A beneficial therapeutic effect is the result of some form of medical intervention with desirable and beneficial results, as judged by the patient and the physician. In evidence-based clinical trials, expected benefits are established at the outset of the trial, and these positive effects are then monitored in the interventional and control groups. When the trial ends and the double blind code is broken, the scientists involved in the trial assess whether there was a greater number of beneficial elements in the experimental group of patients as compared with individuals in the control group. A careful statistical analysis is used to determine whether the difference in the beneficial effects between these groups was due to chance or whether it was likely that the positive effects seen were the result of the intervention.
In daily clinical medicine, therapeutic interventions are not administered in a blinded fashion. In fact, both patient and doctor know the kinds of therapy being administered, and both observe the effect of the therapy on the patient’s sense of well-being as well as various clinical and laboratory biomarkers associated with the patient’s disease state. When patients feel better and look better and when the clinical biomarkers improve, both parties almost always agree that the patient’s illness is resolving. However, it can be difficult to decide whether the improvement in the patient’s status is the result of a specific intervention undertaken or whether disease resolution is the result of multiple other factors, including spontaneous improvement. For example, it has been known for decades that marked elevations in blood pressure often resolve, even in the absence of pharmacologic therapy, when patients are admitted to hospital and sheltered from their usual daily stresses. Of course, such patients usually receive effective pharmacologic therapy when admitted to the hospital. Nevertheless, it is well known that the protective hospital environment is one component of the beneficial response.
When I was a young physician, I thought that the overwhelming factor leading to improvement in a patient’s clinical status was the therapy being administered. As I have gained experience, I have become convinced that the physical presence of the physician in the hospital or the office can play a major role in clinical improvement. I have learned this first hand from things that patients have told me. For example, early in my career, patients would often tell me at the end of an office or bedside visit “Thank you doctor, I feel so much better now that I have seen you.” Often at that time, my initial response was “Oh, but I really did not change anything in your program.” Invariably, patients would respond “Oh, no, doctor, you have made me feel much better.” Over the years, I have experienced this same scenario many times. However, I no longer tell patients that I really did nothing new or extraordinary to their therapeutic program. Rather, I thank them and say that it is a pleasure caring for them. I have realized that my role is not only that of a scientifically oriented physician, but, in addition, I have assumed the persona, so common in medicine of previous centuries, of a healer.
This healing benefit is almost certainly the result of alterations in the function of various components of the central nervous system, for example, reduction of heightened sympathetic nervous activation combined with increases in central nervous system endorphin levels. Some would call this a positive placebo effect. I prefer to refer to it as a healing therapeutic relationship between the doctor and the patient. The opposite also can occur. I have known clinical situations in which inappropriate, unkind, and non-empathetic responses on the part of the physician or the nurse have led to clinical deterioration, the so-called nocebo effect. For centuries before evidence-based medicine became the daily mantra in Western medicine, the therapeutic benefit of the physician’s presence was the only mode available for improving a patient’s clinical state.
Because of these experiences, I always make a strong effort to approach each patient as if they were a friend in need of support and counsel. When dealing with out-patients, I always start the interview by asking what they have been doing recently, such as traveling for pleasure or visiting with family. For in-patients, I always ask whether they have discomfort, and whether we have relieved it. I also ask them how they slept and whether the food they received was good or not. Almost invariably, I sense patient anxiety disappearing with this friendly and positive approach. Even in the coronary care unit, I try to be as friendly and supportive as possible. I am personally convinced that this approach generates a therapeutic benefit, although it would be difficult and perhaps unethical to test it in a randomized trial in which every other patient was treated coldly and impersonally.
When I am involved in teaching rounds in the hospital, I believe that my role is not only to ensure that evidence-based medical practices are being used, but that I serve as a role model for trainees to learn the best possible clinical approach that can elicit a therapeutic benefit. Such an approach is invariably associated with kindness and empathy on the part of the care giver.
As always, I am interested in hearing what other physicians have experienced with respect to their role as “healers” on our blog at amjmed.org.
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-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)
This article originally appeared in the January 2016 issue of The American Journal of Medicine.
