Shame on you, New England Journal of Medicine

Jul 25 2011 Published by under Medicine, Uncategorized

For specialists in internal medicine, the New England Journal of Medicine is one of the journals you really read.  It's not a free throwaway journal or bathroom reading---it's where you find good original research, interesting case studies, cogent editorials.  Usually.  More or less.

Right now it's "less".  A few days ago I posted my review of a recent study on placebos.  I found it interesting but somewhat problematic. It's real benefit seems to have been that it has sparked substantive and vigorous discussions about placebos.   To save you from reading my entire review, the study basically took asthmatics and gave them either real medicine, fake medicine, "sham" acupuncture, or nothing at all.  All the patients reported feeling at least somewhat better, but only the patients treated with real medicine had significant improvement in measured lung function.  Another way to state the findings might be "the placebos and the real medicine all made the patients feel better.  Oh, and only the real medicine made actually better." I have a problem with this presentation as you will read below.

What we've learned about so-called placebos over the years is that "placebo" is not an intervention like a medication or a surgery.  It is an artifact of observation.  A certain amount of change can be expected any time you study a group of people.  "Placebo" is simply all of the change that can't be explained by the primary intervention.  Taking the asthma study as an example, simply enrolling people in the study and doing nothing else caused them to feel a bit better.  But treating them with real medicine caused them to feel better and get significantly better physically.    The bit of "better" that was seen simply by enrolling is referred to as placebo effect, and is a mix of various factors, such as patients' being cared for, regression to the mean, desire to please researchers, and other effects not due to a "real" intervention.  It is likely that a good deal of placebo is subsumed in standard care: if you go to the doctor for a broken leg, being cared for and listened to makes you feel better, but setting the bone and placing the cast does most of the work.  Good doctors maximize our ability to make people "feel" better along with treating the underlying illness.

The current object of my ire is an editorial published in the Journal to accompany the asthma study.  It was written by an anthropologist named Danial Moerman who completely misreads the study, the meaning of placebo, and what a disease actually is.  He first fails to understand that there were actually four interventions:

They found that three of the interventions — active albuterol, sham albuterol, and sham acupuncture — were all equally effective in controlling asthma symptoms, as judged by patient-reported improvement.

[...]

The fourth intervention was “no treatment,” in which patients were told to wait for several hours and then return home. Waiting had no effect on either subjective asthma symptoms or lung function.

Perhaps I misread the results and the graphs, but it appears to me that the "do nothing" group did in fact report feeling better, just not as much as the other groups.   The importance of this lies in the fact that part of the placebo phenomenon is simply being cared for or enrolled in the study (in this case it also involved repeated lung function testing).  If this were subtracted out in some way, we might find a much less significant effect.   But we are still speaking of "subjective" improvement, an important factor, but not one nearly as important as being able to breathe better.

Professor Moerman, perhaps being used to dealing with less concrete ideas, misses the importance of objective vs. subjective outcomes in medicine.  Holding a cancer patient's hand can make them feel better, a lot better in the short term than chemotherapy.   But it won't shrink a tumor.  Moerman thinks we have it the wrong way 'round:

It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor's or the patient's perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.

First, I hate it when people misuse "begs the question", but that's not important.  What's important is that he's asked the wrong question.  It's not whether subjective or objective is most important, or whether a "patient-" vs. "doctor-centered" care (whatever that means) is the best model.   In medicine, we assess both how a patient feels, and how well they are doing physiologically.  We do this in the exam room and we do this in our research.  We (meaning doctors and medical scientists) don't think one is "more important" than the other; we know that any intervention is a balance between changing physiology and making a patient feel better.  Reading this editorial makes me think of Columbus "discovering" America: it was already here, the folks living here obviously knew it, and he really had no idea where he was anyway.

Another example of his profound ignorance is his complete lack of understanding of common medical conditions:

For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson's disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician.

None of the conditions he mentions above are what he thinks they are.  There is nothing "subjective" about the cognitive dysfunction of schizophrenia or the tremors and stiffness of Parkinson's disease.  And there are drugs and other physiologic interventions that improve both the way patients feel and objective measures of how they are doing.

It's not so much Moerman's ignorance that disturbs me: anyone can be ignorant.  But this piece of idiocy was published in one of the world's most respected medical journals.   Well, his ignorance really does disturb me too.  He closes with a false dichotomy:

Do we need to control for all meaning in order to show that a treatment is specifically effective? Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”

As a physician and a patient, I'm unwilling to settle for "no negative side effects over the short or long term."   There are no such things as "side effects"; only "effects", some of which we desire, some of which we do not, so risk can only be minimized, never eliminated.   The precept is "First, do no harm", not "Do nothing and hope for the best."

