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SundayReview | OPINION

TheConversationPlacebo
ByDANIELLEOFRI JAN.19,2017

Inmydailyworkasaprimarycareinternist,Iseenoletupfrompain.Everysinglepatient,itseems,hasanaching
shoulderorabumkneeorapainfulback.Ourbodiesevolvedtoliveabout40years,Ialwaysexplain,andthenbe
finishedoffbyamammothoramicrobe.Thankstoacenturyofstaggeringmedicalprogress,wenowlivepast80,
butevolutionhasntcaughtupthecartilageinourjointsstillwearsdowninour40s,andwearemoreobeseand
moresedentarythanweusedtobe,whichdoesnthelp.

Soitsnosurprisethatchronicarthritisandbackpainarethesecondandthirdmostcommonnonacutereasons
thatpeoplegotothedoctorandthatpaincostsAmericaupto$635billionannually.Thepainremediesdevelopedby
thepharmaceuticalindustryareonlymodestlyeffective,andtheyhavesideeffectsthatrangefromnauseaand
constipationtoaddictionanddeath.

Whatsoftenoverlookedisthatthesimpleconversationbetweendoctorandpatientcanbeaspotentananalgesic
asmanytreatmentsweprescribe.

In2014,researchersinCanadadidaninterestingstudyabouttheroleofcommunicationinthetreatmentof
chronicbackpain.Halfthepatientsinthestudyreceivedmildelectricalstimulationfromphysicaltherapists,and
halfreceivedshamstimulation(alltheequipmentissetup,buttheelectricalcurrentisneveractivated).Sham
treatmentplaceboworkedreasonablywell:Thesepatientsexperienceda25percentreductionintheirlevelsof
pain.Thepatientswhogottherealstimulationdidevenbetter,thoughtheirpainlevelsdecreasedby46percent.So
thetreatmentitselfdoeswork.

Eachofthesegroupswasfurtherdividedinhalf.Onehalfexperiencedonlylimitedconversationfromthe
physicaltherapist.Withtheotherhalf,thetherapistsaskedopenendedquestionsandlistenedattentivelytothe
answers.Theyexpressedempathyaboutthepatientssituationandofferedwordsofencouragementaboutgetting
better.

Patientswhounderwentshamtreatmentbuthadtherapistswhoactivelycommunicatedreporteda55percent
decreaseintheirpain.Thisisafindingthatshouldgiveallmedicalprofessionalspause:Communicationalonewas
moreeffectivethantreatmentalone.Thepatientswhogotelectricalstimulationfromengagedphysicaltherapists
weretheclearwinners,witha77percentreductioninpain.

Thistypeofstudyprovideshardevidenceforwhatshamans,witchdoctorsandassortedmysticshaveknownfor
millenniums:Asubstantialportionofhealingcomesfromthecommunicationandconnectionwiththepatient.

Beforewehadtreatmentsthatcouldactuallycounteractthepathologyofdiseaseantibiotics,chemotherapy,
stents,organtransplants,transfusionsplacebowasthemainstayofmedicalcare,andinmanycasesitwas
remarkablyeffective.

Agoodexampleispatientssufferingfromvaguediffusepainswithnodiscerniblecause.Frequentlymypatients
askifamultivitaminwillgivethemmoreenergy.InthepastIwouldsayno,becausetherearenosignificantscientific
studiestodemonstratethis,andalsobecauseintheabsenceofavitamindeficiencytheresnotmuchforabasic
multivitaminpilltodo.NowItakeadifferentapproach.IsaysomethingalongthelinesofManyofmypatientsfind
thattheyhavemoreenergywhentheytakeamultivitamin.Imnotlying,becausemanyhaveindeedsaidso.Without
fail,therearealwaysafewpatientswhocomebackatthenextvisitandsweartheyfeelmuchbetter.

Therearesomewhoarguethatitisunethicaltopromoteplacebostopatients.Butincreasingly,manysayit
wouldbeunethicalnottogiveplacebosatryinsituationswherepatientsarenotgettingrelieffromtraditionalmeans
(andwhereitwouldnotcauseharmorreplaceanecessarytreatment).

Itsclearthathowdoctorsandnursescommunicatetheirtreatmentcanhaveprofoundeffectsonhowpatients
experiencetheresultsofthattreatment.Yettheconversationbetweendoctorsandpatientsisoneoftheleastvalued
aspectsofmedicalcare.Insurancereimbursementsfortestsandmedicalproceduresdwarfreimbursementsfor
talkingtopatientsorspendingtimethinkingaboutwhatailsthem.Andthepharmaceuticalindustry,withitsdirect
toconsumeradvertising,haspromulgatedthefallacythateveryailmentmustbemetwithapillbrandname,of
course.
 Ashealthcarefacesitslatestoverhaul,itscrucialforthemedicalprofession,aswellasinsurancecompaniesand
decisionmakersingovernment,torecognizethepowerofthedoctorpatientconversation.Itsthemostvaluable
diagnostictoolwehaveandcanberemarkablyeffectiveasatreatmenttoolaswell.Trainingfordoctorsandother
medicalprofessionalsshouldemphasizecommunicationskillswiththesamerigorthatitdoesforotherclinicalskills.

Callconversationaplaceboifyoulike,butifithelpswithoutcausingharm,thenitslegitimatemedicine.
Relievingsuffering,afterall,iswhattheHippocraticoathisallabout.

DanielleOfriisanassociateprofessorofmedicineatN.Y.U.,theeditorinchiefoftheBellevue
LiteraryReviewandtheauthoroftheforthcomingWhatPatientsSayWhatDoctorsHear,from
whichthisessaywasadapted.

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AversionofthisopedappearsinprintonJanuary22,2017,onPageSR2oftheNewYorkeditionwiththeheadline:TheConversationPlacebo.

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