When I heard Professor Clare Gerada and Dr Margaret McCartney on the Today programme discussing the news that three quarters of GPs ‘administer placebos once a week’, I was surprised. I am not sure I have never knowingly prescribed a placebo. I might have been persuaded by a patient to prescribe something I wasn’t 100% sure about – but that’s shared decision-making in practice. I am concerned about deceit of medicine at many levels.
I can understand why some GPs are tempted to prescribe when they think it may not be effective. It’s quick, and it gets patients out of the door faster than you could with an honest conversation, or at least it does for that consultation, but it also encourages help seeking behaviour and repeat attendances.
But at my surgery – where this week we triage 115 patients on the phone one morning – if we gave every patient a face-to-face consultation then we’d never give everyone the time they need. Most of the solutions to patients’ problems can be found in their history, and many of the problems they bring to GPs can be solved through information, reassurance, advice about self-care or over the counter treatment.
Strictly speaking, any treatment a patient doesn’t need is a placebo – examinations included. For instance, I would resist performing a chest examination in a child just because the mother wants me to do one. If there is no clinical indication such as suspicion of pneumonia because of other features (such as chest pain, high fever, unwell, breathlessness), then I really don’t need to listen to the chest. To do so without an explanation as to why it is unnecessary would be deceitful.
When you take time to explain why it is not helpful, then most parents are happy. You give them confidence to know when to be worried, and most of all when not to be. For the same reason most GPs would instinctively decline to prescribe an antibiotic, a viral URTI doesn’t need me to listen to them breathing. However, it still needs me to understand their concerns, inform, reassure, advice and most importantly empower to self assess and self care.
The ‘magical stethoscope’ myth
Placebos take power away from the patient and give power to the doctor. We begin to see magical treatments and examinations – the stethoscope that can hear a virus, or the antibiotic that can cure all infections. But this myth hurts everyone.
The sooner patients realise and doctors admit the limitations of medicine, the sooner we will get the demand for NHS services back on track.
I have said before that the NHS is a paternalistic institution. Like all professions, medicine is a myth-builder which relies on its own jargon and tools of the trade to keep a bit of mystique.
But the time has come to be open and honest about what medicine can offer, and what it can’t. We have so much opportunity now for patients to self-care, for everything from self-limiting respiratory infections to diabetes and hypertension, and it’s a big missed opportunity.
GPs are key patient educators, and the solution to demand is by admitting that sometimes it’s more effective if we don’t intervene. I myself have a long-term condition and just this morning, emailed my GP and consultant a few questions about my treatment while I travelled down to London on the train. Doing that was more time- and cost-effective than booking an appointment, and although I admit that I probably get a bit of ‘special treatment’ because I myself am a GP, there are a couple of doctors at my surgery who use email to communicate with their patients. The NHS has been incredibly slow at adopting new ways of communication.
We should always come clean with the public and our patients. To any GP who would defend placebo treatments and examination I would ask, why can’t we have an open and honest conversation with patients?
It’s my belief that it’s a doctor’s duty to be honest and open with patients, and that means cutting down on our use of anything with a placebo effect, examinations and treatments alike, it is a short-term solution and frankly a bit of a cop-out.
Dr Steve Laitner is the clinical lead for the Department of Health-funded programme on shared decision-making, and a GP in St Albans.