Its the thought that counts
Its the thought that counts
Making the case for snake-oil to return
Hello everyone, your favourite written radio is back! For today’s broadcast, we will dive deeper into a fascination with a form of gaslamping (‘gaslighting’ to some), in particular the placebo effect. It plays a very important part in modern medical process, and yet I believe it could play a much bigger role…
Pre-Fun Disclaimer
Peppered in this broadcast are references to studies done, and in some areas my point leans heavily upon the conclusions and findings of these studies- I do want to say that none of these are definitive, closed book conclusions of fact: it is a widely held view that more research has to be done on placebos and all placebo-adjacent ideas and phenomena to gain a better understanding. When I do mention a study in this broadcast, I have adopted a “huge if true” stance, and I recommend the listener doing the same :)
Placebos Current Use
Currently, placebos are used largely as testing benchmarks for new and potential drugs and treatments, ideally in double blind trials, where half the volunteers are given the new potential cure, and the other half are given a placebo, often a sugar pill or an IV, with the idea that any new cure should be better than a ‘no-cure’ situation represented by the placebos themselves.
However, patients receiving the placebos do nevertheless lead to patients receiving some sort of ‘treatment effects’ both in self reported and objective measures…
The Opening
Increasing studies on placebos have resulted in more questions than answers, with some interesting phenomena:
Go Big or Go Home: Much like the placebo effect where beneficial impacts are felt from no active ingredient, the flip-side has been found to exist as well- where patients feel negative side effects from a treatment or procedure, even though it contains no medically active ingredients. This is currently a hotspot in research, and it appears to be from expectations of adverse symptoms, and can be mitigated with improved communication, better patient- doctor relationship and clearer instructions appear to help mitigate the nocebo effects.
The Bigger the Better: Although there have been no comprehensive studies confirming it as such, there is evidence suggesting that placebo’s can go beyond simple sugar pills. There have been links found suggesting that a bigger placebo effect is felt with a bigger pill, even more so with a placebo injection. This appears to extend even to sham surgeries, where placebo surgeries (prepping a patient, under anesthesia and then creating an opening or puncture only to cover it back up) have had a similar impact to the real deal. One example of this was a trial for arthroscopic knee surgery for osteoarthritis, and more instances can be found here.
The Bubble That Wouldn’t Burst: Perplexingly, studies suggest that the impact of placebo’s is inured to revelations of its existence. it is not like silence where once it is named it disappears, but even when patients are told they are receiving a placebo, appear to still have an impact (albeit only in self reporting measures, not on objective measures, but more on that later)[disclaimer].
These new non-deceptive or open label placebos are beginning to challenge one of the easier criticisms of placebos, as if one can gain the benefit of placebo’s without having to hide the fact that they are placebo’s and only masquerading as ‘actual cures’ from the patient (a murky ethical dilemma, which we will return to), then that creates a plausible alternative to conventional placebo methods and exciting possibilities for future study, if nothing else.
The Vision
So, so far we know(‘ ‘) that the placebo has an evil twin, can be somewhat scalable and is immune to a lack of deception. This creates a vision for us where we can take action to negate the wallows of nocebo effects while simultaneously maximising the placebo effects. A passage I came across, written by Fabrizio Benedetti, really stood out to me:
One of the most interesting and challenging aspects of placebo research is related to the new emerging concept that placebos activate the same biochemical pathways that are activated by the drugs administered in routine medical practice. [source]
This notion, together with the aforementioned possibility of being able to scale and therefore adjust the dosage of the placebo effect, presents us with a vision. There is a saying that if it quacks like a duck, and walks like a duck, it’s probably a duck. Well if placebos look like medicine, walk like medicine, could they be a potential source of medicine? This vision is still a little hazy, lets put some more focus on the vision for a better resolution…
The Potential’s Market
So, we have the makings of a product. But do we have the customers? I’ve largely been touting the benefits of placebos, but at the end of the day a broken arm is a broken arm, cancer is cancer- we may not be exactly sure how they work, but that does not mean they are miracles. However, there are certain groups of patients where the approach “would be worth the try” could be applicable for placebo hospitals: hypochondriacs or palliative care patients. Furthermore, a placebo’s strength is in improving the vibes - it’s largely observed that their strongest impact is in “self-observation” symptoms, like pain, fatigue or nausea.
Chronic sufferers of these three, where conventional treatments appear not to work, may be open to the news of hearing that there is a new potential cure out there. And this is no small group of people: Just as an indicator of what that could entail:
the global market for pain management is huge- estimates place it at around $80 billion.
The antiemetic (to combat nausea) drug market is currently around $8 billion, and only set to rise.
The presence of caffeine and other stimulants in society is ubiquitous, a loud indicator of people’s drive to conquer fatigue.
