What Matters More?

The doctor’s…or the patient’s perception of their treatment?  Interesting question!  Even more interesting, it is one that was posed in an editorial in the current edition of the New England Journal of Medicine.

The question arose after a new study showed that patients’ self-assessed outcomes in clinical trials can mask a real lack of an objective effect. The accompanying editorial took a completely different stance – asking, “What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception?”

The double-blind, crossover study in question was led by Michael Wechsler, MD, an SRxA Advisor.  It set out to determine whether responses to placebo differ from the physiological changes that occur without any intervention in patients with asthma. To address this, they compared the effects of an albuterol inhaler, two placebo interventions (an inert inhaler and sham acupuncture needle) versus “no treatment” in which patients were told to wait for several hours and then return home.

46 patients with stable asthma underwent each of four treatments over a series of visits. At each visit, lung function was measured by spirometry every 20 minutes for 2 hours.  Also at each visit, patients were asked to score any perceived improvements in asthma symptoms on a visual-analogue scale with scores ranging from 0 (no improvement) to 10 (complete improvement). Patients were also asked whether they thought they had received a genuine therapy or placebo.

Among the 39 patients who completed the study, improvement in maximum forced expiratory volume in 1 second (FEV1) was significant only after albuterol, however albuterol provided no incremental benefit with respect to the self-reported outcomes.

In other words… from the patients’ perspective all the interventions, except waiting, worked.

While the authors acknowledged that placebo effects can be clinically meaningful and can rival the effects of active medication in patients with asthma, they argued that from a clinical-management and research-design perspective, patient self-reports can be unreliable.  They concluded: “Objective outcomes should be more heavily relied on for optimal asthma care.”

However an accompanying editorial in the same journal questions the authors interpretation.

In it, Daniel Moerman, Ph.D. asks: “Are patients wrong if they report improvement even if there is no evidence for this?” He argues that it is after all subjective symptoms such as wheezing, rather than reduced FEV1 that brings patients to seek medical attention in the first place.

Hence the question, What is the more important outcome in medicine: The objective or the subjective, the doctor’s or the patient’s perception?

All medical procedures whether active or placebo, he argues, are meaningful insofar that they represent something. These meanings create expectations that can dramatically modify the effectiveness of even the most powerful proven treatments. He gives an example of a recent experiment that showed the effects of an opioid drug were either doubled or extinguished by manipulating subject expectations and that  MRI scans showed brain mechanisms differed as a function of these expectations.

Moerman asks: “Do we need to control for all meaning in order to show that a treatment is specifically effective?” Maybe, he suggests, it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects.

What do you think? Is perception reality?  We’d love to know.

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One thought on “What Matters More?

  1. Fascinating study. I have always been in favor of using patient cented quality of life evaluations as a key component of medical decision making. This is particularly true for conditions that are not high risk and where symptoms are the key. Allergic rhinitis is a perfect example of this. Asthma is a different situation, since good control means better long term outcomes. A blend of symptoms and objective tests are probably the way to go.
    One sidebar, in headaches placebo has a 50% success rate even with migraine and this can last for some time. Eventually, however, placebo loses its effectiveness. I suspect this would also be true for this study if followed long enough.

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