Placebos, & Doctors, & Patients (oh my!)
Hello there :)
Welcome to issue twenty nine of Manufacturing Serendipity, a loosely connected, somewhat rambling collection of the unexpected things I’ve recently encountered.
This newsletter is free to receive, but if you’d like to support me in this odd little endeavour you can buy me a coffee :)
Speaking of coffee, grab yourself a suitable beverage my loves, let’s do this thing…
Part I: Things I’ve Encountered Online…
You’re likely already aware that in drug trials, a control group is often given a placebo in order to measure the efficacy of the drug being tested. The placebo might take a variety of forms - an oral placebo (sugar pills), a topical placebo (a cream containing no active ingredients), or an intra-articular placebo (something that’s injected directly into the joints).
What you might not be aware of, is that patients given different types of placebo report different effects:
“Here’s one study that’s interesting - researchers from Tufts Medical Center looked into how patients with osteoarthritis react differently depending on which type of Placebo they receive.
An intra-articular placebo is more effective at relieving pain than topical placebos, and topical placebos are more effective than oral placebos.
This is perhaps fairly intuitive - my impression is that, in some sense, I take an injection more seriously than I do taking a pill.
What is interesting is that the difference in effect size between an intra-articular placebo and an oral placebo is sometimes larger than the difference in effect size between active pain relief drugs and oral placebo.
The difference in effect size between an intra-articular placebo and an oral placebo is 0.29 (CrI 0.09 to 0.49), whereas the difference in effect size between acetaminophen (paracetamol) and an oral placebo is only 0.18 (CrI 0.05 to 0.30).”
But the type of placebo used isn’t the only thing that can affect results, apparently the characteristics of the physician administering the placebo can also make a difference:
“In this study, doctors injected histamine into patients to induce an allergic response, and then gave patients a placebo cream.
Patients were either told that the cream would alleviate the response (positive expectations) or that it would exacerbate the response (negative expectations).
The doctors administering the placebo changed how warm/cold they were to patients, as well as how competent/incompetent they came across.
To appear warm, doctors called patients by their names, made more eye contact, and so on. To appear more competent, they made no mistakes in the procedure (as opposed to those appearing incompetent, who put the blood pressure cuff on incorrectly), made sure the room was tidy, etc.
Patients perceived these differences - they rated the doctors attempting to appear warm as more warm, and they rated the doctors attempting to appear competent as more competent.
The result can be seen in the chart below:
Dear reader, initially I found this one tricky to understand. The bars shown on the chart above depict the size of the allergic reaction. Negative expectations (the white bars) are the patients who’ve been told the cream they’re given will make their allergic reaction worse, positive expectations (the black bars) are the patients who’ve been told the cream they’re given will ease their allergic reaction.
What’s interesting here, is that across the board, the patients who’ve been told that the cream they’ve been given will ease their allergic reaction do indeed appear to react less severely - i.e. in each instance the black bar is shorter than the white bar.
(Possibly this is why I found this hard to understand - normally when you look at a bar chart the taller bar is the winner; but in this instance it’s the shorter bar. )
Essentially, it seems if you tell someone a placebo is going to make them better people experience better outcomes than if you tell them it’s going to make them worse. That’s the power of suggestion, huh?
What’s also interesting is the data from this study appears to suggest that if a doctor appears either personable, or competent, or both personable and competent AND they tell you that a placebo is going to work then people experience even better outcomes.
However, if a doctor appears either personable, or competent, or both personable and competent BUT they tell you that a placebo is going to make you worse, we’re back once more to poorer patient outcomes.
Essentially I think this means that having great bedside manner will perhaps only impact patient outcomes when delivered alongside positive expectations.
But we’re still not done yet…
The characteristics of patients can also affect the outcome of drug trials:
“Characteristics of the patient can also make a difference to how effective a placebo is - children are more receptive than adults (study can be found here).
The study here gestures at a problem that all of these findings may lead to: in RCTs comparing how responsive adults and children were to anti-epileptic drugs, the treatment effect was significantly lower in children.
The reason for this was not actually that the drugs were any less effective in children, but that because children were more receptive to the placebo, the active drug looked less effective in comparison.”
So where are we at?