If even a small fraction of these markets could be captured by our idea, that’s enough to create something out of this idea.
The Potential
Perhaps we need to transform the act of going to a hospital into an experience. I do not want to say this lightly, as we don’t want to make hospital visits ‘enjoyable’ in that sense- we do not want people to come in more than they should, overburdening the system. The experience shouldn’t be akin to going to a haunted house to experience horror, Disneyland for entertainment or Sagrada Familia for wonder.
The experience should obviously be less volatile, more mundane, and calm, more like a documentary (this is not to call documentaries boring, on the contrary: I recently crushed a >3hour documentary ranking all 26 of Napoleon’s marshals). It should also feel informative, professional and helpful, with a heavy emphasis on the latter.
In a statement, the ultimate potential for this is the creation of a Frugal Theseus’ Placebo Hospital (FTP Hospital, or FTP’s/FTPH’s from now).
Although a bit of a long winded name, I believe it aptly describes what would be the creation of such a type of hospital: Lets imagine Theseus with his ship (and it is Theseus himself who dabbled with the ship), but has unfortunately been struggling as of late (even in imagination, the cost of living crisis spectre looms). Therefore, when Theseus begins to swap out swap parts of his ship, he does not switch them for uniform, identical wooden parts, instead settling for parts that still look the same, but of a lower quality; maybe some of the belts of wood are a shade thinner. Maybe others have a lower purity or are more worn out.
And wooden you know it, Theseus’ ship has been complete. Different, and yet to all intents and purposes, the same (of course, the whole concept of Theseus’ ship is stretched in this variation, but not yet snapped). Maybe the ship is not as sturdy or as safe on water as it was before in more extreme circumstances, it still serves its purpose nevertheless, while also managing to save Theseus a pretty penny or two.
This is exactly what I would like to do with an upcoming classic hospital project: strip out everything from the building that makes it a hospital, and replace it with placebo-mimics. This way a hospital could be created, which admittedly does not treat as many patients as well, but nevertheless delivers medical service to a degree while at a fraction of the cost.
From a very, very untrained eye, there feels as if there are three phases or experiences in a hospital:
The Waiting Room Phase
Discussion phase
Treatment/Testing/Resolution Phase
Lets examine each phase to see what can be stripped out and replaced (even improved!) with a placebo perspective.
Waiting for Salvation
When researching how much of the hospital experience can be improved, I was drawn to glancing over at Disneyworld’s experiences, to see if anything can be copied over to the house of healing. Wait times and queuing instantly stand out:
Disney has near perfected the art of queuing, with its snaking lines that go around corners so that people can’t see the full extent of the queue, making the queuing as interactive as possible, selling merchandise on the way, even installing virtual queue methods, so customers can wander wherever they wish while waiting for their turn on the ride.
While most of these can not be implemented in any hospital - nobody wants patients to be wandering around hospitals or have them purchase stethoscopes at stalls, professionality does need to be maintained- there are still avenues for manipulating queues to everyone’s benefit. Even though some hospitals already require booking appointments beforehand, the static waiting rooms with no clear waiting time is sure to sour the experience.
Instead, perhaps a system that is more dynamic and/or feels faster should be implemented: one books an appointment for a specific day online, and (lifting from airports here) have a boarding-pass-adjacent, a ‘hospital pass’ if you will, generated for you. Once checked in at the hospital, patients should also receive an exaggerated, overinflated wait time estimation, in order to set up an expectation and then beat it, giving the patient a pleasant surprise, inherently improving the ‘customer experience’, making the process feel faster.
To compound this feeling, a live waiting list could be displayed on a website or app, for instance saying “ you are #57 in the queue”. However, this number would also be inflated, and would be lowered at such a speed to evoke impressions of efficiency, but not so fast so as to alarm a skittish patient of potential brevity of their appointment.
Transitory Process - Doctors and Nurses
In addition to medical expertise, a nurse and doctor’s ability to empathise, show adequate concern and professionalism is paramount to the success of any FTPs. In order to avoid the aforementioned nocebo effects of poor doctor-patient relationships, doctors and nurses should never, never appear or feel dismissive - the patient must feel heard, no matter how ridiculous their words are. It is important to remind the listener that as no real medicine is being provided, any healing impacts or feeling are entirely internally generated by the patient, so they must feel as if they are being healed in the best manner by the medical staff.
Doctors must provide an air of assurance assurance and professionality. Any act of note-taking or writing up prescriptions should be done ideally out of patients vision or as briefly as possible. History taking should be interactive, in particular any discussions surrounding past medications, which should be frequented by the question “and how did they make you feel?”. Focus should at all times be on the patient and how they feel.
