Howard Brody, MD, PhD

In this issue of JFP, Potter and colleagues¹ point out that there are few reliable empirical data to guide family physicians in the use of narcotics for chronic nonmalignant pain (CNMP). They have, however, contributed to our understanding of the issue with their careful survey of physicians in Northern California. I would have been interested to see 2 other hypotheses addressed.

Using the same methods, the authors might have asked whether those physicians who are more willing to prescribe stronger narcotics for CNMP are also those who have had more experience in the care of pain in terminal illness. Hospice physicians have been among the first to report that their clinical experience in the use of high-dose narcotics has been at odds with the dire warnings that were prevalent in medical training until very recently. For example, tolerance is hardly ever a serious problem in malignant pain; when a patient’s dosage needs to be increased it usually means the tumor is advancing and not that the patient has developed tolerance. Anecdotal evidence suggests that physicians who have had their eyes opened by the way narcotics perform in end-stage malignancy may be more willing to employ such drugs for CNMP.

Another hypothesis would require a different research method. The finding that the study physicians were more concerned about addiction and dependency issues than regulatory oversight may be the correct story. However, fear of addiction may have seemed the socially more acceptable answer. These physicians might have been unwilling to admit that they withheld needed drugs because of their fears of administrative repercussions. Therefore, deciding that the drugs were contraindicated based on the risk of addiction may have been a more comforting theory. A focus group or semistructured interview method would have allowed for the follow-up questions needed to tease out these strands and to see how closely the fear of addiction was tied to fears of regulatory oversight.

The time to prescribe

By turning to the study findings and making the assumption that potent narcotics do have a role to play in managing some cases of CNMP, Potter and coworkers show us the harm caused by physicians who are unable or unwilling to spend sufficient time with each patient. They point out that the state of California had taken care to inform physicians they could be virtually assured freedom from adverse consequences for prescribing narcotics for CNMP, provided they adhere to some documentation guidelines. Many in the sample were unwilling to prescribe the drugs at all, however, and many who did admitted that their documentation fell far short of what had been recommended. The more patients seen per unit time, the less likely the physician was to prescribe narcotics. It might be suggested by these data (though the connection is admittedly indirect) that high-quality care of CNMP patients takes extra time, and physicians who lack enough time will either shy away from taking care of such patients or will be tempted to skimp on documentation (and potentially land in trouble despite having provided a reasonable quality of service).

Appropriate management of CNMP in primary care, including the appropriate use of narcotics, is one of the most vexing problems now facing family physicians. Given the astonishing prevalence of chronic pain in the United States population, it is a sad indictment that so little solid evidence is available to guide our treatment.

In this issue of JFP, Potter and colleagues¹ point out that there are few reliable empirical data to guide family physicians in the use of narcotics for chronic nonmalignant pain (CNMP). They have, however, contributed to our understanding of the issue with their careful survey of physicians in Northern California. I would have been interested to see 2 other hypotheses addressed.

Using the same methods, the authors might have asked whether those physicians who are more willing to prescribe stronger narcotics for CNMP are also those who have had more experience in the care of pain in terminal illness. Hospice physicians have been among the first to report that their clinical experience in the use of high-dose narcotics has been at odds with the dire warnings that were prevalent in medical training until very recently. For example, tolerance is hardly ever a serious problem in malignant pain; when a patient’s dosage needs to be increased it usually means the tumor is advancing and not that the patient has developed tolerance. Anecdotal evidence suggests that physicians who have had their eyes opened by the way narcotics perform in end-stage malignancy may be more willing to employ such drugs for CNMP.

Another hypothesis would require a different research method. The finding that the study physicians were more concerned about addiction and dependency issues than regulatory oversight may be the correct story. However, fear of addiction may have seemed the socially more acceptable answer. These physicians might have been unwilling to admit that they withheld needed drugs because of their fears of administrative repercussions. Therefore, deciding that the drugs were contraindicated based on the risk of addiction may have been a more comforting theory. A focus group or semistructured interview method would have allowed for the follow-up questions needed to tease out these strands and to see how closely the fear of addiction was tied to fears of regulatory oversight.