The type of placebo might affect the outcome of a drug trial
A doctor’s bedside manner, and the expectations they set might affect the outcome of a drug trial
Patient characteristics might affect the outcome of a drug trial
Scary, no? As the author notes:
“The implications of this are pretty serious - the placebo effect in the United States has actually become quite a lot stronger over time, meaning that drugs that once would have been approved may not be now - because their performance relative to that of placebo is less convincing.
This study makes the point clearly - by 2013, drugs produced 8.9% more pain relief than placebos, compared to 27.3% in 1996.”
Moar serendipitous finds:
This article in the New Yorker is simultaneously fascinating and chilling. It kicks off with a 2009 study which successfully found a way to communicate with a patient in a vegetative, or locked-in state (clearly a great application), before moving on to newer studies and their potential applications.
When you start thinking about how such a technology might be used in the future, it’s all a bit discomforting; particularly when you consider that iARPA, an R. & D. organization that’s run by the Office of the Director of National Intelligence have funded a bunch of this research.
This one’s a long read, but it’s packed with interesting stuff about how our brains might work, and well worth your time.
In this piece for the New York Times, Amanda Hess explores our continued fascination with botox; a poison that by some macabre coincidence both causes botulism and cures wrinkles. When injected at low doses into a wrinkled forehead, it blocks nerve signals to muscles and smooths the skin atop them. She notes:
“It presents the kind of bargain one might strike with a nefarious sea witch: She will grant you eternal youth, but at the price of being able to move your face.”
Botox also has medical applications, including treatment for migraines, but the focus of Hess’ article is on cosmetic usage, and how our attitudes to said usage appear to have changed:
“There was a moment when this trend was seen as a bad thing — for acting, for society, and especially, for women. Then came the Kardashians, the “Real Housewives,” a fire hose of memes and an army of spunky aestheticians waving hypodermic needles on TikTok.
A Botoxed face used to strike viewers as an uncanny spectacle, but uncanny spectacles fuel reality television and internet culture, and thanks to those ascendant forms, Botox has accumulated a gloss of campy pageantry, helping disarm cultural fears around its use.
Botox once suggested vanity, delusion and self-consciousness, but now it has fresh associations: with confidence, resilience, even authenticity, as the idea of “having work done” has come to be seen as a legitimate form of work.
In the land of influencers, Botox is pitched less as a nightmarish habit than a relatable vulnerability. Also, a self-esteem booster and tool of self-invention.”
“In February, 1981, the French artist Sophie Calle took a job as a hotel maid in Venice. In the course of three weeks, with a camera and tape recorder hidden in her mop bucket, she recorded whatever she found in the rooms that she had been charged with cleaning.
She looked through wallets and transcribed unsent postcards, photographed the contents of wastebaskets and inventoried the clothes hanging in closets.
Her only rule, it seems, was to leave untouched any luggage that owners had had the foresight to lock. That is, unless they also left the luggage key, which, for Calle, was as good as an invitation.”
I found this article interesting mainly because I’ve never considered that insects might NOT have feelings. Of course they have feelings and emotions, right?
Happily, it turns out that I’m not the only one who thinks like this. In truth, perhaps, this was all a bit of a science-y language problem. Here’s an excerpt from the article:
“When Waddell first started his own research group in 2001, he had a fairly simple goal in mind. He wanted to find out if flies are better at recalling where to find food when they haven't eaten for a while – i.e. when they might, if they could experience subjective moods, be feeling "hungry". (It turns out they are, and they can.)
To begin with, Waddell cautiously chose the word "motivation", rather than "hunger", to describe the flies' state of mind – he suggested that they were more motivated to find food if it had been withheld.
“And people found it a little problematic," says Waddell. “Some other scientists felt that this was too anthropomorphic and preferred the term "internal states". So I often had arguments that I thought were essentially meaningless, because they were just playing with that word," he says.
“Then in a matter of years, studying insect intelligence became significantly more fashionable – and all of a sudden the term "motivation" was abandoned, with researchers making the case for insects having "emotional primitives", says Waddell.
In other words, they experienced what looked suspiciously like emotions.
"I had always thought of these physiological changes that occur when animals are in deprivation states – deprived of sex, deprived of food – as subjective feelings of 'hunger' and 'sex drive'," says Waddell. "I've never really bothered labelling them as 'emotions', pretty much because I thought it was going to get me into trouble. But before I knew it, everyone seemed to be more comfortable using that [word]."
