In medicine, the phrase “the placebo effect” is often prefaced by the word “just”—as though the word “placebo” were a synonym for a psychological trick or a fraud, nothing more than an annoying complication for companies running drug trials. But as longtime Wired contributor Steve Silberman discovered while writing about the increasing placebo effect in drug trials—a story that was later selected for The Best American Science Writing 2010 and The Best Technology Writing 2010 and won the 2010 AAAS Kavli Science Journalism Award in the Magazine category—the placebo effect “is actually a completely awesome phenomenon, not just a statistical annoyance.” “The Placebo Problem” appeared in Wired on August 24, 2009.
Here, Silberman tells TON co-founder Siri Carpenter the story behind the story. (This interview has been edited for length and clarity.)
How did you get interested in doing a story on the placebo effect?
In November 2008, I got an email from now-former Wired editor Ted Greenwald, saying, “Story idea for you?” with his phone number. I called Ted and he told me that he didn’t know exactly what direction this story would go in, but that pharmaceutical companies were having increasing trouble controlling placebo effects. The story seemed absolutely perfect for me, in part because it had widely divergent angles: it had a hard business angle, a hard neuroscience angle, and also a dimension of human mystery—how does the knowledge that you’re taking medicine jump-start this network in our bodies that helps us feel better? So I immediately agreed to the assignment. Ted suggested a word count of 3,500. I’m a very verbose writer, so I asked for 4,000, and he gave that to me.
This problem that Big Pharma is encountering with placebo responses has been brewing for a while. What made you feel the subject was ripe for a story now?
That was as much a zeitgeist call as anything else. I just felt like the world is really interested in the placebo effect right now, or could be. And that’s exactly what I like to find; I feel like that’s the secret sauce for a hit story, if you can find a subject where there’s a critical mass building up among specialists and experts, but that dialogue has not really leaked out that much to the public, and yet it’s a topic would be of concern to those readers if they knew about it.
How did you report the story?
After we settled on the assignment, Ted did something very unusual. By the end of that day, he had sent me 13 emails with 27 attachments containing background material, from articles he had seen to titles of books he thought might be interesting, and even notes from interviews that he had done with some of the principal researchers. He provided tremendous, in-depth background.
How much time did you spend reporting?
For this story, I read about ten books and 300 journal articles to write a 4000-word story. That’s not bragging—it’s probably a fault! But the thing I never want to do is to write a story where someone who is an expert in the field would look at it and say, “This guy is clueless.” I never want to be that guy.
How many sources did you interview?
I talked to about twice as many sources as ended up being in the story. When I do my first interviews for a story, I’ll often tell my sources, “Please forgive me if my questions seem naïve.” I don’t need to come off like I’m an expert if I’m not. But what’s really exhilarating is toward the end of a story when a real expert in the field starts to explain something to me, and I already know it. So I spent a few weeks both reading and interviewing before I started writing.
Talk about the reporting trips you took for this story.
I try to make my writing as “cinematic” as possible. I want to put the reader in various places and contexts. Ted had suggested that I look at the work of a researcher named Fabrizio Benedetti, and once I found out that Benedetti was doing all this fantastic research at the University of Turin—working in this beautiful medieval building—I really wanted to go there. I wanted another setting, another location to shoot the film in, in a sense.
I also went to Boston—it was basically the placebo tour of Harvard. One person I met there was Ted Kaptchuk. One thing Kaptchuk did which was so important was that he gave me a copy of Henry Beecher’s original 1955 paper from the Journal of the American Medical Association, “The Powerful Placebo.” This paper, which established the template for the process by which all new drugs are tested for the pharmaceutical industry and is one of the most influential scientific papers of all time, was not online—but Kaptchuk gave me a Xerox of his Xerox. The paper had such a lasting influence on medicine and the pharmaceutical industry, I really wish some open-access journal, or JAMA itself, would make it available for free online.
Kaptchuk also told me a story that haunted me. He’d been working in a chronic pain clinic in Boston, and kept hearing from the older patients that they always felt better after talking to one of the people in the clinic. However, that person was not a doctor; he was just someone responsible for referring people to doctors for care. So Kaptchuk eventually went up to the guy, whose name was Victor, and asked, “What the hell are you doing with these patients?” Victor explained that he was a survivor of the Auschwitz concentration camp, where he had worked in the infirmary. The Nazis would give him a single aspirin to treat 500 people, and he would dissolve the aspirin in a bucket of water and then give everyone a sip of the water. Then he told Kaptchuk, “That’s how I learned to help people.” That experience had launched Kaptchuk into more than a decade of research on the placebo effect. I found that story very inspiring, although it ended up getting cut from the piece.
Why was it cut?
For space reasons, primarily, but it may not have seemed as “hard science” as the rest of the piece.
That story, like the one you tell about the World War II nurse who was assisting Henry Beecher and inspired his interest in the placebo effect, is so powerful. Either one would make a natural lede to the story. What made you decide to instead lead off with the business angle, showing how the placebo effect is throwing a wrench in drug trials?
That was a very calculated move. I knew that certain things would interest the Wired organism. For example, I knew that the editor in chief, Chris Anderson, would be interested in the pharma business angle, but would be allergic to the mind-body woo-woo hippie angle. Leading off with a business anecdote was a way of making sure that Chris would be interested in the story and would know that I was talking about a real thing. I also knew that if I launched the story with something about “healing,” a million middle managers at IT companies would immediately turn the page. At the same time, the people who would be prone to reading an article about some curious mind-body phenomenon might be interested even if I led with a business angle.
