by Shawn Kirby L.Ac.

placebo effect

n. The beneficial effect in a patient following a particular treatment that arises from the patient's expectations concerning the treatment rather than from the treatment itself.
The American Heritage® Dictionary of the English Language, Fourth Edition
Copyright © 2009 by Houghton Mifflin Company.

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Placebo Effect and Cardiothoracic Surgeons

My wife and I have friends and colleagues in the western medical community that we keep in contact with. One of those old friends, a doctor who has been in private practice for over 35 years, and his wife, sat down with Malia and I for brunch shortly after our wedding, and chewed the fat with us about all things medical. “Doc” as we call him, and his wife, are very interested in alternative therapies and complementary medicine and are very supportive of acupuncture. We got some very good advice that day on how to run our practice and how to succeed in the medical game without going nuts. As the second round of mimosas arrived, Doc got around to spinning a yarn in which he explained that you could always tell what track medical students were on by how they spent their free time.

The future pediatricians, he told us, were the sweet and nice ones – and by far the most boring. The future dermatologists and plastic surgeons were unbelievably smart, and they knew it. Most of them were insufferable bastards who wouldn’t even deign to speak with anyone not of their intellectual ilk. But it was the folks on the cardiothoracic track that were by far the most fun. They were the ones who did tequila shots for breakfast and played savage, no-holds-barred tackle football on the lawn every time they had an extra five minutes.

Specialties, he told us, while they were ostensibly the student’s choice, were essentially determined by the peer groups in the various programs as well as by the residents. A sweet little doe-eyed intern with visions of being “the doctor who cared” wouldn’t last five minutes in the cardio program. They ran them out on a rail. Why?

According to Doc, it was all about patient expectations – in other words, placebo effect. Two patients on the operating table suffer identical complications – why is it that one patient dies under the knife and the other lives? Simple. The one who lived believed in their doctor. You’re about to go in for heart surgery. You meet your surgeon. He is a mealy-mouthed, pasty-faced, soft-spoken dork with a stutter. You are dead meat. That’s why the heart surgeons are gonzo. It’s not just because it takes a gonzo human being to cut into a beating human heart – it’s that it takes a gonzo personality to convince the patient that he can cut into their beating heart and they will walk away from it.

The moral of the story?

“Believe in yourself,” Doc told us. “Always project god-like confidence in everything you do. And don’t let anyone take that away from you. It’s the most important thing you can give your patient.” We both nodded sagely at him.

Then he said, “And always remember this too – if it’s not your time to go, even your doctor can’t kill you.”

Placebo Effect and Acupuncture

My granddad loved to fish. I remember gently rocking back and forth as I stared at my bobber, enjoying the sun and the sound of the water lapping against the side of the boat. We hadn’t had a bite in hours. Finally, granddad broke the silence by saying, “The fish aren’t biting. We must not be holding our teeth right.”

Astonished by his pronouncement (at the age of five) I asked him in all seriousness, “How do you hold your teeth to catch fish?’

He grinned from ear to ear. “You’ll know when they start biting.”

Have you ever wondered why it is that turning a needle clockwise is “supplementing” and turning a needle counterclockwise is “draining?” Why would that be, exactly? Could it be that, on the eleventh day of creation, the Lord said,

“…Let there be acupuncture points. And lo, let all that would presume to perform the art of acupuncture adhere to following, lest they shalt surely die, and their children shall be cursed with a curse of boils, and even their children’s children, amen. For lo, if thou dost wish to supplement, then thou shalt take a thin piece of wire and stick it into the flesh of the diseased and twiddle it deosil, which is to say clockwise (for lo, in the future, there shall be invented clocks, and their hands shall be made to move deosil). And lo, if thou dost wish to drain, then thou shalt stick a thin piece of metal wire into the flesh of the diseased and twiddle it widdershins, which is to say counter-clockwise (see above). Thus spake the Lord.” (Taken from the Book of Acupuncture chapter 2 verses 9-21, which is not to be confused with The Book of Armaments in which are found the instructions for the use of the Holy Hand Grenade of Antioch.)

Here’s a wild thought.

What if… as common sense would dictate, twiddling a needle one direction over another, as though you were operating an occult screw-driver, doesn’t mean jack squat?

What if… this is nothing more than a training device to trick the newbie acupuncturist into having confidence that they actually were doing something?

And what if… that misguided confidence was then projected outward, and was so convincing that the patient picked up on it… and got better?

Naw. Couldn’t be. I’m just being cynical.

