Asthma can be terrifying. One minute you're breathing, the next, you're gasping for air. I'll never forget my little brother, chest heaving, rushed to the emergency room during middle-of-the-night attacks.
But despite its dramatic and objectively physical nature, asthma is also a disease with an element of subjectivity.
That point is elegantly underscored in a new study just published in The New England Journal of Medicine. Harvard Medical School investigators found that when asthma patients were treated with the medication albuterol, their lung function improved significantly compared to those given placebo, or fake, treatments. However, and here's the rub, when the same patients were asked to report how they were feeling — a subjective measure — placebo treatments turned out to be as effective as real medicine in helping to relieve asthma symptoms and alleviate patients' discomfort.
Indeed, the placebo effect seemed to be on full display here: whether patients were on albuterol, the placebo inhaler or undergoing sham acupuncture (which feels real, but in fact uses trick needles that don't penetrate the skin) they all reported significant symptomatic improvement compared to little improvement among patients who got no treatment at all.
The takeaway, researchers agree, is that there's something therapeutic about the act of treatment itself, the ritual of care and the reassuring bond between doctor and patient that makes people feel better, whether or not their treatment includes pills or drugs with an active ingredient.
Here are some of the research details, summed up in the news release and in the paper results:
The study examined 39 adult patients with chronic asthma who were randomly assigned to undergo treatment with an active albuterol inhaler, with a placebo albuterol inhaler, with sham acupuncture or with no intervention at all. The researchers administered one of each of the three treatment interventions to each of the study participants, plus a no intervention session, in random order during sequential medical visits (three to seven days apart from each other).
The procedures were repeated in two more blocks of visits, such that each patient had a total of 12 medical visits.
At the study’s conclusion, findings showed that treatment with the albuterol inhaler resulted in a 20% increase in a key measure of lung capacity, technically, the maximum forced expiratory volume in one second, or FEV1. This compared with an increase of approximately seven percent in each of the two placebo treatments as well as the “no treatment” control.
However, patients’ reports of improvement after the intervention did not differ significantly for the albuterol inhaler (50% improvement), placebo inhaler (45%), or sham acupuncture (46%), but the subjective improvement with all three of these interventions was significantly greater than that with the no-intervention control (21%)
Interestingly, the researchers interpretations of the impact of the placebo effect was itself somewhat subjective: the way they framed it depended on their own particular area of expertise.
For senior study author Ted J. Kaptchuk, a trained acupuncturist who directs the Program in Placebo Studies & Therapeutic Encounter at Beth Israel Deaconess Medical Center, the experiment was important "not because of what it says about asthma, but what it says about the ritual of medicine." Clearly, he says, for patients that ritual "can be very powerful." The placebo effect, he says, "isn't just about the sugar pill, it's the context in which it's embedded. For patient-centered outcomes, just caring for people and giving treatment carries a significant punch for relieving illness and reducing complaints."
Kaptchuk's not an asthma specialist, but he says in many cases, particularly with harder-to-measure conditions such as back pain, anxiety, insomnia and depression, he believes it's possible "we could reduce the dosage, or reduce the quickness with which we prescribe the drugs, especially when physicians and patients both acknowledge that just caring for people can be therapeutic."
As someone who actually treats asthmatics, lead study author Michael Wechsler, MD, Associate Director of the Asthma Research Center at Brigham & Women's Hospital, is a little more emphatic that by objective measures, the drugs worked and the placebo didn't. "The albuterol had a measurable effect," he said, noting that perhaps using subjective markers for asthma may be unreliable. "A lot of patients with asthma don't realize how bad they are."
But wait, says Daniel E. Moerman, Ph.D., an emeritus professor of anthropology at the University of Michigan-Dearborn who wrote an editorial accompanying the study, shouldn't patient impressions count here? It's their impaired breathing we're talking about, after all. Moerman writes:
What do we learn from this study? The authors conclude that the patient reports were “unreliable,” since they reported improvement when there was none — that is, the subjective experiences were simply wrong because they ignored the objective facts as measured by FEV1. But is this the right interpretation? 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?
Indeed, on a subjective level, Wechsler concedes things were different. "When we asked people how they felt, there was a placebo effect," he said. "There was a difference between subjective appreciation and when we did nothing."
The eye-opener, he added, was that, "just by having a medical interaction there was some kind of subjective benefit and that's important in terms of the doctor-patient relationship; you can heal without really doing anything. But if you're looking for physiological beneft, placebo doesn't do much." (This study didn't examine what, if any, biological changes or changes in brain activity took place with the placebo treatments.)
I asked Wechsler if the study, which was funded by the NIH's National Center for Complementary and Alternative Medicine, will change the way he practices medicine in any way.
He said: "I'll advocate for continued use of medication, because we know that works and we don’t want to put patients at risk of life threatening consequences. But also, as much as I'm focused on my patients, this will give me pause; it'll make me that much more conscious of the art of medicine and just being there for my patients."
That seems like a good thing. For practicing medicine, as Moerman says, is about much more than merely medicating.
All medical procedures (active or inert) are meaningful — that is, they represent something — and meaning has effects. Clinicians often dress up in special uniforms that convey power and au- thority. They have very expensive machines that can look inside your heart or brain. All this, plus the magnificence of the hospital building (ours has two helipads!), the decor of the office, the lights of the operating room, the computers on every lap, the magical prescription pad, and the caring nurse, piles up meaning with increasing power regardless of what may be in the capsule or syringe.
This program aired on July 13, 2011. The audio for this program is not available.