Physician Assurance reduces patient symptoms

Relation

Leibowitz KA, Hardebeck EJ, Goyer JP, Crum AJ. Physician assurance reduces patient symptoms in US adults: an experimental study. (Link removed). 2018;33(12):2051-2052.

Objective

To study the effect of the doctor's reassurance, a simple, single sentence, in the absence of pharmacological treatment on the patient's allergic reactions.

Draft

Blinded, randomized study

Participant

The study included 76 adults, 54% under 22 years of age, with the following demographic characteristics: female (61.8%), male (38.2%); White (40.8%), Asian (23.6%), Hispanic/Latinos (9.2%), African American (9.2%), and “other” (15.7%).

Inclusion criteria

Patients presenting for a histamine skin prick test

intervention

Participants were randomized into 2 groups: a trust group (n=36) and a control group (n=41). All participants (n=76) received a histamine skin prick from a Quintip lancet soaked in 10 mg/ml histamine dihydrochloride on the forearm. Each participant rated their itch/irritation immediately before and 3, 9, 12, 15, and 18 minutes after the histamine skin prick. The provider visually examined participants' forearms after the 3-minute assessment.

After 3 minutes, the assurance group was told, “From this point on, your allergic reaction will subside and your rash and irritation will disappear.” The control group (n=41) was not told anything by the provider.

Study parameters assessed

A stopwatch was used to measure the duration of the reaction, and an allergy ruler and tape were used to measure the size of the skin reaction. The response was recorded on a computer or iPad. All measurements were performed by the research assistant, and the provider was not present during participant reporting of symptoms.

analysis

Multilevel longitudinal regression models used time predictors to model differences in itch before and after medical confirmation. Two-sided Z-scores were calculated andP≤ 0.05 was considered statistically significant.

Key insights

Itching during the 3 minutes between skin prick and medical confirmation increased equally in both groups. After confirmation by the doctor, the itching decreased significantly faster than in the group without confirmation (P=0.05), so that the insured group felt significantly less itching after 9 minutes than the control group (P=0.19). This difference lasted between 9 and 12 minutes (P=0.047), while the decrease in itching decreased at almost the same rate for each group. By minute 15, there was no statistically significant difference between the two groups as itching achieved more complete resolution in both groups.

Placebo is an inert substance, but words have rich, vivid and powerful meaning; they are anything but sluggish.

Briefly, a single sentence of reassurance from a physician reduced subjects' ratings of itch/irritation of a histamine reaction compared to the control group.

Practice implications

The “I will please” placebo effect was found to be clinically significant in a 1955 study and was thought to result from the role our brains play in physical health.¹Its use in medicine officially dates back to 1811, although some claim that Samuel Hahnemann used empty lactose pellets on patients and examiners (healthy volunteers) in the 1790s. An 1811 medical dictionary defined placebo as an epithet given to any drug that is more likely to please than benefit the patient.²The medicine of this time consisted of bleeding, leeching and purging. George Washington was bled four times in 8 hours and died that evening (December 14, 1799), while Wolfgang Amadeus Mozart was bled at least once and died the next day (December 5, 1791).^3.4Using something, or more accurately anything, to pre-empt the “standards of care” of those days was arguably the better choice.

Dr. Arthur K. Shapiro spent much of his career studying the placebo effect. He first became interested while recovering from mononucleosis in his second year of medical school, when double-blind placebo trials were used to study antipsychotic, antidepressant and anti-anxiety medications. He defined placebo, in part, as “any therapeutic procedure that 1) is given intentionally to produce an effect, or 2) unknowingly has an effect on a symptom syndrome, disease, or patient, but is objectively devoid of specific activity for the condition being treated.”^5.6Three decades of research later, his definition of placebo remains essentially unchanged; Placebos cause the placebo effect.⁷Dr. Shapiro is also known for his work with Tourette syndrome, proving that it is a neurological condition rather than a psychological one.⁸

The doctor's presentation or doctor's costume, stethoscope, manners, style, language, examination table and medical equipment influence the result as well as the diagnosis and prognosis.^9-12Essentially, the doctor's message is the therapy or becomes part of the therapy. This was called the “meaning response.”¹³Placebo is an inert substance, but words have rich, vivid and powerful meaning; they are anything but sluggish.

As clinicians, we have seen this meaning response in our clinical practice, but we underestimate its power. Outside of a research study, we don't take the time to craft the words, inflections, and body language that convey the message we want our patients to hear or believe. We simply move from patient visit to patient visit to provide the best possible care. The administration of an inactive placebo raises certain moral and ethical concerns that are distinct, although similar, from asserting a treatment or response outcome.

Background documents not published in the journal article note the setup of the examination room in the form of a medical examination room, the doctor's attire, and the exact punishment to be pronounced to each treatment member of the group. So while this has been called a placebo study, it is actually a study of the “meaning response,” a term coined by Moreman and Jonas in their review of the placebo effect.¹³In fact, they argue that by simplifying pain treatment by relying on salicylates, for example, modern medicine has lost touch with the birch, willow, and wintergreen trees from which salicylates can be derived.¹³Or, to put it in the context of this study of allergic reactions to histamine, medicine has lost the nuances of language that could give meaning, comfort, and relief to our patients in certain painful circumstances. We spend too much time looking at a computer screen or lab or study results and not enough time looking at the patient and giving them sincere words of comfort. I remember John Bastyr, ND, telling a small group of us at the end of a clinical shift at the National College of Naturopathic Medicine in 1990 how important it is to touch each patient as part of the therapeutic process. Much of today's medicine has lost and ignored the subtle nuances that can make the difference between a result and a very positive result. We should not stage our patient responses, but we should speak from the heart and offer appropriate, honest hope that can benefit our patients. The delivery of our therapy is as important as the therapy we deliver.

Summary

In this study, a histamine prick allergy test was administered to both groups on the forearm using a Quintip lancet dipped in 10 mg/ml histamine dihydrochloride. After 3 minutes, the doctor examined the forearm and explained to the trust group, "From this point on, your allergic reaction will subside and your rash and irritation will disappear." The control group was not told anything. The difference in response between the 2 groups based on self-assessment was significant after 9 minutes. The doctor's language appeared to significantly reduce itching and rash in those who received the positive affirmation.