To dial it up further past the realms of normalcy, if the FTPH is aware of a difficult patient or a patient who has been unable to shake the suffering, a situation could be arranged where the nurse, as part of their nursing tasks, can create an expectation where the doctor and nurse is described as having “dealt with a similar situation- not that your pain can be easily compared to another” (remembering not to reduce the patients suffering to a typical scenario- finding the balance between comforting and not sounding dismissive).
As the patient enters the room, they see a patient having an enthusiastic conversation with the doctor, thanking him, proudly detailing how he feels much better ever since been treated by the doctor. Whether the patient is anything more than an actor employed by the FTPH is irrelevant- the expectation has been set, the patient may finally believe that it is this doctor that may help them overcome their suffering once and for all: and that is all we need.
In essence this stage of the hospital experience should be all about countering nocebo effects, with the most important role being the selection and the “selling” the efficacy of the placebo treatment the patient is about to receive. It will be a delicate balance between setting realistic yet positive expectations for the treatment.
The main difference between these doctors and ‘real’ doctors would be emphasis on the ‘performance’, making sure the patient feels heard.
The Big Finale
Now for the more controversial aspect: replacing expensive medicines with placebos. A range of treatments should be available, from small sugar pills to larger sugar pills, depending on the magnitude of the effect required. Even colours of the pills can be used: Colours affect the perceived action of a drug and seem to influence the effectiveness of a drug(disclaimer): For instance, Yellow, red orange for stimulant effect, blue and green for tranquilising effect. To take it even a step further, saline injections and IV fluids can be additionally used, for those seen to be requiring an even stronger placebo.
FTP’s could even provide an additional, complementary use-case in the provision of second opinions for doubting patients. Now, if the doctor is unsure himself of the first diagnosis, it goes without saying that a different, regular hospital should be referred to. However, if it appears as though a patient is demanding a second opinion among more unreasonable lines, why not save capacity, money and time for all concerned by using a second opinion from an FTP?
Placebo mimics replacing MRI, X-Ray, CT Scan and all other imaging and testing machines can be installed, essentially empty boxes that generate convincing, applicable noises. FTP doctors and nurses could take the patients through all the same steps in taking these scans, but when it came to analysing the results, the same/similar images generated, the same conclusions as the original hospital would be reached. This would help the patient grow comfort and confidence in the original doctor’s opinion, and this improved perception will aid the patient in being more receiving to any treatment given to them.
Even as I write this sounds ethically murky- but I do believe that there is an argument that the patient has not been to lied to: all the results and conclusions are genuine: they have merely been repackaged again to bolster the patient’s well-being.
Referring back to ‘The Opening: The Bigger the Better’ section, mock surgeries could also be implemented: patients undergo the same process as for a real surgery, put under anesthesia (okay here we might want the real deal, to ensure the risks of putting a patient under anesthesia are considered and managed), and the ‘surgery’ then takes place. Of course nothing occurs, merely a skin puncture, but the patient wakes up groggy to the blinding view of a surgical light, and will feel the scar of the surgery for weeks. As the saying goes, if it works, it works (remembering the ‘huge if true’ stance adopted in the beginning)
Fun Killing Begins
Of course, this idea is not perfect. The ethical debates and issues that these FTPH’s would cause would be enough to fill a whole bookshelf, and frankly, I don’t know what I don’t know with regards to the ins and outs of hospital and patient care ethics.
For one, the act of providing placebos instead of potentially working cures in trials is already an ethical minefield, and to extrapolate these hurdles to the scales we are talking about may be even too high for Duplantis to vault over.
Furthermore, how would these FTP Hospitals even be created? Would it be a government initiated secret, another secret the government-is-lying-to-you conspiracists can feast on? Or would it be one of those Stalinist open secrets everyone knows about but no one is inclined to bring to the light? However it would be done, those who do decide to breathe life into this idea would need to have the best lawyers on hand, in cases where people believe they are not treated properly in a FTP Hospital- perhaps regulation would be needed to even create the framework for the foundations.
The magic touches of placebos are everywhere, to make everything feel just a little more safe, trustworthy, higher quality and efficient. One well known example is that Beats puts weights in their headphones to make them feel higher quality. Low quality items are often associated with being cheap; easy to throw away. Adding weights make them feel higher quality, as being heavier enables the headphones to be harder to literally and metaphorically ‘throw them away’.
Bottom line, the placebo has often been used a baseline with regards to testing new drugs, but should it not be extended to be the baseline for everyday treatment (especially for ailments which do not have a treatment or in lieu of heavily problematic treatments)?
Many of the suggestions above do not seem too outlandish- is improving waiting times or communication with the doctor that controversial? Instead of creating separate placebo hospitals, the answer may lay in embedding some of the placebo findings into current hospitals. Raising the ceiling is always the goal, but raising the floor should not be left behind either.
Make sure to give this broadcast a coherence score!
That’s all from me for now, but stay tuned for future broadcasts,
This has been Kunga’s Written Radio,
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