Placebo Effect and Chinese Herbal Medicine

No matter where I travel in the U.S., and no matter who I talk to, the absolute, complete and total indigestibility of rehmannia is a taken as a scientific fact and article of unquestionable faith among everyone in the Oriental Medical community. While it is generally acknowledged that, theoretically, this herb can, in either its unprepared form as Sheng Di Huang or the prepared form of Shu Di Huang, do miraculous things for patients with yin or blood vacuity, it is, nonetheless, impossible for anyone to digest. Ever. Period.

Just one, tiny, innocent capsule of Liu Wei Di Huang Wan will, in the average patient (which is to say everyone), invariably result in the poor schmuck spending the majority of their morning 15 minute coffee break at work perched on the toilet experiencing the most violent diarrhea they’ve had since that college trip to Tijuana. After returning to their cubicle, they will then spend the next hour fighting the good fight, suppressing a backlog of flatulence with Olympian intensity as beads of sweat roll down their face. Internally, a fight with anxiety rages as they are deeply concerned that, should they try to somehow discretely let fly, they might well soil their undergarments. As a last resort they finally call in sick, go home and lay upon their bed farting and belching like a medieval friar. At this point they call you at the office to let you know, in no uncertain terms, “DO NOT EVER GIVE ME ANOTHER FORMULA WITH REHMANNIA IN IT!!!”

Wait a minute – how did your patient know there was rehmannia in the formula? And how did they, without the benefit of years of Chinese herbal education, know that that rehmannia was IMPOSSIBLE to digest?

Because that's what you told them.

I was still an intern in school when I discovered the secret to making rehmannia completely digestible. One day I had a patient with insomnia that, based on her pattern discrimination, I felt would respond well to Tian Wang Bu Xin Dan. I was hesitant to prescribe this formula though, because of the rehmannia in it and also because my patient was a hypochondriac who had told me, repeatedly, that she had “delicate digestion.” At that time I had a student following my rounds, my “intern,” a quiet studious girl who said very little, but had the charming habit of raising her eyebrows to high heaven every time I did something out of the ordinary.

As I sat down to explain to the patient how she should take her herbs, I first explained that this formula would be perfect to help her with both her anxiety and insomnia. At that point, inspiration (or idiotic over-confidence depending on your viewpoint) took over and I said something, straight faced, that I could scarcely believe escaped my lips.

“It should also,” I said, “have a really good effect on your digestion. The herbs in this formula are not only good for anxiety and insomnia, but they also tend to make people who take this formula have cast iron stomachs. Heck, you might be tempted to eat jalapeno poppers while you’re taking it” I gave my patient a mischievous wink, and tried to quell the voice in the back of my head that was screaming “fraud.”

At this, my intern’s eyebrows shot so far into her skull that I lost track of them in her bangs. She had been through enough of Materia Medica to know what rehmannia was, and she had also seen the script I had written which included enough rehmannia to kill a small bull calf. True to form, she said nothing, and we saw the happy patient out the door before she turned on me and hissed, “You LIED to that woman.”

“Did I?” I smirked. I had no idea what would happen. All I knew was, I was sick of people and their “delicate digestion” and was willing to play a hunch. After all, the worst thing that would happen would be a mild case of indigestion or perhaps diarrhea.

The next week our patient returned to the clinic, pleased as could be. She had slept through the week and her anxiety was greatly improved. And, lo and behold, she also claimed that her digestion had improved as well. She had even gone out for fish and chips, a guilty pleasure that she and her husband, both English, loved but rarely indulged in because of her “delicate digestion.”

“The only thing odd I’ve noticed is that my stools have gotten quite a bit darker…”

I didn’t see my intern’s eyebrows for the rest of the semester.

Belief Systems and Placebo Effect

Oriental Medicine is filled with “beliefs.” People often believe that their tradition is actually “correct” and that the other tradition is “false.” Upon hearing that another practitioner, who practices another form of acupuncture or herbalism has success with a patient, they dismiss these positive results as “placebo effect.” There is a word for this particular mental attitude – fundamentalism.

Alan Watts, in a lecture given decades ago had the following to say about this mental attitude –

“So, if someone says that a sacred text is true, be it the Bible, the Vedas or the ancient texts of Shinto, it always comes back to you. Are you going to believe it or aren't you? If nobody believes in a particular religious tradition, it will be perfectly plain that the tradition has no authority, because the people are always the source of authority. In the end, we all get the tradition we deserve.”