From: apland@mala.bc.ca
Newsgroups: bc.general
Subject: Re: How Often Are Placebo's Prescribed?
Date: 9 Nov 92 20:41:22 -0700
X-From: km@cs.pitt.edu (Ken Mitchum)
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In article <1992Nov3.004937.29395@cis.uab.edu| sloan@cis.uab.edu (Kenneth Sloan) writes:
|In article <17239@pitt.UUCP| geb@cs.pitt.edu (Gordon Banks) writes:
||...
||I'm not sure what the statistics are, but there are many, many
||prescriptions given that are not strictly placebos, but are given
||for that purpose.  A real placebo (sugar pill) is rarely given.
||What is given are penicillin shots to people with colds, etc.
||When people visit the doctor, they don't like to leave without
||having gotten a prescription.  Many of the the things they come
||with have no treatment or need no treatment, but if the doctor
||doesn't give them something, they'll find another doctor.
|
|I've seen this paragraph numerous times in the last few years.  I still
|don't quite understand it.  So...a few questions:
|
|*who are these "people"? - this doesn't describe the behavior of anyone
|that I know

Hmm. This describes the behavior of hundreds of patients that I know.
To come back from the doctor empty-handed is a sign to these people
that they didn't need to go in the first place. If these people have
colds, they demand PRESCRIPTION MEDICINE for them, and oftentimes,
specific antibiotics ("My previous doctor always gave me [insert name
of expensive, hard to spell and pronounce oral cephalosporin here] -
I came in for some today - I'm sure YOU'LL give me some, right doc?").

|*what, specifically, is wrong with letting them "find another doctor"?

Most doctors prefer to see patients than to not see them! Many patients
see the supply-and-demand side of medicine only in terms of trying to
get a new appointment with the "best" physician in town (the one "everyone"
goes to). Would it suprise you that for a new physician, starting out
in a new practice, it is common to borrow enough money to live on for
a couple of years, knowing it will be about that time before you make
any money? 

|Are you saying that unnecessary drugs are presribed for the express
|purpose of maintaining market share?

Absolutely. Everywhere but Birmingham, Alabama.

|*Gordon: are you describing your own practice?  rationalizing the
|practice of your colleagues?  condemning the practice of quacks?
|blaming the patient for the sins of the physician?

Are you a preacher?

|It seems to me that prescribing or administering drugs which have no
|chance of being helpful is quackery (unless, of course, they have been
|diluted to homeopathic doses).  At the very least, it is the first step
|onto a slippery slope which leads to "Dr. Feelgood" practices.

Hmm. Giving water is not quackery, but giving drugs for less than
specific reasons is? This does not make sense to me. All of this is
very different from the Dr. Feelgood types. These people do neither
a history nor a physical examination, but operate on one principle
only: give them money and they will give you a prescrition for a
narcotic, or other recreational drug. In my view, this is a bit different
from giving a patient an antibiotic for a cold.

Also, there are rational uses of antibiotics in a prophylactic sense.
The COPD patient in your office may have all the indications of a viral
respiratory infection, but the numbers show that he will in fact
do better if you give him an antibiotic. Some doctors, rightly or
wrongly, generalize such legitimate usage of antibiotics to other
groups of patients. After all, your flu shot is unnecessary if you're
never exposed to the flu.


|While Gordon didn't say this here (someone else did, elsewhere) - I'd
|like to take this chance to express astonishment that a physician would
|consider the dispensing of sugar pills (for their placebo effect)
|unethical, but would simultaneously consider the dispensing of drugs
|(such as penicillin) which are known to be ineffective (for their
|placebo effect).  The only difference that I can see is that one has
|more likely (admittedly minimal) side-effects than the other.  For the
|record, I consider *both* practices to be highly unethical, absent the
|context of a controlled study.  Perhaps someone can explain why I am
|confused.

The sugar pill is an attempt to trick the patient, and is clearly
unethical. In the other situation, the patient is already tricked: he
is convinced he needs an antibiotic, and is not seeing the physician for
purposes of diagnosis and treatment, but merely as a means of obtaining
the antibiotic. 

I am not sure why all of this bothers you so much, anyway. Anyone who
follows this group for long will realize that doctors are not terribly
ethical people in any situation, let alone this one. When there is a
question, we refer things to ethics committees, which are capable of
mucking things up to a degree well beyond the capability of an individual
physician. Since most people assume we are crooks anyway, there is not
much sense in pretending to be anything else.

Are you sure you're not a preacher?

 -km


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