Health beliefs and the placebo effect

Interviewer: Sam Walter (Interviewer, Ideas Lab)
Guest: Jonathan Shapiro
Recorded: 14/05/2013
Broadcast: 28/05/2013

Intro VO: Welcome to the Ideas Lab Predictor Podcast from the University of Birmingham. In each edition we hear from an expert in a different field, who gives us insider information on key trends, upcoming events, and what they think the near future holds.

Sam: So we’re here today with Dr Jonathan Shapiro who’s an Honorary Senior Research Fellow at the University of Birmingham. So can you tell us a bit about what you do at the university?

Jonathan: I’ve had a connection with the university for well over twenty years in various capacities which reflect my fairly eclectic interests. Originally I was a GP so I was a clinician and I spent time in management before I came to the university and I was based at the Health Services Management Centre in the School of Public Policy for about fifteen years and then I came over to the Medical School because I wanted to work more with clinicians and I thought they would see someone working in a Medical School with more sympathy than someone who was working in a management centre. So I’ve looked at a number of different aspects of health services and particularly the interface between clinicians and managers, the role of the clinical role, the managerial role and there’s a little bit there which perhaps we’re going to talk about between the science and the art of medicine. I think that’s quite important. 

Sam: So it’s very much about understanding how management works from a practitioner’s perspective. 

Jonathan: It’s understanding what drives people. So I mean the research that we’ve been working on at the university more recently is knowledge transfer – how do we get the clinicians to change their behaviours? Do you bully them into it, do you persuade them? And actually the conclusions that we’ve drawn from that is there’s a lot more marketing involved than perhaps just evidence and science and again, that’s back to this interface between art and science. Just taking a purely rational approach to making professionals change their behaviour doesn’t work, you need to appeal to other senses and it’s very much like marketing. I think what we want to talk about today more generally is if you like, how we appeal to people in terms of illness and getting better, as much as we’re talking with clinicians and changing their behaviour. Let me ask you a question. How do you know when you’re ill?

Sam: I guess there’s a series of different things aren’t there? I mean sometimes it’s when other people say, you know, ‘you’re looking ill’ and then you start thinking maybe I should go to the doctor. And then other times it’s a feeling in the stomach or you’re literally not feeling very well. 

Jonathan: And some of them are clearly objective symptoms but there’s also something about knowing when you’re ill and I’m wondering where one learns that? Where do you think you learnt your beliefs about health?

Sam: I guess it’s very much from what you brought up with by your parents really isn’t it? You were told ‘I think you should go to the doctor, I’m not happy that you’re this unwell, I think you should see someone for peace of mind’. 

Jonathan: That’s precisely the point we’re getting to, that it’s something that you learn at a very early age and it’s fairly deeply ingrained and health beliefs are beliefs. Now beliefs, a bit like religious beliefs, are not amenable to reason. If you’re sensible you’ll never get into a religious debate with anyone because it’s based on very simple and sometimes illogical beliefs, and health is the same. So for example if I use myself as an example, if I had a temperature, my mother would keep me at home because she believed that I was ill. I may feel fine but if I had a temperature I had to stay at home. If I didn’t have a temperature I may have felt like death warmed up but I still had to go to school. So that was her belief and she’s passed that onto me. So people throughout time have grown up with health beliefs and they do modify and change but they’re a very important part of how we deal with illness. If you follow that through, if we go back to Aboriginal society in Australia, famously if the witch doctor pointed the bone at you and said ‘you will be dead within a month’, then you would be dead within the month. Now nobody knows how that works and you somehow believed yourself into a state of dying and most societies have that sort of aspect. Our own society until the advent of scientific medicine which was what, in the mid-19th Century, you’d have cupping and leeches and bleeding and all these other behaviours that weren’t based on evidence but had a very strong element of belief and some people got better and some people didn’t. And that sense, that aspect of care, continues. There’s an aphorism that’s used in general practice by Voltaire which is ‘the art of medicine is to keep the patient entertained while nature takes it course’ and there’s an element in most medicine of working with the body rather than forcing yourself onto the body and clearly the body is formed of its physical side as well as it’s psychological beliefs side. In recent years we’ve started to think of that as the placebo effect. It’s the bit of treatment that we can’t account for with our drugs or our operations or whatever and here, if you like, is the centre of my thesis that it’s a shame that we’re wasting that. If you look at all the studies that are being done, the first thing they do is to discount the placebo effect so they can see the actual effect of whatever it is they’re treating. And that’s fair enough. If you’re introducing a new anti-depressant you want to know that it’s better than just giving a sugar pill and quite interestingly in fact, the evidence about anti-depressants is very mixed. A lot of people say they aren’t much better than a placebo. My point isn’t about that. My point is that we’re discounting a third of all therapeutic impact and we shouldn’t be. So most medication, most treatments that we do, about a third of the effect is due to our own beliefs and the fact that we are treating ourselves in some sort of social and psychological way, the placebo effect, and it would be a shame to lose that. So we do surgery. Now, nobody knows whether surgery has a placebo effect. It probably hasn’t, but for example there was a big argument about ECT – electric convulsive therapy – and whether that was because you believed it would make you better or it actually made you better. It’s a very brutal treatment; it’s not used very often now. It is only now used because they think it does have a very definite effect. So I think the more interventionist you are, clearly then you want to be careful that what you’re doing is worthwhile. But when you’re getting into areas of self-limiting disease and how people treat themselves, then it’s really important to capitalise on the placebo rather than discounting it. 