The time to prescribe

By turning to the study findings and making the assumption that potent narcotics do have a role to play in managing some cases of CNMP, Potter and coworkers show us the harm caused by physicians who are unable or unwilling to spend sufficient time with each patient. They point out that the state of California had taken care to inform physicians they could be virtually assured freedom from adverse consequences for prescribing narcotics for CNMP, provided they adhere to some documentation guidelines. Many in the sample were unwilling to prescribe the drugs at all, however, and many who did admitted that their documentation fell far short of what had been recommended. The more patients seen per unit time, the less likely the physician was to prescribe narcotics. It might be suggested by these data (though the connection is admittedly indirect) that high-quality care of CNMP patients takes extra time, and physicians who lack enough time will either shy away from taking care of such patients or will be tempted to skimp on documentation (and potentially land in trouble despite having provided a reasonable quality of service).

Appropriate management of CNMP in primary care, including the appropriate use of narcotics, is one of the most vexing problems now facing family physicians. Given the astonishing prevalence of chronic pain in the United States population, it is a sad indictment that so little solid evidence is available to guide our treatment.

In this issue of JFP, Potter and colleagues¹ point out that there are few reliable empirical data to guide family physicians in the use of narcotics for chronic nonmalignant pain (CNMP). They have, however, contributed to our understanding of the issue with their careful survey of physicians in Northern California. I would have been interested to see 2 other hypotheses addressed.

Using the same methods, the authors might have asked whether those physicians who are more willing to prescribe stronger narcotics for CNMP are also those who have had more experience in the care of pain in terminal illness. Hospice physicians have been among the first to report that their clinical experience in the use of high-dose narcotics has been at odds with the dire warnings that were prevalent in medical training until very recently. For example, tolerance is hardly ever a serious problem in malignant pain; when a patient’s dosage needs to be increased it usually means the tumor is advancing and not that the patient has developed tolerance. Anecdotal evidence suggests that physicians who have had their eyes opened by the way narcotics perform in end-stage malignancy may be more willing to employ such drugs for CNMP.

Another hypothesis would require a different research method. The finding that the study physicians were more concerned about addiction and dependency issues than regulatory oversight may be the correct story. However, fear of addiction may have seemed the socially more acceptable answer. These physicians might have been unwilling to admit that they withheld needed drugs because of their fears of administrative repercussions. Therefore, deciding that the drugs were contraindicated based on the risk of addiction may have been a more comforting theory. A focus group or semistructured interview method would have allowed for the follow-up questions needed to tease out these strands and to see how closely the fear of addiction was tied to fears of regulatory oversight.

The time to prescribe

By turning to the study findings and making the assumption that potent narcotics do have a role to play in managing some cases of CNMP, Potter and coworkers show us the harm caused by physicians who are unable or unwilling to spend sufficient time with each patient. They point out that the state of California had taken care to inform physicians they could be virtually assured freedom from adverse consequences for prescribing narcotics for CNMP, provided they adhere to some documentation guidelines. Many in the sample were unwilling to prescribe the drugs at all, however, and many who did admitted that their documentation fell far short of what had been recommended. The more patients seen per unit time, the less likely the physician was to prescribe narcotics. It might be suggested by these data (though the connection is admittedly indirect) that high-quality care of CNMP patients takes extra time, and physicians who lack enough time will either shy away from taking care of such patients or will be tempted to skimp on documentation (and potentially land in trouble despite having provided a reasonable quality of service).

Appropriate management of CNMP in primary care, including the appropriate use of narcotics, is one of the most vexing problems now facing family physicians. Given the astonishing prevalence of chronic pain in the United States population, it is a sad indictment that so little solid evidence is available to guide our treatment.

Since the placebo response was last reviewed for family physicians¹ new research has added to our basic knowledge of this phenomenon, but placebo research remains in its infancy. Outcome studies have shown how various physician behaviors and practice styles can enhance the health status of patients. Seldom, however, are these 2 bodies of research carefully integrated to show the clinician how to best use the science of the placebo response to improve patient outcomes. Such integration is possible and would be useful for family physicians.

