Lucille Marchand

Placebo, Meaning, and Health

Placebos are boon and bane to medical theory and clinical practice. On the one hand, randomized controlled trials employ concealed allocations of placebo to control for effects not due to specific pharmacological mechanisms. As a result, nearly all of evidence-based medicine derives from principles and practices based on placebo. On the other hand, medical researchers and physicians have tended to ignore, minimize, or deride placebos and placebo effects, perhaps due to values emphasizing scientific understanding of mechanistic pathways. We argue that intention, expectation, culture, and meaning are central to placebo-effect phenomena and are substantive determinants of health. We introduce three dualities that are integral to placebo/meaning phenomena: body-mind, subconscious-conscious, and passive-active. These placebo-related dualities should be acknowledged, explored with research, and incorporated in theory. While we view consideration of placebo and meaning effects as essential to any adequate understanding of human health, we feel that lessons from this area of inquiry may already provide practical tools for astute clinicians. Toward this end, we list eight specific clinical actions: speak positively about treatments, provide encouragement, develop trust, provide reassurance, support relationships, respect uniqueness, explore values, and create ceremony. These clinical actions can empower patients to seek greater health and may provide a healthful sense of being cared for.

What Complementary and Alternative Medicine Practitioners Say About Health and Health Care

BACKGROUND We wanted to explore the beliefs and practices of complementary and alternative medicine (CAM) practitioners. METHODS A representative sample of local CAM practitioners was selected for 32 face-to-face in-depth interviews. Interviews were taped, transcribed, and reviewed by all coauthors. Analysis and interpretation were reached by consensus, using an iterative process in multidisciplinary group meetings. RESULTS The CAM practitioners interviewed stressed the holistic, empowering, and person-centered nature of CAM. They described themselves as healers, employing attentiveness, touch, and love to increase self-awareness and strengthen the healing process, usually in chronic illness, often with pain. They affirmed goodwill and respect toward conventional medicine, calling for greater integration of conventional and complementary health care; however, they identified the major differences of conventional medicine and several formidable barriers. They displayed concern about accessibility issues in health care and stressed that attitudes and beliefs were often larger impediments to integration than were economic or scientific considerations. CONCLUSIONS In general, CAM practitioners want to work with physicians and other conventional health care workers in seeking a holistic, accessible, patient-centered, integrated health care system.

Qualitative Aspects of Nasal Irrigation Use by Patients With Chronic Sinus Disease in a Multimethod Study

PURPOSE We qualitatively assessed attitudes regarding use of hypertonic saline nasal irrigation (HSNI) for frequent rhinosinusitis and chronic sinonasal symptoms in a 3-part, multimethod study. METHODS We conducted semistructured, in-depth interviews with 28 participants who recently used nasal irrigation in studies assessing HSNI. RESULTS Four themes emerged: (1) HSNI improved self-management of sinus symptoms, creating a sense of empowerment; (2) HSNI produced rapid and long-term improvement in quality of life; (3) participants identified discomfort, time, and mild side effects as barriers to HSNI use; and (4) participants identified aspects of training and at-home use that overcame these barriers. CONCLUSION HSNI is a safe, well-tolerated, inexpensive, effective, long-term therapy that patients with chronic sinonasal symptoms can and will use at home with minimal training and follow-up. Success with HSNI will likely be improved by patient education.

Quality of Work Life of Independent vs Employed Family Physicians in Wisconsin: A WReN Study

PURPOSE Family physicians in Wisconsin who are mainly employed by large health care organizations have voiced concerns regarding the quality of their work lives. We explored the quality of work life and its relationship to employment by health care organizations. METHODS We conducted a cross-sectional survey of the 1,482 active members of the Wisconsin Academy of Family Physicians in 2000. RESULTS A 47% overall response rate was obtained, and 584 respondents could be identified as independent or employed by a health care organization. There were no differences in age or sex between the 2 groups. The independent physicians worked longer hours, were in smaller work groups, and had been in practice longer and in their current practice longer than the employed physicians. Independent physicians reported better working relationships, more satisfaction with family time, more influence over management decisions, better satisfaction with being a physician, better perceived quality of the care they provided, greater ability to achieve professional goals, and lesser intention to leave the practice. CONCLUSIONS Independent physicians have significantly more positive ratings of several aspects of the quality of their work life compared with physicians employed by health care organizations. Health care organizations need to address these issues if they are to have a satisfied and stable workforce.

