Why Looking Like a Doctor Makes You a Better Doctor

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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