The science of the placebo

Two recent findings highlight the continued controversy over the placebo response. The apparent importance of the placebo response was recently emphasized by the ethical debate over the use of sham surgery control groups in studies of fetal cell brain implants for intractable Parkinson’s disease.^2,3 The need for a sham group and the ethical question of whether exposing subjects to this risk is warranted arises because subjects receiving the sham procedure typically exhibit marked improvements in their Parkinson’s symptoms for up to 6 months and are indistinguishable from patients given the active treatment. This improvement does not seem to be due to either the natural history of the disease or observer bias.

However, the preliminary findings from a carefully conducted meta-analysis⁴ failed to demonstrate any consistent sizeable benefit from receiving a dummy treatment in a randomized blinded trial when another nontreatment group was included with which the sham-treatment group could be compared. These findings do not exclude the possibility that the psychosocial aspects of the physician-patient encounter may exert independent healing effects, but they do cast doubt on the placebo response as traditionally conceived-the so-called power of the sugar pill.

Although much controversy remains, the bulk of the literature supports the proposition that the placebo response is real and potentially powerful, and some of its underlying mechanisms are becoming better understood.

Definitions

Defining “placebo” and “placebo response” in a logically coherent fashion is difficult, perhaps impossible.^5,6 Terms commonly used in medical definitions, such as “inert” and “nonspecific,” range from useless to misleading. Ideally, a definition would be precise enough to clearly demarcate the phenomenon, yet open enough to include a range of possible empirical hypotheses on cause and mechanisms. Terminologic problems, among other factors, have led some thoughtful family physicians to suggest that we eliminate “placebo effect” from our lexicon.^7,8

Assuming that the placebo response falls under the general heading of psychosomatic processes, how wide a range of such processes do we want to admit under the definition? At one extreme, the placebo response can be defined in a very narrow way as bodily changes that occur following the administration of a dummy treatment. This type of placebo response is of little interest to family physicians in daily practice. This definition appeared in a recent review in which the authors claimed that there is no scientific evidence that the placebo response exists.⁹ Since they insisted on the ubiquity and robustness of psychosomatic processes generally, they leave themselves with a conundrum-why should the mind-body connection be so powerful except where it would work by giving dummy medications?

I argue for a broader definition: The placebo response is a change in the patient’s health or bodily state that is attributable to the symbolic impact of medical treatment or the treatment setting. By this definition, a placebo response would be predicted whenever a conscious patient engages in any form of medical encounter (or self-treatment activity). But the definition explicitly excludes from consideration mind-body changes that are not directly related to medical treatment. This definition highlights why family physicians should be particularly interested in the placebo response. Also, since bodily change can be negative as well as positive (nocebo effects),¹⁰ it warns us that if we fail to understand the placebo response, we may unwittingly do harm. For example, a frequently quoted study¹¹ showed that expressing diagnostic uncertainty regarding common nonspecific symptoms can adversely affect symptom resolution.

Frequency of Placebo Responses

The first modern review of the placebo effect made the often-repeated claim that an average of approximately one third subjects will respond to placebos.¹² It was later shown that this average, even if accurate, masks an extremely wide variation in placebo response rates among studies.¹³ Roberts and colleagues¹⁴ recently reviewed the original uncontrolled trials of therapies introduced with great fanfare in past years and now universally dismissed as medically useless. They found a 70% average rate of “excellent” and “good” responses to those treatments before properly designed double-blind trials were conducted. They concluded that in settings of heightened expectancy, the placebo response rate could be much higher than previously thought.

Attention has recently turned to meta-analyses of the placebo response.^9,13,14 One sophisticated analysis of placebo-controlled studies with more than 2 arms suggests that so-called “nonspecific” effects may be substantial and may be either synergistic or antagonistic toward “specific” effects, so the merely “additive” model of the placebo and drug effects, implicit in the design of most randomized controlled trials, is overly simplistic.¹⁵

Hypothetical Models

According to a meaning model,¹⁶ a positive placebo response is most likely to occur when the meaning of the illness experience is altered in a positive direction. A positive change in meaning occurs when one or more of 3 things happens: The patient feels listened to and receives a satisfactory, coherent explanation of his illness; the patient feels care and concern from those around him; and the patient feels an enhanced sense of mastery and control over his symptoms. Because the meaning that we attach to events in our lives often hinges on the stories we construct about those events, this model helps explain the importance of narrative in medicine.^17,18

Support for this model comes from several directions. In a psychology laboratory, a group of subjects told about the potentially healthful effects of brief hand immersion in ice water had better pain tolerance than a group briefed on the dangers of cold immersion, and both groups were significantly different from control subjects given a neutral message.¹⁹ In clinical research, the informed consent process is often thwarted by the “therapeutic misconception,” the tendency of subjects to believe that they are getting medical care aimed at their personal medical problems despite being told that their treatment is selected by the research protocol.²⁰ The therapeutic misconception might enhance the placebo response and make it more difficult to show that an active drug is superior to placebo.

