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BOOK REVIEW Doctors, Patients, and Placebos. By Howard M. Spiro. New Haven, Conn.: Yale University Press, 1986. Pp. 261. $27.50. There is a temptation to imbue placebos with a magic life of their own. Spiro's book could, on one level, be considered a romantic glorification of the placebo, but there is more to the book than that. One can unequivocally applaud the author's position that molecular biology is not all there is to medicine, that physicians need to listen to their patients, that providing relief to the sick is important whether we understand the mechanisms involved in either complaint or cure, that Norman Cousins's overpublicized illness that "responded" to vitamin C and laughter is impossible to evaluate on the basis of the published information, that holistic medicine describes "with wonderful words" some "very spongy concepts," and that randomized controlled clinical trials are a far cry from medical practice. Spiro's account of the gradual depersonalization of "grand rounds" is also one with which many readers will resonate: "Grand Rounds" give some clues to the changes in medicine. They began, as the name implies, literally as a tour around the wards by the chief physician and his associates. The patient was the center ofthe discussion, even ifhe might be ignored once his problem had been resolved, serving only as a focus for discussion. Then, becoming unwieldy as a teaching exercise because too many physicians came to such rounds, Grand Rounds were moved to an amphitheater. At first patients were brought to the conference, so that physicians could still have someone to talk to, to listen to, to see. The discussion was personal, oral, informed, and patient-centered. Gradually the aim ofthe conference shifted from a problem patient whose disease might be explored and subsequent therapy improved by discussion, to an interesting patient whose disease was used to focus discussion intended to improve the knowledge and skills of physicians. At that point the particular patient ceased to be of any importance, and his disease took precedence. It was the shift from a patient to a case. At the same time concern for the patient's rights and privacy made displaying him at a conference seem a breach of diat privacy. Less and less time was allowed for talking to the patient, until he became an icon of himself, a case, present like the American flag to show that there was a patient/ person somewhere in the background. Anyone could have been put into a bed to represent die patient, for all of the good it did to bring the patient to Grand Rounds. That is probably why the patient is no longer present—no one knows what to do with him! Permission to reprint a book review printed in this section may be obtained only from the author. Perspectives in Biology and Medicine, 31,2 · Winter 1988 \ 309 But many will find themselves in disagreement with other Spiro views; I certainly did. To begin with, I do not believe that most doctors—at least once out of their residency training—are preoccupied with "cure," neglect "care," and focus excessively on acute diseases. Hospitalized patients emphasize the acute episode, the dramatic turn of event, because that is often why they are in the hospital. Nor do I follow the logic in asserting that "looking at the placebo forces the physician to regard the patient as a whole person," anymore than prescribing an active drug forces the doctor to do so. The prescribing of a placebo surely is not necessarily more effective (or admirable) than a dozen different ways of caring about a patient qua person. The book fails to stress clearly enough that placebo "success"—whether in a clinical trial or real practice—may reflect not only psychological predisposition to respond to medical mystique, suggestion, therapeutic intent, and so on, but also to spontaneous improvement. I also wish that Spiro had criticized controlled trials in which an anti-ulcer drug is allegedly pitted against placebo, but the patients on placebo are on substantial doses of effective antacids! Spiro seems to believe that placebos only relieve pain, whereas the literature is replete with "responses" to placebo of almost every imaginable...


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