 Can you tell me about the placebo effect? What is it? The placebo effect is interesting both historically and its mechanisms. The placebo effect really was publicized as a result of a paper I think in 1955 by somebody named Beecher called the powerful placebo and he didn't do any new research But he evaluated existing literature and he showed that for a variety of treatment modalities About a third of the for a variety of different disease states about a third of the people that don't get treated get better and That's the wide-way cited statistic where about 30 or 33 percent of people who get a placebo Get better. So what do you mean by a placebo? What's what's a placebo a placebo? Well placebo can be anything it could be if the Treatment is a is a drug a placebo can be something that looks like the drug but doesn't contain the active ingredient if the treatment consists of the Application of a machine like a hearing aid a placebo would be an in effect You know a something that looks like that hearing aid not turned on but not turned. Yeah, okay, okay, so So how does the police it? How does the placebo effect work? What's the mechanism well that allows you to somehow have a physiological reaction even though there is no active drug or substance? well, we when you say have a physiological reaction the placebo effect is Based on the patient's report of the feeling better and that's to be distinguished from a physiological reaction Although there are occasional isolated reports There are really not good studies that are stood up to replication that said that a placebo Can have a physiological effect in terms of producing tumor regression for example or rather placebo effects are seen primarily in two areas Analgesia that is pain relief the patient reports that they're in less pain and Depression the patient reports at the less depression and these are all kinds of private symptoms They're only available to the patient they're not available to anybody else outside the patient and so the patient has to report on them In terms of public symptoms Blood pressure or asthma symptoms and things like that placebo effects and much less pronounced So let me tell you about an interesting study that was done recently where Patients who had asthma Had a there's a drug that's effective called albuterol and if patients get albuterol You can demonstrate that the symptoms are released by changes for example in respiratory volume so if you Give half half your patient what they gave a third of the patient's nothing a third of the patients an albuterol inhaler and a third of the patients a placebo inhaler that didn't have the active drug in it and The patients that got the placebo inhaler reported they felt as good as the patients that got the actual active ingredient inhaler and both of them did better than the patients who got nothing but if you actually measure respiratory volume It was only the patients who got the active albuterol inhaler that performed better so If the patient says they feel better that's usually taken as evidence of the placebo effect But often if you measure whether they get better and if you have some physiological index like Respiratory parameters then then you will find that there is no placebo effect Well, what does it what does it mean for something to be a real effect though? So how would you react to someone who said well and even though you feel or you're reporting? You have less depressive symptoms. You don't really have less depressive symptoms because I gave you a placebo But that seems strange because I do have less. I am actually reporting feeling a report us. Well and that People make mistakes and the mistakes are understandable Even with the best diagnostic procedures Physicians that do a pen that Appendix surgery are going to do unnecessary surgery 10 to 20 percent of the time Because they don't want to make the type of error which is exactly there are two types of mistakes And one type of mistake is horrendous that is missing an infected appendix the undit the other type of mistake that that would be a A false negative the other type of mistake a false positive where the patient doesn't really have appendicitis But you do the surgery well, that's pretty bad You're doing unnecessary surgery, but it's not as bad as missing an inflamed appendix So the physics we understand the physician can make a false positive errors when when considering the Costs and benefits of the different types of of errors that they make well now the patient is in pain and gets a drug and Or gets a substance Which the physician? Assures the patient will alleviate the pain Well, it's just like the physician had a hard time diagnosing the appendicitis The patient has a hard time deciding whether the pain or the depression or whatever is better or not They have to pain is fluctuating in intensity. They have to somehow compare the current level of pain with some presumably Arithmetic mean of the of the pain in the recent past and how recent past so it's a very difficult decision to make the patient if the patient In fact gets an inert substance But doesn't know that doesn't know whether they get an inert substance or placebo then if they make one type of mistake They'd be this they suppose they actually got a active ingredient and if they said I don't feel better They'd be disputing the the expertise of the physician. They might be Labeled a complainer. They might be prolonging their stay in the house. So there are pressures on the patient That's right. So placebo effect for a patient is a false positive response And it's understood that is mistakenly saying I feel better when I don't feel better And it's as understandable as a false positive response that the clinician makes and diagnosing appendicitis in the patient It's interesting. You said before that a placebo can be anything Are there any factors that affect the strength of a I guess if the patient is more and more convinced that the substance that they get might be one with active ingredients because for example It's very expensive or it's it's It's Comes from a bottle. It looks like an orthodox medicine bottle rather than or a big syringe. That's right Yes, that's right. Yeah, okay, but I don't want you to think that that that All the CBO effects are simply false positive response. In fact, most of them and All of them in Beecher's case in 1955 are explained by a much simpler mechanism Which is simply regression to the mean that is most people that are sick repoint a Approach of clinician seek treatment When the sickest and most people who are sick get better get better anyway My name is Shep. I think about anticipation