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Friday, June 1, 2012

Prayer as placebo

Faith and healing have been intertwined for millennia. Even before the dawn of monotheism, healers have either invoked the name of forces beyond their own or been regarded as conduits for some higher power. This has been the rule whatever the culture or religion, and it continues to be so outside the so-called Abrahamic religions. (This term seems to be taking over from Judeo-Christian in order to recognize that Islam also derives from Judaism.)

The shaman, the medicine man, the healer has been around long before physicians in the modern sense were recognized. I believe it was Hippocrates who was the first to emphasize the skills of the doctor over the power of the gods.

In my own tradition, appeals to God for healing go back to the time of Jesus. At my synagogue, our prayer service always includes a prayer for healing. As a rule, Jews don't get too carried away with "faith healing" as do some Christian sects, but our rabbi, after the prayer, does list members of the congregation and even members of the general public who lie on a bed of pain and who he would appeal be included in God's mercy.

In fact, perhaps an ironic example of his practice was that during the last few months of Christopher Hitchens' life, our rabbi always included him in his prayers, despite the fact that he was a widely published and erudite advocate of atheism. I soon learned to my astonishment that despite their differing views, the two were long acquaintances and good friends.

So how does my own faith inform my practice of medicine? I must say at the outset, I have none. Shortly after I attained the age of reason, I began to doubt and soon concluded that God could not possibly exist. I found completely unconvincing the answers that have been given by every religious leader to the age-old question, "If God is omniscient, omnipotent and benevolent, how can there be evil, suffering and natural disasters in the world?"

I suppose I started out as an atheist, but in more recent years I have recognized that it is not the existence of some higher power that I doubt, but his/her relationship to the universe in general and humanity in particular. In confronting the mystery of how or why the universe should even exist, I have to acknowledge that creation is at least one possible explanation. So in that sense I might be called an agnostic. But I have a much more skeptical attitude. I cannot rationally accept the idea that even if there was a God at the beginning and he is still out there, that the problems of humanity in general and all of us as individuals are worthy of his attention. You could say I am a lapsed agnostic.

Whether he is benevolent or not, I cannot believe that an all-powerful God is out there keeping watch over each and every one of the 7 billion souls on this planet, not to mention the likely presence of hundreds of trillions of creatures on all of the other habitable planets in the universe where life now, has or will exist. I just don't believe that we are so special. So the idea of praying to God for healing is to me nothing but wishful thinking.

Yet God often enters the exam room with me. Most of my patients belong to some faith, and many of them do pray. Many of them pray for healing for themselves or their loved ones. Many of them pray for me, that God should guide my hands. Not only do I accept their prayers, but I encourage them. If I know a patient or family member is religious and they are in serious trouble, I will even tell them that they or their family member will be in my prayers.

Am I a hypocrite? (You could say so, in that I took a Hippocratic oath, but all kidding aside, the words are just coincidental sound-alikes.) You could even accuse me of being dishonest with myself: on rare occasions before doing a colonoscopy on a high-risk patient, I utter a prayer under my breath that I will arrive safely at the cecum (beginning of the colon) and return without perforation or other mishap. As we say in Yiddish, "Go in health; return in health!" I am even reassured at some visceral level when I note that the blanket happens to one of the ones at my hospital that has three blue stripes at each end, because as it resembles a Jewish prayer shawl.

So how can I encourage my patients in their beliefs even though I don't share them? Here's one explanation: There are two fairly well-circulated clinical studies that are familiar enough to many of you that I won't take the time to find the citations on Medline. One concerned two groups of randomly selected, matched patients, one of which was prayed for by a convent of nuns who volunteered to do so. The prayer group had a better outcome than the control group even though the doctor and patient were blind to the allocations. In the second study that I believe came out of Boston, a group of patients were told by their physician that they were going to be given a placebo, but that it had been observed that "sugar pills" often work anyway. (Another irony. Isn't sugar recently considered toxic?) This time, the patients who knowingly took the placebo did better.

I am reminded of the story of the farmer who encountered his neighbor nailing a horseshoe over his barn door, long considered a totem of good luck. "I had no idea you were superstitious," said the farmer. The neighbor looked down from his ladder and replied, "Oh, of course I wouldn't be so foolish as to believe that nailing horseshoes on barns really brings luck! But I've heard it works even if you don't believe in it."

This in large part explains why I have no problem speaking to my patients as though I believe in God. It reassures them to think that in fact my hands are being guided. They like to think that my own prayer might enhance my ability as a healer. They might even believe that faith makes me a better individual, and this is the sort of doctor they want. And for me, I can't help but believe it helps them to deal with their illness or that of their loved one. And that is the essence of my thesis: prayer is at the very least a placebo, and placebos have been shown time and time again to be effective.

I want to conclude this entry with an anecdote. I was asked by our hospital chaplain to participate in an ecumenical prayer service observing the National Day of Prayer, in which hospital staff would all share our prayers for world peace. She needed someone to recite a Jewish prayer. Not wishing to offend, I told her I would be happy to but I didn't know any Hebrew. That didn't matter, she said, English was fine. But why not have our mutual friend who is in fact a Jewish chaplain at our hospital give the prayer, I said? I would have, she said, but she won't be back from her sabbatical in time. Finally, cornered, I confessed that I don't even believe in God. "That's all right," was the response, "You're in transition."

I immediately thought of the ending to the movie "Some Like it Hot", with Marilyn Monroe, Tony Curtis and Jack Lemmon, in which the millionaire played by Joe E. Lewis becomes infatuated with a cross-dressing Jack Lemmon, who is doing so in order to escape gangsters. In the final scene, escaping in his motor launch, Lewis proposes marriage to Lemmon. Lemmon offers objection after objection, each one dismissed by the importunate Lewis. Finally, Lemmon insists "But I can't marry you!" "Why?!" responds Lewis. "Because I'm a man!" says Lemmon. "So," says Lewis, "Nobody's perfect!"

To my surprise, the prayer service turned out to be quite moving, and I left the chapel with an unanticipated sense of peace and a new sense of purpose in my calling as a healer. Who knew?

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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