Placebo-Prone Personalities

Much of the early literature on the placebo response was devoted to identifying a “placebo personality type,” in the vain hope that such subjects could be eliminated from clinical trials so as not to confuse the results with placebo responses. In general, this early literature^21,22 concluded that no such personality type exists and that the placebo response is more a contextual situational phenomenon than an enduring personality trait.

One important exception to this general conclusion is highlighted in a superb recent review of the placebo literature. Fisher and Greenberg²³ argue that the “acquiescent” personality type is more likely to experience positive placebo responses. At first misunderstood as passivity, the label “acquiescent” is now better understood as an active coping mechanism. This type of person deals with adversity by developing positive relationships with others and using them as a healing resource. This suggests the importance of continuity of care and effective interpersonal relationships in producing positive placebo responses as part of daily practice.

Theories of Placebo Action

Experimental data currently support 2 general theories about the placebo response: expectancy and conditioning.^22,24 The first proposes that bodily changes occur to the extent that the subject expects them to; the second, that bodily changes occur when the subject is exposed to a stimulus that has been linked in the past to active processes that produce the change.

A classic study of expectancy²⁵ showed subjects unable to distinguish the pharmacologic properties of amphetamines and chloral hydrate when they had no expectancy cues for the drugs they were receiving. A recent study of conditioning²⁶ showed that young asthmatics, exposed over time to a vanilla aroma at the same time as they used their metered dose inhalers, demonstrated objective bronchodilation when later exposed only to the vanilla.

We may view these theories, taken in conjunction with the meaning model, as complementary not competing. Conditioning theory may explain how the past experiences of the patient affect the meaning attached to present events, while expectancy focuses on how the patient’s thoughts of the future may influence therapeutic outcomes.

Biochemical Mediators

Neither expectancy nor conditioning theory explains the process by which the altered meaning in the patient’s mind causes a change in bodily status. The complete answer to the neuroanatomy and biochemistry of the placebo response is unknown. The most interesting research has focused on 3 pathways: endorphins, cathecholamines and cortisol, and psychoneuroimmunology. All are capable of altering bodily symptoms, and all are known to be connected intimately with the individual’s emotional and cognitive state.

An elegant, recent, 12-armed trial conducted in a psychology laboratory²⁷ compared 2 aspects of placebo response to pain: expectancy versus conditioning, and conditioning with morphine versus conditioning with ketorolac. The results showed that placebo analgesic effects produced by expectancy could be reversed by naloxone, suggesting that these might be endorphin mediated. Similarly, placebo conditioning with morphine could be reversed by naloxone, but the placebo response was not naloxone-reversible when ketorolac was used as the initial stimulus. The authors concluded that the biochemical pathway for placebo conditioning might depend on the biochemical pathway activated by the active drug.

Future Research Directions

My brief review suggests a number of requirements for advancing knowledge of the placebo response. The greatest advances will come from multidisciplinary research teams set up to integrate qualitative measures of meaning and perception with quantitative measures of biochemical mediators and bodily change.

Intriguing studies conducted in psychology laboratories²⁷ must be replicated and expanded in the less controlled environment of clinical practice.

Creative use of brain imaging techniques, such as positron emission tomography and functional magnetic resonance imaging may be used to identify which neuroanatomical centers’ activation correlates with placebo responses.

Carefully designed meta-analyses may increase our understanding of selected facets of the placebo response.

Integrating Science and Practice

The [ Figure] suggests how the scientific elements reviewed here can be interwoven into a causal account of the placebo response that can guide physician behavior. Although all elements are of interest for research, the meaning model is most helpful for suggesting therapeutic interventions, since it describes those parts of the process that the physician can most easily influence.

