The Power of Bedside Manner on Pain
New research shows how doctors' beliefs and attitudes impact patient outcomes
W hen he practiced as a psychotherapist, Luke Chang, PhD, now an Assistant Professor of Psychological and Brain Sciences at Dartmouth College, frequently used his body language and tone of voice to develop trust and rapport with his clients.
Whether he communicated warmth through his posture or exaggerated his expression to show shock or surprise, he knew his "bedside manner" would play a role in his clients' emotional healing process.
"It's been known for a while that nonspecific factors like expectations and the therapeutic relationship contribute a lot to treatment outcomes in the context of mental health," Chang says. "And while there's some evidence that these things probably matter for physical health as well, it's been studied even less."
To get a more concrete answer about the effects of a doctor's attitude on a person's well-being, Chang and his colleagues conducted a study, which was published this month in Nature Human Behavior. Their findings confirm Chang's hypothesis: if providers believe in a treatment's effectiveness, and they express that belief through facial expressions, their patients could experience less pain.
T he researchers ran three experiments focusing on how doctors' beliefs (when reflected to the patient) can impact patients' response to painful stimuli. First, to rule out possible explanations for a placebo effect - basically, to ensure there was no personality type or experience level that could explain the results - the authors randomly assigned 194 participants the role of "doctor" or "patient." Then, the researchers gave each "doctor" two creams to administer to patients, who had been exposed to "thermal pain" (hot temperatures on their forearms).
The important part of the study happened in conditioning the "doctors'" beliefs about the creams. While both creams were actually placebos (meaning they wouldn't actually impact a patient's pain), Chang and his colleagues told the "doctors" that one was a placebo and one was effective for reducing pain.
Patients - who knew they weren't being treated by real doctors - consistently reported lower pain levels with creams the "doctors" believed would work. Because the researchers observed that "doctor" participants' facial expressions changed according to the cream they applied, Chang thinks how much a doctor believes in the efficacy of a given treatment could make a difference in patient outcomes.
" If I as a clinician really believe and trust a treatment and I think it will work really well with a patient, I'll have a complete difference in response to pain than if I act like I'm not sure."
Chang's findings also suggest that bedside manner, which includes "soft skills" like empathy, communication, and friendliness, could play a significant role in patient outcomes - and he's excited to see how it all translates to a real, clinical environment.
"It's one thing if you're in our lab, and it's another thing if you're in a hospital setting," Chang says." "In a real clinic, where your physician has had a decade of school, and there's all these other contextual factors like fancy machines and a nice building, all these things could contribute even more to the effects we saw. We are hoping to explore that in the future."
D avid J. Tauben, MD, a pain specialist and instructor at the University of Washington Medical School, says he regularly sees the power of his beliefs and attitudes impact his patients, especially those dealing with chronic pain. Doctors use a term called 'therapeutic allegiance.'
"If I as a clinician really believe and trust a treatment and I think it will work really well with a patient, I'll have a complete difference in response to pain than if I act like I'm not sure," he says.
But it's not just confidence in a treatment plan that makes a difference in peoples' health outcomes. Tauben says confidence paired with empathy and warmth make an even more profound difference, especially in treating people with pain. Since pain is complex and often comes with a number of judgments from the doctor and sensitivities on the patient's part, how a doctor communicates efficacy of treatment can lower someone's anxiety, and, in turn, make the treatment more effective.
"Being told 'this is the worst MRI I've ever seen' or 'your X-ray shows severe degenerative disease' sends the brain into thinking 'this is awful.' When you worry and have anxiety, you anticipate suffering, and pain intensity clearly goes up," Tauben says. "It's well documented that if your state is fearful, the same sensation delivered is heightened, compared to in a mindfulness state of relaxation and calm."
O ther findings confirm the outcome of Chang's research on the effects of a doctor's beliefs and expressions on overall health. For example, in one 2009 study in which people came to the doctor with a cold virus (which can't be cured with medication), the level of their doctors' empathy decreased the duration of their illness and increased immune markers, suggesting that how doctors treat their patients socially and emotionally is just as important as how they treat them medically.
As it stands, many doctors aren't formally trained on how to interact with patients in a way that could benefit patients' treatment. For example, only in the last few years, Chang says, did the MCAT (the test required for admission to medical school) begin incorporating questions on concepts like psychology in addition to science topics such as biology and chemistry.
Chang hopes his findings could influence future medical training, and encourage practitioners to consider fostering relationships with patients as a valid form of treatment. "We could potentially train people faster or deliver more focused treatment if we know why these things work. There's a lot of opportunity to improve."
While medical school is complicated and there's not always room in curriculum for "intuitive" concepts like patient-doctor communication, Tauben believes incorporating topics that encourage medical students to see patients as whole individuals would be beneficial to patient outcomes, and the field of medicine in general. "In order to improve health outcomes, it's more than just curing a disease; it's caring for the patient," he says.
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