Sam: So it’s perhaps health organisations such as the NHS should perhaps be looking into marketing and psychology to address these health problems that we have. 

Jonathan: Well, it’s very interesting because it’s a very important element of what is happening now in little bits. Our problem is that we tend to respond to the urgent and the immediate rather than the long term and the preventive. The metaphor that’s often used is we’re so busy fishing people out of the river that we don’t think much about how we stop them falling in in the first place. What we’re talking about is how do we stop them falling in, or feeling that they’re falling in, in the first place. 

Sam: How does the future look when it comes to our perceptions of health?

Jonathan: I think you can either be optimistic or you can be pessimistic and reality is probably somewhere in between the two. How it feels at the moment is this increasingly cognitive dissonance, that we’re not actually taking into account what’s changing so the media pressures, the Government publicity, is all about; you can have more and more and the system will supply it, and actually it can’t. So the pessimistic line is we’ll go on until it breaks and that’s really quite depressing. The more optimistic side is that we are now a bit more aware of things like how we influence behaviour in these not just scientific ways but in ways that include marketing and advertising and media and so on, and we are also perhaps more aware that it’s more than just the science, we do need to go back to some of these beliefs and try and capitalise on those rather than abandoning those. So if we put all those together and make people have a better sense of their own responsibility – let me give you a political metaphor to finish with – if you look at Soviet Russia, the communist system, the State had absolute precedence and the individual was completely nothing within that. So the State was doing you a favour and that didn’t work because people felt disempowered, their health was very poor, the systems didn’t work very well. If you take the opposite extreme and you get these American capitalist versions, there the individual is completely predominant and society doesn’t matter. So people are all about me, me, me and actually that doesn’t work either because you get enormous disparities and inequities and we in Europe and in Britain don’t like either of those and we’ve sort of taken some sort of middle ground, some sort of social democracy idea, that we know we want individual and we want entitlement but we are aware that there is a broader context and so there is a bit more of a balance within that. So my guess is if I was a politician or an opinion former in that sense, I would be trying to develop that theme and that is yes, it is entitlement, it is about what you’re doing but in a much more responsible way, appealing to people and how they link with society, whether it’s using energy and fuel, whether it’s the way that we use the health service, whether it’s the way we demand things and begin to modify those using all these levers that we’ve talked about and it’s doing those very subtle changes that over a period of time, if it’s concerted, if it’s allowed to be apolitical, will probably reap results. So that’s if you want to be optimistic where we’re going. 

Sam: Dr Jonathan Shapiro, thank you very much indeed. Jonathan: Thank you. 

Outro VO: This podcast and others in the series are available on the Ideas Lab website: On the website, you can find out how to e-mail us with comments, questions or suggestions for future topics for the podcast. There's also information on the free support Ideas Lab has to offer to TV and radio producers, new media producers and journalists. The interviewer and producer for the Ideas Lab Predictor Podcast was Sam Walter.