Practice implications

This review suggests a number of therapeutic strategies for office practice that many sensitive and astute clinicians are already using. The available evidence suggests that although we do not fully understand why or how these strategies work, they are relatively inexpensive and notably nontoxic, so no barriers exist to their employment.

Although the focus here is on specific techniques, the importance of the background rituals of medical practice, such as listening to the heart with a stethoscope and writing a prescription, should not be forgotten. History and culture have imbued these rituals with multiple layers of meaning, and their simple predictability may bring great comfort to a frightened patient.

Sustained Partnership

Perhaps the best single concept of how to structure one’s interactions to maximize the placebo response is that of the “sustained partnership” between physician and patient.²⁸ Sustained partnership consists of 6 physician characteristics:

• Interest in the whole person
• Knowing the patient over time
• Caring, sensitivity, and empathy
• Viewed as reliable and trustworthy by the patient
• Adapts medical goals of care to the patient’s needs and values
• Encourages the patient to participate fully in health decision making

These 6 elements were selected because empirical studies link them to superior health outcomes in practice settings. Relating to patients in this way leads to measurable improvements in the patient’s health and an ethically sound (as well as cost-effective) practice. Sustained partnership is a nondeceptive mode of practice, so the ethical problem created by the use of sugar pills and other dummy remedies never arises-the placebo effect is present without the placebo.²⁹

Meaning Model

The meaning model suggests that physicians will obtain the best therapeutic results if they listen carefully to patients’ accounts of their illness, offer explanations that fit with patients’ world-views, express care and concern, and help patients feel more in control of their symptoms (or of their lives, despite the persistence of their symptoms). This will happen more often if the clinician spends sufficient time with the patient, so it is not surprising that good health outcomes correlate with the length of the primary care visit.^30,31 Family physicians must act as advocates for their patients with today’s financial managers by bringing these data forcefully to the managers’ attention.

Mastery

Of the different elements of meaning, perhaps the most challenging to achieve when treating chronically ill, somatizing, or depressed patients is the heightened sense of mastery and control. Malterud³² has summarized an encounter plan to deal with one difficult population, women presenting with pelvic complaints without detectable organic cause, suggesting 4 basic questions:

• What do you most of all want me to do for you today?
• What do you yourself think is the reason for your problem?
• What do you think I should do about your problem?
• What have you found so far to be the best way to manage your problem?

Malterud points out that previous physicians, by approaching these patients in “rule out organic causes” fashion, have firmly cemented the idea of victimhood in the minds of these women. Malterud’s strategy is designed to make each encounter an exercise in seeing oneself as potentially worth listening to, potentially wise about one’s bodily needs and their management, and thus potentially powerful. Physicians can achieve progress with some of the most difficult patients when they curb the urge to supply a diagnosis and therapeutic plan before the patient has a chance to speak.

A more formal strategy has been suggested for family counseling that seems readily applicable to daily practice.³³ This entails asking at each visit, “How much is [the symptom or problem] in control of your life, and how much are you in control?” Patients can readily assign a percentage score to this variable. It is not unusual for a suffering patient to state at the first visit in which this question is asked that the problem controls 80% of his life and he feels in control of only 20%. In keeping with the mastery goal, it is critical to allow the patient, if at all possible, to choose the name of his problem. (One of my patients elected to name her complex entanglement of psychosocial stressors her “box of rocks.”) The follow-up instruction is, “Between now and the next visit, see if you can discover things that you can do, on at least some days, to make you feel more in control.” It is again desirable, unless forced, to stifle the advice-giving urge, as that can subtly undermine the patient’s sense of potential mastery.

During the next visit, the patient may report that he has discovered something that works and that he feels 25% in control of his life and the problem controls only 75%. After praising the patient for this accomplishment, your follow-up question might be, “Do you think it would be possible to try that technique even more often in the future?” or “Do you think, now that you have done such a good job of finding one thing that works, that you might think of another?” Patients may want to keep a formal written diary of their progress. By using this approach, the patient may eventually be able to report that his sense of control has risen to more than 50%. Usually that will produce a substantially improved quality of life.^34,35

Story

A further implication of the meaning model is the value of explicit “story work” with patients with chronic complex problems. Since most people attach meaning to important events in their lives by implicitly or explicitly constructing narratives about the events, story work allows the physician and patient to work together with the issue of meaning. Steps in working with the patient include:

Ask for your patient’s story about the illness or problem, including its root causes, its present effect on his life, and how he imagines the rest of life unfolding with the problem. This may be done with take-home written assignments between visits to conserve office time.