How did you access sources in Big Pharma?
I told my editor Ted that I wanted to focus on the mysterious increase of placebo effects in clinical trials and what Big Pharma was doing to try to eliminate it. He said that sounded great, but that the trouble would be finding someone at a major pharmaceutical company who would be willing to talk about that. Indeed, I had sent out a bunch of emails to PR people at pharma companies and had gotten sort of boilerplate responses saying, “We are well aware of this problem and have effective ways of controlling placebo effects in trials,” et cetera. So I knew they were not eager to talk about the nuances of the subject or what they were actually doing to tackle the problem.
How did you get around that?
I did a lot of Google searching, trying to find someone who might be willing to talk. As I was scanning articles, I would look for pointers to rich veins of information; I would look for phrases like “in a remarkably candid study…” I remember being in a hotel late at night while I was on a reporting trip, searching for stuff like “Merck AND placebo”—trying endless search terms to find somebody who might be forthcoming. Then I stumbled on a link to an interview at some little public radio station with a guy named William Potter at Merck who had also worked at Lilly. I was amazed at how candid Potter was about the struggles that Big Pharma faced. It was clear that he had a very wide-ranging and subtle approach to talking about the placebo effect. I sent him a direct email asking if he’d talk with me, and got a very nice response saying yes—but of course we’d have to go through Merck PR.
What do you think persuaded the PR people to let Potter talk with you?
I wrote an email to the PR person at Merck, and we might even have talked on the phone, and I explained what my story was about, that it was going to be more than just some overhyped exposé of Big Pharma. And the news that the placebo effect is increasing is not news to pharmaceutical companies.
I’m interested in a character detail that you included in the story, about Potter being the son of a country doctor. Did you interview him with the idea of getting some personal background on him, or did it just happen come up?
That’s something that I really emphasize in my reporting. It’s the lifeblood of my stories. I feel that readers can understand big and challenging ideas more easily if those ideas are embodied in memorable characters. I’m very oriented toward storytelling. The cheeky infographics that everyone loves now are fine—and they fill the pages of Wired these days—but I believe that people retain information better if it comes to them as a meaningful story about characters they care about.
Do you plan out what you want to learn at a more personal level, or do you wing it?
I run on lots of research beforehand, and then intuition in the moment. At the same time that I’m trying to get the facts that I need from a source, I’m also “scanning” them like Deanna Troi, the empath on Star Trek—noticing what they’re comfortable with and not comfortable with, what gets them excited, and so on, taking notes all the while. And often we’ll reach an unguarded moment, and they’ll say something like “Well, that was when my kid got sick…” or “In fact, my grandfather had Alzheimer’s”—something that tells me that, behind their work in the lab, they have a personal investment in the subject. People talk much more in depth, and more articulately, about their research if they’re able to relate it to their lives.
All my life, for some reason, people have found it easy to talk to me about their personal secrets, and that has served me well as a reporter because I find it easy to establish a level of trust and candor in my interviews. I do risk seeming absurd to a source sometimes when I say, “Do you mind telling me what kind of music you like?” Or “How did you grow up?” Or “How did you become a doctor?” I try to follow the normal course of the conversation, but I’m always pushing it a little. At the same time, I try to be extremely sensitive—I try not to set off any alarms, because if I suddenly probe for something that’s too personal, they’ll just shut down.
How long did you spend writing this story?
Four weeks full time—and when I say full time, I mean 80 hours a week, night and day.
So, translating that to something resembling a regular full-time work week, that would be maybe seven or eight weeks of just writing.
That’s right. I can be a very fast writer, but my best writing is done slowly, with many, many drafts, and lots of time to think about what I’m saying. Part of the success of this article is that it very much represents a model of media that is profoundly endangered these days. It was a very deeply reported story. The story was allowed to incubate over a long period of time. It was not a knee-jerk reaction to some current media obsession. I was given the time by Wired to immerse myself in the very deep scientific background of this profoundly complex subject, and come up with smart ideas about it. But the smart ideas bubble up through a pool of stupid ideas. The length of time that it required is not just for coming up with great ideas, but also getting rid of my stupid preconceptions.
What was the editing process like for this story?
One of the reasons that the story ended up being so influential is because it had so many different sets of eyes on it before it went out. I went through probably three major edit cycles with my editor Ted Greenwald; one major editor cycle from Mark Robinson, a senior editor at Wired; one from another senior editor, Nick Thompson, who has since left Wired and is now at The New Yorker; and one from Thomas Goetz, the then-new executive editor of Wired, and a quick pass from Chris Anderson, the editor in chief. The edit process at Wired is extremely intensive, but because I had been there for so long, I knew how to navigate it and deal with it and use it for the benefit of the story.
The exciting thing about that kind of editing process is that writing is so often a solitary activity. You’re slaving away at your desk for weeks, not knowing if anyone’s going to end up liking what you’re doing. But at the point in the process when the writing and the tough editing were over, and the design team and art director and the final editors started weighing in, evidently enjoying the story and communicating their enthusiasm, it was like having a great rock band suddenly start playing the song you’d been working on as a demo tape in your room. And then when it was published, it was like you were onstage and the band was playing your song. It was a great feeling.
A glimpse behind the scenes:
Siri Carpenter is co-founder and editor-in-chief of The Open Notebook. Follow her on Twitter @SiriCarpenter.