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The Difference Between a Placebo and a Caring Relationship

January 18, 2012

The story of the modern-day analysis of placebos usually begins with Dr. Henry Beecher. Dr. Beecher, while treating wounded soldiers during World War II, ran desperately short of morphine—so desperate, in fact, that he administered saline solution to the injured who thought they were being dosed with morphine. Beecher was amazed that this treatment, though having no medicinal value, nonetheless eased the men’s pain.

A recent New Yorker article, entitled The Power of Nothing and written by Michael Specter, has brought placebos back into public focus. This is not the first time that placebos have stirred interest, of course. As the article points out, placebos—and more generally, the power of suggestion—have been part of humankind’s approach to illness for as long as historians can tell. Placebo-administered control groups play an important role in research, but what seems to capture more attention is the prospect that an inert substance sometimes can ameliorate the symptoms and distress of illness when a patient has reason to believe that the substance is efficacious. Researchers call this the placebo effect.

Because placebos can take many forms—pills made of milk powder, imperceptible doses of electrical stimulation—Specter brings in Wayne Jonas to define the term. Jonas, a physician who has served at the Walter Reed Army Institute and at the National Institutes of Health, is currently the president and chief executive officer of the Samueli Institute, a Virginia group whose stated mission is to “transform health care through the scientific exploration of healing.” He is quoted as saying: “[T]he way we go about delivering those agents—the interaction between doctor and patient, for example—often has a bigger impact than the agent we focus on. More than the drug and more than the surgery. And this has been collectively called the placebo effect.” (p. 34)

Whether and how an inert agent might or might not have an effect on the symptoms of illness is not the point of this essay. Instead, I find myself wondering why Jonas includes “the interaction between doctor and patient” in the category of placebo effects. Jonas is not the only person to make this inclusion; it is common in the placebo literature. Placebo effects “acknowledge the power of the mind to influence health” through suggestion and expectation, as Specter explains. Thus, expecting that a red pill will relieve one’s headache or that a dose of ultrasound will relieve one’s tendonitis may set off a series of mind-body processes that lessen one’s symptoms. So far, so good: Expectations are powerful causes of behavior, as much social-psychological research has shown, and solid evidence for such effects in the area of health and disease may yet be forthcoming.

But the effects of doctor-patient interactions are not due to the power of suggestion and expectation, nor are they tenuous, or “largely unproven and often irrational,” as one letterwriter asserted of placebos, in a January 9, 2012, response to Specter’s article. Instead, whereas the mechanisms behind the possibility of placebo effects are as yet unverified, the effects of doctor-patient relationships are direct, observable, and their effectiveness demonstrated.

There is lots of good research showing that caring interactions between physician and patient contribute to patient health. Health-care researchers call these interactions “patient-centered communication” because they communicate understanding of the patient’s needs and preferences, acceptance of the validity of the patient’s perspective on his/her illness, and appropriate caring and support. Patient-centered communication is associated with better outcomes both on subjective measures of health and well-being and on various more objective markers. For example, Stewart (1995) reviewed several randomized clinical trials establishing that patient-centered communication was more effective than traditional care in helping patients lower their blood pressure and blood sugar levels. Other studies have shown that patient-centered communication is associated with faster recovery from illness, better attendance at scheduled follow-up visits, and greater adherence to treatment protocols and recommendations.

An interesting digression for this era of rapidly rising health-care costs: patient-centered care is also associated with lower costs. In a recent study, patient-centered care predicted less frequent hospitalization, fewer visits to specialists, and fewer laboratory and diagnostic tests over a one-year period (Bertakis & Azari, 2011). In another, my colleague Ronald Epstein and several other researchers (2005) found that patients of the least patient-centered physicians had, on average, 11% higher costs for diagnostic testing and 3.5% higher total expenditures than other physicians. How ironic that budget cutters are making health care ever more impersonal and health care visits ever briefer, since these supposed cost-cutting measures may in fact contribute to rising costs!

In fact, researchers have proposed and examined many different mechanisms for these effects. Several colleagues and I have shown that when patients feel genuinely listened to, heard, and supported, they trust their physicians more and feel healthier. This trust can increase knowledge and reduce their feelings of uncertainty, allowing patients to make better decisions, form more effective therapeutic alliances with caregivers, adhere better to treatment plans, and practice more effective self-care (Street, Makoul, Arora, & Epstein, 2009).

The effects of our interactions with caregivers are not necessarily indirect. Who among us has not been annoyed, frustrated, or even enraged by a physician who was preoccupied, who seemed not to be listening, who dismissed our concerns or fears, who seemed patronizing, or who, after a lengthy wait, spent minimal time with us before moving on to the next patient? Research has shown that such unpleasant, stressful interactions can have direct harmful effects on the body’s neurohormonal, cardiovascular, and immune systems. For example, the stress hormone cortisol is secreted during interactions of this sort. It may not be far-fetched to think that these aggravating interactions are actually bad for us. On the other hand, research has also shown that supportive interactions seem to have the opposite effect—the body reacts to responsiveness and reassurance in a health-promoting way.

None of this is meant to deny the potential value of placebo effects in health care. Scientific research has yet to establish if, when, and by what means placebo effects influence subjective distress and the biological progression of disease, but that is why we do research; compelling evidence may be just around the corner. Nevertheless, whatever these placebo effects may be, the impact of the relationship between patients and their physicians is not one of them.

Patient-caregiver relationships affect our health and well-being not through the power of suggestion and expectation but rather by the power of human interaction to affect motivation, emotion, and behavior. It would appear, then, that the benefits of caring interactions with physicians are anything but placebo effects. They are tangible and real influences on health and disease—perhaps even, as Jonas aptly noted, more potent than drugs or surgery.

 References

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine, 24, 229-239.

Epstein, R. M., Franks, P., Shields, C. G., Meldrum, S. C., Miller, K. N., Campbell, T. L., & Fiscella, K. (2005). Patient-centered communication and diagnostic testing. Annals of Family Medicine, 3, 415-421.

Reis, H. T., Clark, M. S., Pereira Gray, D. J., Tsai, F. F., Brown, J. B., Stewart, M., & Underwood, L. G. (2008). Measuring responsiveness in the therapeutic relationship: A patient perspective.  Basic and Applied Social Psychology, 30, 339-348.

Stewart, M. A. (1995). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152, 1423-1433.

Street, R. L., Jr., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling, 74, 295-301.

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