Words can Harm, Words can Heal
The study of the week explores the power that a clinician has in making people well
The picture below shows how a treatment can make patients better. I see four ways. The drug/procedure may work biologically. The Voltaire effect relates to his quote saying that the art of medicine consists of amusing the patient while nature cures the disease. AKA: natural history. Placebo effects can also contribute.
I will show you an elegant experiment demonstrating how positive energy and words can add to improvement. Indeed the encounter is an opportunity to heal.
The study happened in the 1980s, but it is timeless. Dr. KB Thomas in Southampton England wanted to know whether a positive vs a negative “approach” to the patient encounter would matter.
The study had 200 patients with symptoms but no obvious physical signs or diagnosis. Common symptoms included cough, sore throat, belly pain, back pain, headache, etc. Patients were randomized to two approaches.
Here is a picture of the experiment:
A “positive” approach involved giving a firm diagnosis and confidently saying the patient would improve. If no treatment was given, the positive response was that it was not needed. If treatment was given, patients were told it would work.
The comparator group, the “negative,” approach would be to say the truth: “I cannot determine what is the matter with you.” If treatment was given, patients were told that the doctor was not sure it will work. And if no treatment was given, patients were told that was because there was no diagnosis.
The treatment was thiamine 3 mg. A vitamin with no known healing properties. The author also collected data based on treatment response rate.
Here is a slide of the results (collected at 2 weeks):
Isn’t that something! The response rate for a positive consultation far exceeded the negative consultation (64% vs 39%). Notice also that the treatment made no difference.
The only effective intervention in this study was the doctor. The medicine had no effect.
I show this beautiful experiment because it emphasizes the power of being positive. I am not sure clinicians realize the importance of the actual encounter with a patient. I did not when I was younger.
When I joined private practice in the 1990s there was an older doctor who was often made fun of for his cheery demeanor with patients. He had this friendly face, and with a gentle touch, he nearly always told the patients that “we will help you,” and “you will likely get better.” Some of our colleagues in the group thought this was a silly approach. He also wrote very short notes.
As I aged and gained experience (and had a few turns as a patient myself), I have come to realize the genius of such an approach.
Even when patients have serious illness and a poor prognosis, we can help in some way. Help may not be cure but it can be in smaller ways. Heck, why isn’t the simple act of caring not considered helping a person?
I don’t advocate for deceiving patients. But I believe the best clinicians are those that use the encounter as a time to help.
A short note of thanks. After spending a weekend making educational videos with Adam and Vinay, I feel energized about Sensible Medicine. Your support is amazing. JMM
Dr. Mandrola, I couldn't agree with you more, and I deeply appreciate your contribution to this discussion. For far too long, placebo and nocebo science has been sidelined in medical care, often viewed through an outdated lens that reduces the placebo effect to a mere psychological phenomenon, useful only for patients with psychogenic symptoms. However, the evidence is clear: the patient-practitioner relationship can powerfully trigger top-down neural and biochemical modulation of physiological processes.
Importantly, the placebo effect does not rely on administering an inert substance or acts of deception. Research has demonstrated robust placebo effects even when patients are aware they are receiving a placebo intervention. Of particular significance is the dynamic interaction between patient and practitioner, which can be conceptualized as a socio-biological approach to care (Colloca L. et al., Int Rev Neurobiol. 2018;139:211-231). Empathic communication, central to this relationship, is largely driven by the patient's perception of the practitioner's empathy. This perception triggers measurable neurobiological responses, as demonstrated by neuroimaging studies, and can lead to reduced pain and suffering.
Regrettably, empathy itself is increasingly under scrutiny in today’s climate of social unrest, where it is often mischaracterized as a weakness and leading to emotional vulnerability. Yet empathy—and empathic communication—remains teachable. While it may come naturally to some, others can acquire and refine it through deliberate effort and practice.
It is also noteworthy that around 80% of empathic communication is nonverbal, a crucial factor that has been significantly disrupted over the past generation by the intrusion of computers and electronic medical records (EMRs) into the physician-patient dynamic. However, emerging tools, such as AI-powered medical scribes, offer the potential to refocus attention on the patient, thereby enhancing the bidirectional empathic bond between patient and practitioner.
Now is an opportune moment to explore interpersonal healing and the techniques that can amplify its effects. While skeptics may argue that patient-practitioner relationships will not reduce HIV viral loads or cure cancer, improving quality of life and alleviating suffering are nonetheless vital goals. These aspirations should be prioritized as integral components of holistic care.
It is my belief that a positive attitude generates hope, and that hope itself goes a long way toward bringing about healing. I suppose that is just common sense, but in the face of illness, especially chronic illness, is it so easy to lose your grip on hope, both for the provider and the patient.