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‘Doctor knows best’

A month or so ago I wrote about a conversation I’d had with a doctor friend (who also happens to be my GP), about aspects of the doctor–patient relationship.

I met him again at the weekend, and we sat outside the pub enjoying the marvellous sunny autumn weather while the ducks cruised up and down the river.

I could tell there was something on his mind, and after the second pint it came out. He knows I’ve been agitating for greater patient awareness, particularly in relation to the concept of informed consent. In principle, most doctors would agree with the thesis, notwithstanding the fact that their reasons for agreeing aren’t always the same. Some believe that the more awareness the patient has, the less will be her anxiety about her treatment programme; others think that the more the patient knows, the less grounds she has to sue for negligence.

On the whole, my doctor friend belongs to the first group. He’s never been an advocate of the ‘Doctor knows best’ school of medicine, believing instead that healthcare is a partnership in which the doctor assists the patient to achieve his own recovery. To a greater or lesser degree, of course; but still, partnership is the essence of treatment.

But more and more of his patients are coming into the surgery with reams of print-outs from the internet. They’ve felt a bit queer, maybe a spell of light-headedness or a few moments of palpitations, and they’ve logged on to NHS Direct or Dr Foster, or one of the myriad of academic medical websites. Hey presto, they’re convinced they’re suffering from incipient syncope or acute arrhythmia and are about to pop their clogs. Of course, there’s nothing wrong with either NHS Direct or Dr Foster – in the right circumstances both perform a valuable service; but there’s probably nothing wrong with the patient either, and, at least from my doctor friend’s point of view, it’s often a case of a little knowledge being a dangerous thing.

However, last month a patient had died. Her initial presentation had not been immediately clear-cut, and although the evidence pointed towards a fairly benign outcome, the patient was convinced she had the differential diagnosis. She’d spent days researching on the internet, and as far as she could tell her symptoms matched the more serious differential. The one major difference was the presence (or, in point of fact, the absence) of fever. In most cases, fever would indicate the benign course. However, what this patient did not realise was that the aspirin she took daily for an unrelated vascular condition was also reducing her fever. The upshot was that she had believed she was about to die, couldn’t face the prospect of an undignified and prolonged demise, and committed suicide. Autopsy convincingly ruled out the differential.

This story rang a bell with me. I’d read a paper in one of the Nature journals about the ‘nocebo’ effect,* whereby misinformation can lead to a negative outcome for the patient. Something like the opposite of the ‘placebo’ effect, whereby if the patient believes a treatment will do them good, it will do them good. I asked my doctor friend if he’d heard of the nocebo effect. Yes, he said; but he was much more familiar with placebos. In his younger days he’d worked in Africa, and by far the most frequently efficacious medicine in his bush clinic had been “Hospital Pink”: distilled water with pink food colouring in a brown glass bottle. The patients believed it would work; and so it did.

Later I took another look at the paper, this time more closely. And it certainly seems that the body can be fooled into believing there is something amiss, and reacting to that misperception. To give an example, patients in a trial who had been taking an opiate for pain relief were told – falsely – that the analgaesic effect of the opiate was about to wear off. Sure enough the patients in the sample began to experience high levels of unnecessary pain. The researchers concluded that ‘a patient’s negative expectations have the power to undermine the effectiveness of a treatment’.

In another study,† researchers plotted the action of neurotransmitters on pain pathways and discovered that such negative verbal suggestions were sufficient to generate the production of cholecystokinin, a chemical that is instrumental in the transmission of pain. They concluded that their findings ‘underscore the important role of cognition in the therapeutic outcome, and suggest that nocebo and nocebo-related effects might represent a point of vulnerability both in the course of a disease and in the response to a therapy.’

So what does this add up to? Will it change the way my friend talks to his patients? Probably not. Will it change my views about greater patient awareness? Maybe. What it does mean is that the duty of medical professionals to be honest with their patients remains; but they must also bear in mind the fact that too much information, misinterpreted, can lead to unexpected negative consequences. And it means that moves to open up medical research to non-specialists, in the interest of a wider understanding on the part of patients, must be scrupulously overseen, and the resulting publications must be equally scrupulously edited to ensure clarity, lack of ambiguity and ease of apprehension.
 
* I Tracey, Getting the pain you expect: mechanisms of placebo, nocebo and reappraisal effects in humans.
http://www.ncbi.nlm.nih.gov/pubmed/20948533
 
† F Benedetti et al., When words are painful: unraveling the mechanisms of the nocebo effect.
http://www.ncbi.nlm.nih.gov/pubmed/17379417
 
Both papers require subscriptions; the links are to their abstracts.
 
NHS Direct: http://www.nhsdirect.nhs.uk
Dr Foster: http://www.drfosterhealth.co.uk

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  1. March 4, 2013 at 2:11 pm

    This is very interesting. I’d never heard the term ‘nocebo’, but it makes perfect sense. Is everyone sufficiently armed for total transparency though?

  2. March 4, 2013 at 2:22 pm

    “Is everyone sufficiently armed for total transparency though?”

    No, I don’t think they are. Transparency – at least in this field – needs to be mediated by expertise and experience, and this is one of the essential skills of the good doctor. Elsewhere, I write about breakdowns in communication between doctors and patients, breakdowns which can potentially lead not only to misinformation but to a lifetime of suffering. Medical practitioners (it also applies to experts in other walks of life, but nowhere is the risk so great as in medicine) need to be able to gauge their patients’ receptivity to information, and then to present that information in language (and voice) that is immediately and unmistakably understood.

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