Adjectives are important. Adjectives, of course, describe nouns, and adjectives can bias how you think about the world. In politics, well, you can come up with your own examples. In our skeptical world of science-based medicine, there are the adjectives ‘complementary’ and ‘alternative’ that when applied to the noun medicine, add nothing. Those modalities that like to describe themselves with those adjectives are deluding themselves, given that, as so often noted at this blog, they are neither complementary nor alternative to reality-based medicine. But I would suspect that the adjectives help give SCAM practitioners a feeling that they are actually involved with something positive and worthwhile. Nope.

Reality-based medicine can suffer from the same issues.

For years, I said, there were only two rules in medicine that were true 100% of the time. The first was that infections went to the disc space and then to the vertebral bodies but tumor went to the bone, sparing the disc. That fact was 100% reliable. And then it wasn’t. At the end of my long and storied career, I had a case where the infection went to the vertebral body, avoiding the disc space, a Brodies abscess of the spine. I found there were few other cases in the Pubmeds. So 99.99999999999999999% reliable.

The other rule, however, has remained true to this day. Anyone who uses the adjectives ‘strong,’ ‘powerful’ or ‘big gun’ to modify the noun ‘antibiotic’ is an idjit who knows nothing about the treatment of infectious diseases. I have never witnessed a black swan to disprove the rule. There is nothing intrinsically strong, powerful or big gun about any antibiotic. Like applying honesty and integrity to, well, take your pick, they are adjectives that do not belong. Ciprofloxicin, an antibiotic I have often heard described with those adjectives, is a useless antibiotic if I were treating my central nervous system syphilis. Not that I have CNS syphilis, mind you, but as an example.

Vancomycin, another antibiotic that is often described as strong or powerful, stinks on ice: expensive (well it was), toxic, lousy pharmacokinetics and barely able to kill. In the scheme of antibiotics, it is suboptimal, but sometimes the only choice.

‘Strong,’ ‘powerful’ and ‘big gun’ likely give the prescribing physician the (false) sense they know that they are doing and the receiving patient the (false) confidence that something extraordinary is being done. It ain’t. But saying I am prescribing expensive, toxic, broad-spectrum antibiotics with increased side effects would not be as well received.

What you want, for antibiotics, and for any intervention, is a treatment that is reliably effective for a given medical problem. Two adjectives, reliable and effective, that never apply to SCAMs.

Which brings us to placebo. I have written about placebo before. Actually, much of my SCAM writings are about placebo. For those who do not want to search the site, try here, here and here.

I suspect the most common adjective found in front of placebo is powerful. Powerful shows up in book titles, journal articles, and New York Times editorials

In research settings, placebo responses are powerful but a nuisance, as they make detecting a drug’s superiority over a placebo difficult. And in clinical practice they are powerful, but they often require deception, making them unethical.

There is open label placebo (OLP), where the patient is knowing told they are being treated with placebo.

The OLP approach verbally fosters a positive expectancy, typically by conveying some variation of the following discussion points: (a) placebos are powerful (b) the body automatically responds to placebos compliance is important, and (d) positive attitudes help but are not necessary.

Since the effects of the fantasy-based therapies often discussed here at SBM (acupuncture, homeopathy, etc) are all due to the ‘powerful’ placebo, just what does that mean? What is powerful? Is the placebo able to leap over tall buildings in a single bound?

I don’t know. Powerful is an adjective that isn’t ever strictly defined in reference to placebo that I can find. It appears to be an intrinsic but unmeasured and unmeasurable property of the placebo. Powerful is chi. Powerful is innate intelligence. Powerful is the dilution and succussion. Powerful is all sound and fury, signifying nothing. Powerful is an axiom.

Placebos are not going to have any effect on any of the processes I saw in my career: placebo will not cure pneumonia, send lymphoma into remission or modify a heart attack. If there is an objective medical issue, expect no benefit from placebo. In comparison to placebo, even vancomycin would be powerful. But placebo would be not be reliably effective against any process that would send you the ER. So not powerful for most medical problems.

What the placebo does help is patient reported symptoms, usually pain. It does nothing for the underlying problem, but does change the perception of the problem.

Take, as one of many examples, osteoarthritis and placebo.

Pain and stiffness are improved with a placebo intervention. Walking time, strength, and range of motion are not.

This is a common effect from these ‘powerful’ placebos. Improvements of the subjective but not the objective. Which is nice if you are the patient. But a modest decrease in subjective discomfort does not powerful make.

Placebo interventions are certainly not reliably effective. It perhaps depends on the patient:

Certain personality-types, participants suggested, might be better suited to benefit from OLPs. Some suggested that only open-minded participants would experience improvement.

Open-minded? Lol. Or maybe it is the gullible or fantasy-prone, who come under the power of placebo.

And placebos may cost money

“Please God, tell me it would be dirt cheap.” (Participant # 2)

“On some level, I find it offensive that I would have to pay for a sugar pill.” (Participant # 5)

If you have limited income, having to pay for a sugar pill would be powerfully annoying.

I can’t see how the term powerful can be applied to placebos except as a marketing ploy. It is PR.

I still think the best descriptor for placebo effects is beer goggles.

I look better and am a lot funnier if you have had two pints of IPA. Or maybe three. Let’s make it four. But I haven’t changed. And you are out 10 bucks (it’s happy hour) and your liver has taken another hit.

Same with placebos.

When I was a kid and did a suboptimal job on some assigned chore, my Dad would call the result “half-assed.” Now there is an adjective that can be applied to all placebos.

Next time you see an article promoting the powerful placebo, just substitute half-assed for powerful. It is a better fit.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His multi-media empire can be found at