Placebo Effects and the Common Cold: A Randomized Controlled Trial

PURPOSE We wanted to determine whether the severity and duration of illness caused by the common cold are influenced by randomized assignment to open-label pills, compared with conventional double-blind allocation to active and placebo pills, compared with no pills at all. METHODS We undertook a randomized controlled trial among a population with new-onset common cold. Study participants were allocated to 4 parallel groups: (1) those receiving no pills, (2) those blinded to placebo, (3) those blinded to echinacea, and (4) those given open-label echinacea. Primary outcomes were illness duration and area-under-the-curve global severity. Secondary outcomes included neutrophil count and interleukin 8 levels from nasal wash at intake and 2 days later. RESULTS Of 719 randomized study participants, 2 were lost and 4 exited early. Participants were 64% female, 88% white, and aged 12 to 80 years. Mean illness duration for each group was 7.03 days for those in the no-pill group, 6.87 days for those blinded to placebo, 6.34 days for those blinded to echinacea, and 6.76 days for those in the open-label echinacea group. Mean global severity scores for the 4 groups were no pills, 286; blinded to placebo, 264; blinded to echinacea, 236; and open-label echinacea, 258. Between-group differences were not statistically significant. Comparing the no-pill with blinded to placebo groups, differences (95% confidence interval [CI]) were −0.16 days (95% CI, −0.90 to 0.58 days) for illness duration and −22 severity points (95% CI, −70 to 26 points) for global severity. Comparing the group blinded to echinacea with the open-label echinacea group, differences were 0.42 days (95% CI, −0.28 to 1.12 days) and 22 severity points (95% CI, −19 to 63 points). Median change in interleukin 8 concentration and neutrophil cell count, respectively by group, were 30 pg/mL and 1 cell for the no-pill group, 39 pg/mL and 1 cell for the group binded to placebo, 58 pg/mL and 2 cells for the group blinded to echinacea, and 70 pg/mL and 1 cell for the group with open-label echinacea, also not statistically significant. Among the 120 participants who at intake rated echinacea’s effectiveness as greater than 50 on a 100-point scale for which 100 is extremely effective, illness duration was 2.58 days shorter (95% CI, −4.47 to −0.68 days) in those blinded to placebo rather than no pill, and mean global severity score was 26% lower but not significantly different (−97.0, 95% CI, −249.8 to 55.8 points). In this subgroup, neither duration nor severity differed significantly between the group blinded to echinacea and the open-label echinacea group. CONCLUSIONS Participants randomized to the no-pill group tended to have longer and more severe illnesses than those who received pills. For the subgroup who believed in echinacea and received pills, illnesses were substantively shorter and less severe, regardless of whether the pills contained echinacea. These findings support the general idea that beliefs and feelings about treatments may be important and perhaps should be taken into consideration when making medical decisions.

Building successfuli coalitions for promoting advance care planning

Advance care planning (ACP) has had few successful initiatives. This qualitative study explores the challenges and successes of an advance care planning coalition in Wisconsin called Life Planning 2000 using key informant interviews (n = 24) and grounded theory. Major themes included: commitment (the need for leadership, recruitment of key members, and funding); cohesiveness (disparate groups collaborating toward a common purpose); and outcomes (shift in paradigm from signing documents to process of advanced care planning, new-found collaborative relationships, and educational tool development). Coalitions need to define short-, intermediate-, and long-term goals that result in measurable outcomes and an evaluation process. Resources must be commensurate with goals. Strong leadership, paid staff, adequate funding, and the collaboration of diverse groups working toward common goals are the basic requirements of a successful coalition.

Building successful coalitions to promote advance care planning

This qualitative study explored the challenges and successes of an advance care planning (ACP) coalition formed at the University of Wisconsin called Life Planning 2000. Data were obtained from key informant interviews (n = 24) and grounded theory. Major themes included commitment (the need for leadership, recruitment of key persons, and funding); cohesiveness (disparate groups collaborating toward a common purpose); and outcomes (including educational tool development). Coalitions need to define short-, intermediate-, and long-term goals that result in measurable outcomes and an evaluation process. Resources must be commensurate with goals. Results indicate that strong leadership, paid staff, adequate funding, and the collaboration of diverse groups working toward a common goal are essential if a coalition promoting end-of-life (EOL) care planning is to be successful.

Shared presence: The heart of the therapeutic relationship.

Shared presence is cultivated in every clinical experience, but some interactions lend themselves to shared presence more easily than others. Shared presence requires at least two people to be in relationship, and the patient side of shared presence can be influenced by physician or clinician factors, but not completely. We can only cultivate the qualities in ourselves that facilitate shared presence, and invite the patient, family, and others to enter into this presence with us. But we do know that if we do our part to cultivate presence, the likelihood of a more meaningful interaction with patients may occur together with all of the benefits outlined in this article.