Why Looking Like a Doctor Makes You a Better Doctor
Friday, March 9, 2012
Traditional witch doctors were onto something – while they may not always have had medicines that worked, their appearance and rituals might well have helped their patients get better (or at least think they did).
In follow-up to yesterday’s post on what patients really want, I also read with interest another recent commentary in JAMA, by Howard Brody and Fraklin Miller, discussing the power of placebos and rituals in the practice of medicine.
It turns out that neuroimaging studies have actually shown the activation of neural pathways in the brain (involving endorphins and dopamine) elicited when subjects receive a placebo (especially when they believe they are actually getting an active ingredient).
Even effective drugs benefit from this effect. Thus, the authors describe examples of studies where the effectiveness of a drug (e.g. for pain or anxiety) is greater when the subject knows they are getting the drug than if it is administered to them without their knowledge (in an experiment).
These effects are not only ‘biological’ (meaning real) but are intertwined with psychological phenomena of expectancy and conditioning.
Thus, as the authors explain:
“Positive beliefs about future outcomes, especially when connected with an intervention recommended by a clinician, may trigger those outcomes. Moreover, much of medical practice consists of repeated rituals that may create conditioned responses that can be reactivated in the future by placing the patient in a similar environment. In conscious persons, conditioning overlaps with learning, thus creating positive expectancies.”
This positive effect is also demonstrable for ‘rituals’ (which include both the ‘appearance’ and going through the motions of acting like a doctor).
“Rather than deny medicine’s ritual elements as incompatible with or incidental to scientific aspirations, clinicians can capitalize on the common rituals of daily practice. For example, rather than advising the patient to get more exercise, a physician can write a prescription for exercise on a prescription pad, thus using ritual in a way designed to elicit a placebo response along with increased adherence.”
Also, the healing power of simply providing a positive experience to the patient should never be underestimated:
“…inviting and listening carefully to the patient’s story of illness experience, offering a satisfying explanation for the patient’s distress, expressing care and concern, communicating positive expectations for therapeutic benefit, and helping the patient to feel more in control of life in the face of the illness.”
In this context it is also worthy to point out that such an approach must not necessarily add considerable time to the encounter because such an approach does double duty:
“Listening well is a part of good history taking. Explaining the illness and proposing positive ways to deal with illness are part of therapy and patient education, besides contributing to shared decision making. Care and concern can be expressed by the clinician’s attitude and demeanor as the other activities are performed.”
As I often tell my medical students, it is not enough to just know your stuff – you also have to know how to look and play the part. Not doing so, means giving up an important piece of your ability to help your patients.
AMS
Edmonton, Alberta
Brody H, & Miller FG (2011). Lessons from recent research about the placebo effect–from art to science. JAMA : the journal of the American Medical Association, 306 (23), 2612-3 PMID: 22187283
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Friday, March 9, 2012
Any doctor or doctor-to-be should read 3 books by Lewis Mehl-Madrona, starting with Coyote Medicine, continuing with Coyote Healing and Coyote Wisdom. Dr. Mehl-Madrona is a medical doctor with a Native heritage and has found ways to straddle the two worlds in very healing ways. As a patient of doctors and alternative forms of healing, I think there is much for “medical doctors” to learn from “traditional witch doctors.” All illness has spiritual and emotional symptoms as well as the physical. It is time to acknowledge all aspects of healing. It would be so much more effective to work on all levels.
One of the best medical interventions that I have experienced was my hysterectomy in 2003. After doing all that could to avoid the removal of my uterus due to fibroids, I finally resigned myself to surgery. A friend suggested that I ask my surgeon about his spiritual beliefs. It wasn’t a long conversation. He replied straight-forwardly and I was relieved to know that indeed he had some deep spiritual convictions–not the same as mine BTW. I simply asked him to bring his convictions to the operating room, to which he replied that he always did. On the day of my surgery, he asked me if I had prayed and told me what he had done that morning to honor my request. I trusted him completely and the outcome was one of the best hysterectomies I have ever heard about. Do I put it all down to this? Of course not, his skill and training, my preparation with diet and nutrition, a friend who dropped by soon after the surgery to give me a reiki treatment…these and other things all contributed to an excellent outcome.
Friday, March 9, 2012
Your post made me think of a great book I just read: Cutting for Stone by Abraham Verghese. Most of the characters are physicians, one of whom prescribes important medicine via the ear: “words of comfort”. Its a great read.
Friday, March 9, 2012
Love this blog Arya, I could not agree more. We somtimes become relaxed with our appearance and mannerisms in the clinic, and I think this is wrong. I like the picture of your wearing your lab coat on your website. Personally, I always wear my lab coat in clinic and the hospital. I understand that others do not war lab coats for many reasons and still eloquently play the doctor role, and that is most important. Cheers Sean
Friday, March 9, 2012
Sounds like a good plan for doctors and health professionals.
How about patients? How do doctors react to what patients wear and how they speak?
I have been called to emergency rooms to be with my mother-in-law.
If I come from work I’m wearing a suit.
If I come straight from my garden my clothes are old and grubby, my hands and even face are dirty. I look like a street person.
The response I get from staff and medical personnel is different depending on my appearance.
As a suit, I’m listened to and consulted. No problem.
As a grubby, I’m reassured, bustled to a seat, and left alone – at least until they realize that I talk like a suit and I refuse (politely) to be sidelined and ignored. Then they’ll listen to me, but as if they think they’re doing me a favour, or as if they think I’m uppity.
In an emergency, I can’t take time to change.
If I ever have a planned trip to a doctor or medical appointment, I dress as if I am going to an important business meeting – which, I suppose I am. The clothes you take off before you put on that hospital gown makes a big difference in how you’re treated.
Friday, March 9, 2012
A patient who feels genuinely cared about (who believes that her life and her struggles truly matter to to the person who is designated as her “care” provider) may experience a form of healing that cannot be measured or observed (even with neuroimaging studies). Perhaps rituals help us connect with an unnamed power which, ironically, flows through us in moments of profound vulnerability.