Mind and Body
Physician, Heal Thyself
By JOHN LYDG ATE THE alarming size of the nation's drug bill—even at 2s. a prescription—iS forcing the medical pro- fession to reconsider the whole business of pre- scribing. To a large part of the profession pills and tablets are the essential currency of medical practice; tiny coins with which the doctor repays the patient for the privilege of his confidence. It is an old joke that patients feel cheated unless they leave the con- sulting room clutching a bottle or a pill. Less recognised, but equally true, is the fact the doctor himself often feels a nagging sense of debt if he does not provide his patients with these tangible tokens of treatment-in-progress. The raw house-physician is especially prone to this and will often feel extremely restless and un- happy until he has written something on his patient's prescription chart. The sedatives are a good standby here, and few plitients leave hospi- tal without having had their nightly dose of seconal, blissfully unaware that the doctor ,has probably benefited more than they have. With- out a pill of some sort, few doctors really feel they are treating their patients, being generally unwilling to surrender the active role in the process of recovery. It calls for more wisdom than most practitioners possess to stand back from time to time and act as mere impresarios of spontaneous and natural repair. I do, however, know of one senior physician who has grasped this principle of medical modesty so firmly that he rewards his house man half a crown each time a patient leaves the ward without a drug marked on his prescription card. This mercenary little deal recognises the infla- tion of pharmaceutical currency which prevails today: too many drugs chasing too few illnesses. The clinical trials of modern drugs are a perfect illustration of the mutual benefit derived from prescribing pills. Originally designed to test the value of new remedies, these trials have often revealed more about the psychology of the patient-doctor duet than about the action of any of the various drugs in question.
When a new drug comes on to the market it is assessed by a series of clinical trials. Broadly, this consists of dividing the patients into two large groups. One lot receive the drug to be tested while the others receive placebos, tablets of identical taste and appearance made up of inert substances. If the patients receiving the real pills show a statistically significant improvement over those receiving the placebos the drug is cautiously accepted into the royal enclosure of current therapy. Unfortunately this simple set-up complicated by two factors which often undo the validity of the whole experiment. The doctor himself, powerfully influenced by the reputation of the new drug and by his own desires for a remarkable remedy, can never be relied upon not to convey to a patient into which group he has been put. While he will obviously not explicitly give the game away he will inevitably betray his great expectations with the patients receiving the new drug and will unconsciously phrase his ques- tions so as to yield the most encouraging reply. Patients are curiously reluctant to disappoint their medical attendants and will often give misleadingly favourable reports to avoid ex- tinguishing the touching glint of expectation in the doctor's eyes. Few doctors are objective enough to realise the extent of this tender loyalty on the part of their patients. In this way patient and doctor brainwash each other into enthusiasm for the new drug. The well-designed trial avoids this unconscious conspiracy by a system known as the double-blind in which the physician who actually deals with the patient has no idea Whether he is administering the drug or the placebo, the pills being issued by a doctor Who has no contact with the patient. This ar- rangement yields relative impartiality. It was by using this technique that the Medical Research Council curbed the hysterical enthusiasm with which cortisone was first greeted.
However, unhappily, this is not the only pitfall. Far more disturbing is the fact there is, in the last reduction, no such thing as a real placebo. Patients will often respond in dramatic and quite unpredictable ways to substances which have no known pharmacological effect. The mere fact of their being administered in a therapeutic situa- tion, in hospital, by priestly figures in white coats, will sometimes be enough to provoke a favour- able response. It may not always be favourable: some patients, given a placebo, will feel faint, vomit, get violent headaches or break out in shivering fits. Patients who display this violent response are termed 'placebo reactors' and have been shown to share the same withdrawn, sug- gestible personality. Drugs are sometimes tested on healthy volunteers and it has been shown that 'reactors' are found more frequently among such volunteer groups than in one selected at random. In effect then, those most eager to help in the testing of new drugs are the least qualified to give reliable results.
A recent issue of the British Medical Journal devoted a leader to this topic and a new textbook of pharmacology for students is unique in its cautionary opening chapter which deals sternly with this ticklish problem. If the cost of pre- scribing is to be kept within limits which do not threaten the solvency of the Health Service these facts should be more widely publicised. The role of the drug in the patient-doctor relationship will have to be reconsidered. By encouraging closer and more honest psychological contact we will do away with such primitive tokens of mutual reassurance as the pill. Only then will the valuable drugs stand out in their true and actually very startling perspective.
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