One of my most memorable patients was a young girl who was admitted for a rare disease called Stevens-Johnsons Syndrome – a severe inflammatory skin condition which often has no clear cause, and can be deadly.
Yet her case doesn’t stand out because of her presenting illness, but rather due to the relationship the family had with the Pediatric Intensive Care Unit (PICU) attending, Dr. D. The family had utmost trust in him, and had built a relationship for over a month that seemed, at least to them, essential to their daughter’s clinical improvement. The family would light up as they spoke about how Dr. D took the time to calm their fears, explain the treatment, and make himself available for any questions – regardless of how simple these might have seemed. He also possessed an unparalleled bedside manner; he was kind, and soft-spoken, even towards the most junior trainees.
When the little girl’s parents expressed that they felt she got better because of their relationship Dr. D, I understood – it was the first time I realized that mindset could go a long way to how a patient experiences healing.
Recently, Jeopardy host Alex Trebek credited his ‘optimistic mindset’ as part of why he believes he will recover from stage-four pancreatic cancer. And a number of researchers have looked into this idea – with interesting results.
This month, researchers published results of a trial of oral immunotherapy for peanut allergy in children and teens. During an explanation of some non-life-threatening symptoms that could result from the immunotherapy, half of the patients were told these were side effects, whereas the other half were told these symptoms signalled desensitization (i.e. that the treatment was working). After analyzing the data, The researchers found that the latter group were less anxious, less likely to miss doses of the immunotherapy, and, particularly interesting, they had higher protective antibodies (IgG4).
Previous studies in adults have found similar patterns. For instance, a study among patients with HIV found associations between trust and objective measures – specifically that trust in the healthcare team was associated with an increase in CD4 cell (a key white cell that is targeted by HIV) count.
Similarly, a Taiwanese study from 2010 looked at this issue in 614 patients with type 2 diabetes, and found that glycemic control was better controlled in patients who cultivated a mindset of trust towards their physician.
Even the way physicians discuss a treatment can make a difference to a patient’s symptoms. Last year a group of researchers looked specifically at the idea of ‘priming’ – the way a physician describes a subsequent result – in this case, pain. When the patients were primed positively about pain they reported less functional disability compared to those who were primed negatively.
Mindset and empathy go hand in hand, and another group of researchers reported in their study that when physicians display a high degree of empathy towards their patients with cold symptoms, patients could experience less severe symptoms over a shorter duration.
A recent analysis in the British Medical Journal, has expanded on all of these ideas, looking more generally at how a patient mindset could influence their health outcomes. The authors, all from Stanford University, say that “medical diagnoses and treatments are never isolated from patient mindsets and social context.”
Mindset includes trust in the practitioner, but can also include the hospital’s credentials, drug prices and branding. These factors could be responsible for 60-90% of clinical improvement, and the authors argue that randomized clinical trials often ignores these variables.
As such, the idea of a ‘placebo effect’ is much more than a sugar pill, but a whole range of factors that can influence how patients view their treatment, and ultimately how they heal.
Roy Ziegelstein, a cardiologist based at Johns Hopkins University Medical Center has explored this idea of a ‘broader placebo effect’ over a number of years. In a commentary he penned over a decade ago, he looked specifically at the influence of depression – in this case an example of very negative mindset — on adherence to cardiac medications, and found a link. By addressing the patient’s depression, adherence to the medication improves.
Ziegelstein believes that the shift towards patient-centered-medicine in American healthcare can help foster better healing relationships between physicians and patients.
“There’s no doubt that the mindset of a patient – of which trust in their doctor is one key part – can affect how they experience their care and treatment. The person’s perception, and all of the behaviours that go along with it, can have a powerful effect on an outcome,” Ziegelstein says.
So, the question remains how the social and psychosocial aspects – namely trust and mindset – can be harnessed to help patients heal. The Stanford team calls for medical training programs to begin recognizing and appreciating these elements in the clinical encounters of future physicians. They also argue for incorporating these factors into ongoing research and health systems reform – moving away from an emphasis on the traditional biomedical model of healing.
When I think back to the little girl with the rare disease, I remember how long it took to build a therapeutic relationship based on trust, empathy, and shared decision-making. Thankfully, she made a full recovery, and judging from the family’s visit to see us many weeks later, perhaps we did OK after all.