Analyze the meaning of the story with the patient, looking especially at the negatives that seem to produce unnecessary suffering, such as guilt over the presumed cause of the illness or lack of improvement in the future.

Encourage the patient to begin imaginatively constructing alternative elements to the story, especially happier endings. These are much more powerful when generated by the patient and less effective when the physician suggests them.

Work with the patient to identify changes in day-to-day activities that might reflect and further cement the reality of the revised story in the patient’s life.

A similar approach is typically employed for chronic pain patients, but it is valuable to make the story work explicit.³⁶ At the start of treatment, these patients typically see only 2 possible stories: a future in which their pain magically disappears completely or one of unremitting suffering. It may take much supportive work to facilitate the construction of an alternative story in which the patient can imagine the possibility of feeling less pain and achieving important life goals despite never being completely cured. Often the patients have been so overwhelmed by the pain experience, and the search for a cure, they have simply lost sight of those other goals; the main element of story work is getting them back in touch with those goals. Once the patient has successfully constructed that alternative story, other elements of management (long-term medication use, physical therapy, vocational rehabilitation, depression management, and so forth) often quickly fall into place.

Conclusions

From a research standpoint, many of the proposed interventions are unfortunately sloppy. One would wish to validate an empirical hypothesis such as the meaning model by distinguishing whether a better health outcome is caused by an alteration in meaning or by some other factor. The chronic pain patient who constructs a better story of ongoing life with pain is likely to be much more compliant with other therapeutic recommendations. Did the improved outcome result from the change in meaning, from greater adherence to effective modalities such as physical therapy, or both? Although progress on the research front is expected, it may well come more slowly than we would like.

But this detriment for research purposes is a plus for therapeutics. Clinicians often do not care whether a patient is feeling better because of the pill prescribed, the care and compassion shown, greater adherence, or all of them combined, as long as improvement occurs and the patient is more satisfied. The ease with which elements of the placebo response become comingled with other therapeutic endeavors makes it a more useful tool.

Because of the therapeutic usefulness of the placebo response and the way that it is intertwined with other elements of everyday practice it would seem that family practice investigators would be especially skilled at addressing the research difficulties. This review should encourage more attention to the placebo response and promote a higher priority to its research among primary care investigators and multidisciplinary research teams.

Acknowledgments

This article was partially based on some preliminary work supported by the Fetzer Institute, Kalamazoo, Michigan. The author is grateful for the suggestions of several anonymous peer reviewers for The Journal of Family Practice.

Since the placebo response was last reviewed for family physicians¹ new research has added to our basic knowledge of this phenomenon, but placebo research remains in its infancy. Outcome studies have shown how various physician behaviors and practice styles can enhance the health status of patients. Seldom, however, are these 2 bodies of research carefully integrated to show the clinician how to best use the science of the placebo response to improve patient outcomes. Such integration is possible and would be useful for family physicians.

The science of the placebo

Two recent findings highlight the continued controversy over the placebo response. The apparent importance of the placebo response was recently emphasized by the ethical debate over the use of sham surgery control groups in studies of fetal cell brain implants for intractable Parkinson’s disease.^2,3 The need for a sham group and the ethical question of whether exposing subjects to this risk is warranted arises because subjects receiving the sham procedure typically exhibit marked improvements in their Parkinson’s symptoms for up to 6 months and are indistinguishable from patients given the active treatment. This improvement does not seem to be due to either the natural history of the disease or observer bias.

However, the preliminary findings from a carefully conducted meta-analysis⁴ failed to demonstrate any consistent sizeable benefit from receiving a dummy treatment in a randomized blinded trial when another nontreatment group was included with which the sham-treatment group could be compared. These findings do not exclude the possibility that the psychosocial aspects of the physician-patient encounter may exert independent healing effects, but they do cast doubt on the placebo response as traditionally conceived-the so-called power of the sugar pill.

