug cost scale, not more than two to four dollars for a month's worth of pills, perhaps slightly more for a subeffective dose of a medication that a patient will have name recognition with.

Just looking back over the last couple of paragraphs, I want to explicitly clarify that when I say that doctors should be prescribing placebo medications they should be doing so in addition to the efficacious drugs that will actually help in the patients recovery. I would never suggest that we give out placebos in the place of cancer medications, but the judicial use of placebos may reduce the side effects of those drugs when given in tandem.

The effects that placebos have are in that vein: reducing side effects, lowing the perception of pain, perhaps improving general mood slightly. Since they are not clinically effective they should not be prescribed instead of something that actually works.

The question is, would the prescription of placebos help people? It seems clear that if they are prescribed in tandem with real medications for the purposes outlined in the previous paragraph then the answer is yes. Since placebos already have a measurable medical effect we shouldn't fear to use that effect to the benefit of the patients that we treat. Instead, we should incorporate it when possible as a cheap and surprisingly effective treatment for real symptoms and protect the doctors who want to use it to help their patients.

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