Placebos and Medical Education

THE PLACEBO CHALLENGE Placebos are ubiquitous, counterintuitive, topical, and germane to medical science (1). Current scientific understanding about placebos, however, is sparse, fraught with debates and even explicit confusion (2-4). Whether one subscribes to placebo phobia or placebo mania (5), the domain of placebos draws on definitions, concepts, and paradigms that often baffle not just the general public, but the greater medical community (3). Thus, many modern physicians find placebos difficult to swallow or prescribe for others (6). As we discuss separately in this issue, ethical considerations complicate administration of placebos in clinical settings (7-9). Ethics aside, however, practitioners seem unclear even about fundamental concepts in the science of placebos, including the difference between placebo effect and placebo response (10). The platitudes health care professionals utter about placebos in personal communications and over cocktails provide ample evidence for this trend. The bright McGill University fourth-year medical students who attended my Placebos in Medicine class were products of this dynamic. (McGill Medical School offers Placebos in Medicine as an elective component to a Medicine and Society core course). Medical students receive little education about placebos. This lacuna may well explain why the medical community continues to entertain an incoherent understanding of the placebo effect, largely considering it a sham effect, albeit one coupled with a powerful physiology (11). Furthermore, most contemporary medical students obfuscate the little they know of placebos with what they learn in " physicianship " (i.e., courses focusing on the " softer " issues of medicine, such as bedside manner). Speciously, they seem to view placebos through the narrow lens of grooming and dressing well for the clinic, smiling at patients, and maintaining a cheerful attitude. Consequently, tomorrow's clinicians expect placebos to wield a minor effect, if any. Medical students draw their inspiration from today's physicians, who themselves often maintain erroneous conceptions about placebos (12). As a senior physician-colleague recently put it to me, most placebos are inert, yet to do something (e.g., cause changes) they need to be anything but " inert. " As a matter of fact, most placebos are inert, yet changes do occur (13, 14). Historically, physicians have been keenly aware that sick people get better after taking inert drugs (11). It is less evident, however, that physicians were then, as they are now, largely ambivalent about placebos (15-17). From the outset, the road to a medical career seems congruent with reductionist science but …