Although much controversy remains, the bulk of the literature supports the proposition that the placebo response is real and potentially powerful, and some of its underlying mechanisms are becoming better understood.

Definitions

Defining “placebo” and “placebo response” in a logically coherent fashion is difficult, perhaps impossible.^5,6 Terms commonly used in medical definitions, such as “inert” and “nonspecific,” range from useless to misleading. Ideally, a definition would be precise enough to clearly demarcate the phenomenon, yet open enough to include a range of possible empirical hypotheses on cause and mechanisms. Terminologic problems, among other factors, have led some thoughtful family physicians to suggest that we eliminate “placebo effect” from our lexicon.^7,8

Assuming that the placebo response falls under the general heading of psychosomatic processes, how wide a range of such processes do we want to admit under the definition? At one extreme, the placebo response can be defined in a very narrow way as bodily changes that occur following the administration of a dummy treatment. This type of placebo response is of little interest to family physicians in daily practice. This definition appeared in a recent review in which the authors claimed that there is no scientific evidence that the placebo response exists.⁹ Since they insisted on the ubiquity and robustness of psychosomatic processes generally, they leave themselves with a conundrum-why should the mind-body connection be so powerful except where it would work by giving dummy medications?

I argue for a broader definition: The placebo response is a change in the patient’s health or bodily state that is attributable to the symbolic impact of medical treatment or the treatment setting. By this definition, a placebo response would be predicted whenever a conscious patient engages in any form of medical encounter (or self-treatment activity). But the definition explicitly excludes from consideration mind-body changes that are not directly related to medical treatment. This definition highlights why family physicians should be particularly interested in the placebo response. Also, since bodily change can be negative as well as positive (nocebo effects),¹⁰ it warns us that if we fail to understand the placebo response, we may unwittingly do harm. For example, a frequently quoted study¹¹ showed that expressing diagnostic uncertainty regarding common nonspecific symptoms can adversely affect symptom resolution.

Frequency of Placebo Responses

The first modern review of the placebo effect made the often-repeated claim that an average of approximately one third subjects will respond to placebos.¹² It was later shown that this average, even if accurate, masks an extremely wide variation in placebo response rates among studies.¹³ Roberts and colleagues¹⁴ recently reviewed the original uncontrolled trials of therapies introduced with great fanfare in past years and now universally dismissed as medically useless. They found a 70% average rate of “excellent” and “good” responses to those treatments before properly designed double-blind trials were conducted. They concluded that in settings of heightened expectancy, the placebo response rate could be much higher than previously thought.

Attention has recently turned to meta-analyses of the placebo response.^9,13,14 One sophisticated analysis of placebo-controlled studies with more than 2 arms suggests that so-called “nonspecific” effects may be substantial and may be either synergistic or antagonistic toward “specific” effects, so the merely “additive” model of the placebo and drug effects, implicit in the design of most randomized controlled trials, is overly simplistic.¹⁵

Hypothetical Models

According to a meaning model,¹⁶ a positive placebo response is most likely to occur when the meaning of the illness experience is altered in a positive direction. A positive change in meaning occurs when one or more of 3 things happens: The patient feels listened to and receives a satisfactory, coherent explanation of his illness; the patient feels care and concern from those around him; and the patient feels an enhanced sense of mastery and control over his symptoms. Because the meaning that we attach to events in our lives often hinges on the stories we construct about those events, this model helps explain the importance of narrative in medicine.^17,18

Support for this model comes from several directions. In a psychology laboratory, a group of subjects told about the potentially healthful effects of brief hand immersion in ice water had better pain tolerance than a group briefed on the dangers of cold immersion, and both groups were significantly different from control subjects given a neutral message.¹⁹ In clinical research, the informed consent process is often thwarted by the “therapeutic misconception,” the tendency of subjects to believe that they are getting medical care aimed at their personal medical problems despite being told that their treatment is selected by the research protocol.²⁰ The therapeutic misconception might enhance the placebo response and make it more difficult to show that an active drug is superior to placebo.

