I love my doctors. The two I see most often — my primary-care physician and my dentist — are personable and friendly. (My primary-care doctor even runs a discussion salon for his patients.)
They ask me questions about my health and when I give vague answers, they ask more questions. They're also always pleased to report good results from my checkups or screenings.
I've always thought my doctors were happy to see me because I was in good health and, therefore, an "easy" patient. But new research suggests it might be the other way around — maybe I feel better because they seem to care so much.
Writing in this month's issue of Wired magazine, author Nathanael Johnson reports that what some call the "care effect" may be as potent as the better-known placebo effect in influencing the health of patients.
The placebo effect is the phenomenon in which a person's anticipation of medical benefits from a medication or treatment actually contributes to generating the presumed result. The effect is acknowledged by researchers to be so significant that most large-scale drug trials include a group receiving a placebo — a pill with no actual medicine in it — so that manufacturers can prove their medication is stronger than the power of suggestion.
The National Institutes of Health, in its definition of the placebo effect, adds that beyond the anticipatory benefit of a sham pill, "a clinician's style in interacting with patients also may bring about a positive response that is independent of any specific treatment."
Now there's good evidence of that phenomenon. As Johnson reports in Wired, Ted Kaptchuk, director of Harvard Medical School's Program in Placebo Studies and the Therapeutic Encounter, put this idea to the test in a study of the benefits of acupuncture.
Kaptchuk's team told patients with irritable bowel syndrome that they would be taking part in a study of the efficacy of acupuncture treatment for their condition. The subjects treated by "a warm, friendly researcher who asked detailed questions about their lives," Johnson writes, reported a significant reduction in their symptoms, "equivalent to what might result from any drug on the market."
What the subjects didn't know was that the needles used in their sessions were props that never pierced their skin. When the same sham treatment was given to other patients by brusque practitioners who did not engage in conversation, the benefits mostly vanished.
Kaptchuk's team concluded that the practitioner's empathy made the difference — the therapeutic encounter influenced the results.
Does Your Doctor Care?
The care effect is about more than bedside manner. A cheerful, glad-handing doctor who doesn't ask questions that allow you to express your concerns may be no more empathetic, or effective, than a physician who never looks up from your chart in the examination room.
The belief that doctors and patients can produce better health through conversation is the driving concept behind the narrative medicine movement, in which doctors are trained to "receive" a patient's story about illness and the clues it may contain to get a more complete picture, one that is crucial to diagnosis and treatment.
"When a patient comes in, it's because 'something doesn't feel right,' and people struggle with words to express the problem," says Dr. Rita Charon, executive director of the first-of-its-kind master's program in narrative medicine at the Columbia University College of Physicians and Surgeons in New York. "Predictably, a doctor is more likely to focus on the organ systems and do a test or ask questions like, 'Are you having trouble with your bowel movements?' Right away, we're missing the first floor of the edifice. Life, love, dreams, hopes, fears — all that gets bypassed in the rush to find out what’s wrong and fix it."
Johnson believes the power of the care effect to boost the benefits of treatment is evident in the success of the nation's $34 billion alternative medicine industry, encompassing acupuncture, energy healing, herbal remedies and other non-pharmaceutical or non-surgical approaches to illness. Along with their actual, therapeutic benefits, alternative techniques often come with a bonus care effect, he believes: "Alternative practitioners tend to express empathy, to allow for unhurried silences and to ask what meaning patients make of their pain," Johnson writes, and their clients feel better for it. "Suffering people reflexively seek care, but in mainstream medicine, care tends to mean treatment and nothing more. Many patients who really need empathy and advice are instead given drugs and surgery."
This approach, he adds, leads to expensive and potentially dangerous overtreatment. Citing an Institute of Medicine study that said $210 billion is wasted each year on overtreatment in the United States and a Medicare study that said as many as 30,000 people die annually from it, Johnson argues that the number of American adults "who die from too much medicine is now higher than the number who die for lack of it."
"We need to stop thinking of care as just another word for treatment and instead accept it as a separate, legitimate part of medicine to be studied and delivered," he concludes.
Narrative medicine pioneers agree and make a case that the nation's medical schools must begin producing empathetic doctors en masse. "There is the mistaken belief that there just isn’t time for this work because doctors are forced to see the maximum number of patients during the day," says Craig Irvine, academic director of the Columbia program. "But when doctors aren’t allowed to elicit stories from their patients, it increases the cost of medical care because they miss aspects of those problems and end up doing more tests. Patients have to return again and again for treatment because their doctors aren’t really addressing the problem."
That's a concern we can all empathize with.
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