References

Moerman, Daniel E. Meaningful placebos—controlling the uncontrollable. N Engl J Med 365(2):171-172 (2011). DOI:10.1056/NEJMe1104010.

8 responses so far

  • When we moved from 7200 feet in elevation down to 5400 feet, I expected my already mild asthma to be nearly non-existent. The problem is that more stuff grows here in the milder climate, and there's more air pollution. So now I feel like my previously mild allergies have gotten worse, triggering more asthma attacks. The best laid plans.... I'll be interested to see the spirometry comparison, though.

  • "It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question..."

    ...are placebos potentially harmful (in at least in certain situations) in that they can result in a subjective assessment of improvement when the underlying problem has not been addressed? Is is a good idea to help someone think that their asthma is effectively managed when you've only improved the subjective assessment and done nothing to reduce the risks of asthma?

    Technically those people sought medical care because a pathological condition caused them to wheeze and feel suffocated. Those people are still wheezing, but now may think they are not wheezing as badly. They may well be inclined to think that they can manage their asthma just as well with the other (inert) interventions, which is a risky proposition.

    When there's an condition underlying symptoms that has risks associated with it, such as death, it's a good idea to make sure you don't just worry about the subjective assessment of the condition, but also focus on the actual problem, since that's what carries the risk.

  • It's amusing that a typical alt-med/sCAM claim is that real "western, evil, reductionist, etc" medicine treats the symptoms and not the disease (or person), and yet alt-med/sCam is generally not concerned with the pathology underlying the symptoms. (Unless you count supposed imbalances or blockages of vitalistc life energy, and there's numerous unscientific and mutually exclusive beliefs about what causes and cures those in sCAM)

    Homeopathy, for example, is the king of (attempting) treating the symptoms and not the disease. Even if homeopathic nostrums weren't usually only water and inert (which they are), the law of similars concept of like cures like cares only about the symptoms and what causes similar symptoms rather than the disease underlying the patient's symptoms and its pathology.

  • brooksphd says:

    Ah, the National Enquirer Journal of Medicine are at it again. who even commissioned and approved this bullshit editorial anyway? Does that not indicate a motivation on the part of the publishers/exec editors?

  • Zuska says:

    It annoys the hell out of me that he calls migraine a disease defined by symptoms, as if there were no real underlying pathology to be investigated, understood, and treated. I guess it really is just all in my head!!! How does this kind of crap make it into a medical journal? It hurts patients. Somewhere I'm sure there's an insurance executive rubbing his hands together in glee and muttering "let them eat placebos!". Next year I'll probably have to prove to my ins company that I don't get just as much relief from sham Botox as from real treatment.

  • Marvin says:

    Diseases defined only by symptoms can hardly be called diseases. The one's mentioned in the editorial are not defined just by symptoms (with the exception of "back pain" which is a symptom). There are real pathologies involved whose mechanisms are known, at least to some extent. Sure, many 'placebo' treatments lead to subjective improvements. However, if the objective pathologies are not treated properly, the subjective feelings of improvement will be short lived. Ya gotta try and fix the actual problem if the problem is known.

    Chronic Fatigue, Fibromyalgia, and personality disorders do not have definite underlying pathologies that are understood or known to be common to all sufferers with these conditions. That is why they are so hard to treat.

    Diseases that are defined only by symptoms are essentially conditions defined by their definitions. Now that's "begging the question".

  • Larry Ayers says:

    Good post, PalMD! I just had to stay three days in a hospital. My experiences with the medical establishment are minimal, and I'd never taken a prescription drug in my life . A nurse exclaimed, "57 years old and you haven't ever taken prescription meds? That's amazing..."

    I was impressed by the diligence and compassion of the nurses, and I even had a good doctor who was willing to take the time to explain things to me. (My only other hospital stay some years ago was just for an hour, a cubital tunnel operation, and the doctor I had was not friendly or empathetic). There was a definite placebo effect caused by compassionate care, but the blood-work and CATscan along with the meds I was prescribed did the real work, I'm convinced.

    Of course, without insurance I'll be a poor man for the rest of my life, but at least I feel good and have some evidence that I'm basically healthy. I'd never had a physical before.