The Placebo Effect and Health: Combining Science and Compassionate Care
http://www.100md.com
《新英格兰医药杂志》
These are discouraging times for physicians and their patients. Science has expanded the possibilities for healing and curing, but the specialization and commercialization of health care have fragmented its delivery and increased its cost. Into the formerly intimate space between doctor and patient have marched insurers, regulators, administrators, lawyers, drug representatives, the media, and politicians. This massive intrusion has corroded the fragile social contract that is at the core of medical practice. The placebo response encapsulates this healing doctor–patient interaction, and by reviewing it in detail, W. Grant Thompson gives us a unique opportunity to see both what is possible and what is missing.
The book has two parts. The first is a comprehensive review of the literature on the placebo effect, and the second is an overview of the various influences that either enhance or worsen patients' outcomes and satisfaction.
The placebo effect is a perennially fascinating subject. Its appeal lies in its apparent mysteries: How can an inert substance cure a disease? And how can the mind affect the body? Placebo research has recently expanded, culminating in brain-imaging studies describing the neural circuitry that mediates a placebo's relief of pain. All this research has demystified the placebo response, at least among knowledgeable experts, who consider it an example of an expectancy response. Thompson does not cover this research in detail, so this book is not a good source of information about modern placebo research. Furthermore, the book contains factual mistakes, including the statement that patients will show an analgesic response to a placebo treatment even when they are informed that it is a placebo. Chapter 13, "The Placebo Responder," in particular, omits a description of the research showing that implicit learning and explicit instructions that alter patients' expectancy are the major determinants of placebo responses, rather than preexisting psychological traits.
Although his understanding of the underlying neural and psychological mechanisms is superficial, Thompson does an excellent job of defining, describing, and explaining the placebo effect. He elucidates common areas of confusion, such as the natural history of disease and the regression to the mean, which explain much of the improvement after the administration of placebo. This discussion will be helpful for anyone evaluating or designing a clinical trial of a new treatment. Furthermore, a full understanding of the placebo response is crucial for defining the limits of research on clinical outcomes. In the most informative and thought-provoking parts of his book, Thompson covers areas in which placebo responses inevitably cloud the evaluation of treatment efficacy. Two are handled in a particularly illuminating way: the efficacy of complementary and alternative medicine (acupuncture, homeopathy, and herbal medicine) and the efficacy of psychotherapy. Thompson raises the critical point that, since giving a placebo is a form of psychotherapy, comparing psychotherapy to placebo may be meaningless.
In the second part of the book, Thompson outlines the threats to a salubrious doctor–patient relationship, which is exemplified by the placebo response. Although this material is largely anecdotal and personal, it is extremely important. He emphasizes the value to both patient and doctor of a personal, long-term relationship and offers ways to defend it from the forces of fragmentation and isolation. This book is a call to action by a wise and compassionate physician who cares deeply about his ancient profession.
Howard L. Fields, M.D., Ph.D.
University of California, San Francisco
San Francisco, CA 94143(By W. Grant Thompson. 350)
The book has two parts. The first is a comprehensive review of the literature on the placebo effect, and the second is an overview of the various influences that either enhance or worsen patients' outcomes and satisfaction.
The placebo effect is a perennially fascinating subject. Its appeal lies in its apparent mysteries: How can an inert substance cure a disease? And how can the mind affect the body? Placebo research has recently expanded, culminating in brain-imaging studies describing the neural circuitry that mediates a placebo's relief of pain. All this research has demystified the placebo response, at least among knowledgeable experts, who consider it an example of an expectancy response. Thompson does not cover this research in detail, so this book is not a good source of information about modern placebo research. Furthermore, the book contains factual mistakes, including the statement that patients will show an analgesic response to a placebo treatment even when they are informed that it is a placebo. Chapter 13, "The Placebo Responder," in particular, omits a description of the research showing that implicit learning and explicit instructions that alter patients' expectancy are the major determinants of placebo responses, rather than preexisting psychological traits.
Although his understanding of the underlying neural and psychological mechanisms is superficial, Thompson does an excellent job of defining, describing, and explaining the placebo effect. He elucidates common areas of confusion, such as the natural history of disease and the regression to the mean, which explain much of the improvement after the administration of placebo. This discussion will be helpful for anyone evaluating or designing a clinical trial of a new treatment. Furthermore, a full understanding of the placebo response is crucial for defining the limits of research on clinical outcomes. In the most informative and thought-provoking parts of his book, Thompson covers areas in which placebo responses inevitably cloud the evaluation of treatment efficacy. Two are handled in a particularly illuminating way: the efficacy of complementary and alternative medicine (acupuncture, homeopathy, and herbal medicine) and the efficacy of psychotherapy. Thompson raises the critical point that, since giving a placebo is a form of psychotherapy, comparing psychotherapy to placebo may be meaningless.
In the second part of the book, Thompson outlines the threats to a salubrious doctor–patient relationship, which is exemplified by the placebo response. Although this material is largely anecdotal and personal, it is extremely important. He emphasizes the value to both patient and doctor of a personal, long-term relationship and offers ways to defend it from the forces of fragmentation and isolation. This book is a call to action by a wise and compassionate physician who cares deeply about his ancient profession.
Howard L. Fields, M.D., Ph.D.
University of California, San Francisco
San Francisco, CA 94143(By W. Grant Thompson. 350)