The studies seem to indicate that the feelings and emotions amongst insects have a much broader range than just hungry and horny; there’s evidence to suggest that bees can become cynical, and fruit flies can exhibit behaviours that look a lot like depression.
After working in the game development industry as an art director and lead designer for 25 years, Hungarian illustrator and designer Peter Szucsy decided it was time for a change. He spent years bringing his imaginative monsters and creatures to life in a myriad of fantastical virtual worlds, but it was finally time for him to create something in the physical world.
Instead of working with pixels and vector graphics, Szucsy turned to metal, using pieces sourced from antique watches and other found objects to fabricate intricate sculptures.
Part II: Books I’m Reading Right Now
This fortnight I read The Book of Form and Emptiness by Ruth Ozeki. It’s a novel with an unusual structure, and whilst it definitely won’t be for everyone, I really enjoyed it.
Benny Oh is a boy who hear voices. Every and any object you can imagine seemingly speaks to him, even the leftovers in the fridge. He hears the groans of mouldy cheeses, the sighs of old lettuces, and half-eaten yoghurts whine at him from the back shelf.
His mother Annabelle is understandably worried. But she too has problems. Since Benny’s father died she can’t seem to bring herself to let go of anything, and their home is bursting at the seams.
Meanwhile, the book itself addresses the reader directly; (yes you read that right - the book is a character in this novel), and it also addresses other characters in the story.
At its heart, I think it’s a story about otherness, family, love, and loss. If this sounds like your bag go get yourself a copy.
Part III: Things I’ve Been Watching
I’ve been poorly over the past week or so, as as a result I’ve mainly been falling asleep in front of stuff as opposed to actually watching it. However I did watch a documentary film called Finding Vivian Maier (Amazon Prime).
Around 2007, John Maloof picked up a box of Vivian Maier’s undeveloped photo negatives at an auction. He was fascinated by her work, and tried to track her down, but was unable to find out anything about her. After her death, he subsequently found out about a storage unit rented in her name, which was filled to the brim with negatives, prints and miscellaneous effects. For a modest payment, the contents of the storage unit became his.
The documentary charts Maloof's mission to develop, catalogue, and publish Maier’s work; and to find out more about the artist herself, an intensely private woman, who spent most of her adult life working as a nanny.
Part IV: What I’ve been up to…
Trying out a Four-Day Work Week in December
As I mentioned in the previous edition of this newsletter, I’m trying out a four-day work week. Dear reader, I’m very pleased to report that for the past two weeks I’ve worked only four days per week, and I’ve not done any work at all on non-work days.
Nevertheless there have been moments when I’ve been sorely tempted to do some work on a non-work day; and even though I’ve not actually done said work on that non-work day, I’ve definitely been guilty of thinking a lot about work on non-work days. Ultimately I’d really like to get to the point where I’m not thinking about work on non-work days, but it’s a start I guess?
One thing which I think has been really good for me, is the realisation that I can complete everything I need to within four days. I have to be more focused, more organised, and I do work longer hours on the days that I do work, but it is all do-able. I may even extend the trial to January.
I have done some Christmas Shopping! Not all of it, but some of it and that is a significant improvement on previous years.
Finishing my short story
Some of you might remember me mentioning that I signed up to do a fiction writing course in October. Whilst on the course I started working on a short story, but since the course finished I’ve done nothing with it. In the last newsletter I said that within the next fortnight I would finish the story.
Dear reader I have not done this (but I definitely will), and I do have quite a good excuse.
In the past fortnight I met up with my friend Matt and he asked me if I could help him write a short comic book for one of the side projects he’s currently working on. I said yes, drafted him a thing (which happily, he liked), and now some artists are working on it. I cannot wait to see how it all turns out.
I will absolutely, definitely finish my short story.
I will also being writing a “2021: 100 Good Things” post (you can read 2020’s post here if you’re not sure what I’m blethering on about).
I will be taking some time off over the holidays to spend time with my family, read lots of lovely books, and eat all the food.
That’s all from me for now :)
If you enjoyed this newsletter, please consider sharing it, and if you would like to support me in this odd little endeavour you can buy me a coffee.
I’ll be taking a little break over the holidays, the next issue of Manufacturing Serendipity will arrive in your inboxes on January 7th.
Wishing you all the merriest of merries my loves,
PS Wanna find out more about me and my work? Head over to Worderist.com