Jeremy Howick. CEBM Research Fello
Empathetic doctors who communicate well can improve patient outcomes as much as some blockbuster drugs. A common response to this statement is: “Maybe being nice improves someone’s psychology, but it can’t improve biomechanical problems”.
In fact dozens of studies show that patients’ expectations (for example after being given a placebo, or a positive suggestion such as “this pill is really going to make you better”) can improve both symptoms and biological causes of pain, anxiety, Parkinson’s Disease, and many other conditions.
Take placebo surgery. Bruce Moseley is the team doctor for the Houston Rockets and surgeon decided to test arthroscopic knee surgery against placebos. He found 180 patients who had knee osteoarthritis and who had not responded to maximal drug treatment for at least six months. He randomized patients to receive ‘real’ arthroscopy or placebo arthroscopy. The patients who received real arthroscopic surgery had their damaged cartilage repaired and bone fragments removed. Those in the placebo group were put anaesthetized and had a small incision made, but no cartilage or bone was repaired. The results were striking: all the patients in the trial got better! The placebo worked as well as the ‘real’ surgery. Here is how a 76-year old patient named Sylvester Colligan described his experience being in the trial – he was in the ‘placebo’ group:
“I was very impressed with him, especially when I heard he was the team doctor with the [Houston] Rockets… So, sure, I went ahead and signed up for this new thing he was doing… The surgery was two years ago and the knee never has bothered me since… It’s just like my other knee now. I give a whole lot of credit to Dr. Moseley. Whenever I see him on the TV during a basketball game, I call the wife in and say, ‘Hey, there’s the doctor that fixed my knee!”’
You might think that the knee pain might have disappeared spontaneously even without (placebo or real) surgery. This is a good general objection but is unlikely given that the participants in the trial were not responding to maximum drug therapy for at least 6 months. Placebo surgery has been shown to be as effective as ‘real’ surgery in dozens of trials.
Here a placebo treatment cured what appeared to be a mechanical rather than a ‘psychological’ problem. How could this be? How can a biomechanical problem be solved with a psychological intervention (placebo surgery)? Well you might continue to point out potential biases in the study, and no study is perfect. However the study has been replicated many times. A bigger problem is that we seem to be programmed to believe that the mind and body are separate, and therefore that psychological interventions (like placebos) can’t possibly affect biomechanical problems (like knee problems caused by cartilage damage). This separation of mind and body contradicts your own experience. If mind and matter were really separate, then how could alcohol and drugs (legal or illegal) change how you feel and how your mind works? René Descartes is probably most responsible for separating mind and matter. Almost all philosophers and scientists before Descartes believed that ‘mind’ (or ‘soul’ or ‘vital force’) was an inherent part of all matter, so to change the mind was (by definition) to change matter. Until Descartes, therefore, the idea that something just affected the mind just didn’t make sense. Descartes separated the mind from the body and turned the body into a machine. If you believe Descartes, then it is literally difficult to see how changing your mind can change your body. Your body produces its own endorphins (pretty much the same as morphine), dopamine, adrenaline, growth hormones, and many other powerful drugs. These healing processes can be suppressed under chronic stress (and most of us are chronically stressed). Nice empathetic doctors can help your body activate these inner healers simply by reducing anxiety and deactivating the stress response.
Summing it all up in the New England Journal of Medicine, Dan Moerman states:
“Does this [belief effects and doctor effects] mean that we might double our gas mileage if we wished for it hard enough? Well, no. But people are not machines, and we shouldn’t treat them as such.”
Dr. Jeremy Howick runs a course on the History and Philosophy of Evidence-Based Healthcare (EBHC), where he explores the underlying justification for EBHC