Placebo-Prone Personalities

Much of the early literature on the placebo response was devoted to identifying a “placebo personality type,” in the vain hope that such subjects could be eliminated from clinical trials so as not to confuse the results with placebo responses. In general, this early literature^21,22 concluded that no such personality type exists and that the placebo response is more a contextual situational phenomenon than an enduring personality trait.

One important exception to this general conclusion is highlighted in a superb recent review of the placebo literature. Fisher and Greenberg²³ argue that the “acquiescent” personality type is more likely to experience positive placebo responses. At first misunderstood as passivity, the label “acquiescent” is now better understood as an active coping mechanism. This type of person deals with adversity by developing positive relationships with others and using them as a healing resource. This suggests the importance of continuity of care and effective interpersonal relationships in producing positive placebo responses as part of daily practice.

Theories of Placebo Action

Experimental data currently support 2 general theories about the placebo response: expectancy and conditioning.^22,24 The first proposes that bodily changes occur to the extent that the subject expects them to; the second, that bodily changes occur when the subject is exposed to a stimulus that has been linked in the past to active processes that produce the change.

A classic study of expectancy²⁵ showed subjects unable to distinguish the pharmacologic properties of amphetamines and chloral hydrate when they had no expectancy cues for the drugs they were receiving. A recent study of conditioning²⁶ showed that young asthmatics, exposed over time to a vanilla aroma at the same time as they used their metered dose inhalers, demonstrated objective bronchodilation when later exposed only to the vanilla.

We may view these theories, taken in conjunction with the meaning model, as complementary not competing. Conditioning theory may explain how the past experiences of the patient affect the meaning attached to present events, while expectancy focuses on how the patient’s thoughts of the future may influence therapeutic outcomes.

Biochemical Mediators

Neither expectancy nor conditioning theory explains the process by which the altered meaning in the patient’s mind causes a change in bodily status. The complete answer to the neuroanatomy and biochemistry of the placebo response is unknown. The most interesting research has focused on 3 pathways: endorphins, cathecholamines and cortisol, and psychoneuroimmunology. All are capable of altering bodily symptoms, and all are known to be connected intimately with the individual’s emotional and cognitive state.

An elegant, recent, 12-armed trial conducted in a psychology laboratory²⁷ compared 2 aspects of placebo response to pain: expectancy versus conditioning, and conditioning with morphine versus conditioning with ketorolac. The results showed that placebo analgesic effects produced by expectancy could be reversed by naloxone, suggesting that these might be endorphin mediated. Similarly, placebo conditioning with morphine could be reversed by naloxone, but the placebo response was not naloxone-reversible when ketorolac was used as the initial stimulus. The authors concluded that the biochemical pathway for placebo conditioning might depend on the biochemical pathway activated by the active drug.

Future Research Directions

My brief review suggests a number of requirements for advancing knowledge of the placebo response. The greatest advances will come from multidisciplinary research teams set up to integrate qualitative measures of meaning and perception with quantitative measures of biochemical mediators and bodily change.

Intriguing studies conducted in psychology laboratories²⁷ must be replicated and expanded in the less controlled environment of clinical practice.

Creative use of brain imaging techniques, such as positron emission tomography and functional magnetic resonance imaging may be used to identify which neuroanatomical centers’ activation correlates with placebo responses.

Carefully designed meta-analyses may increase our understanding of selected facets of the placebo response.

Integrating Science and Practice

The [ Figure] suggests how the scientific elements reviewed here can be interwoven into a causal account of the placebo response that can guide physician behavior. Although all elements are of interest for research, the meaning model is most helpful for suggesting therapeutic interventions, since it describes those parts of the process that the physician can most easily influence.

Practice implications

This review suggests a number of therapeutic strategies for office practice that many sensitive and astute clinicians are already using. The available evidence suggests that although we do not fully understand why or how these strategies work, they are relatively inexpensive and notably nontoxic, so no barriers exist to their employment.

Although the focus here is on specific techniques, the importance of the background rituals of medical practice, such as listening to the heart with a stethoscope and writing a prescription, should not be forgotten. History and culture have imbued these rituals with multiple layers of meaning, and their simple predictability may bring great comfort to a frightened patient.

Sustained Partnership

Perhaps the best single concept of how to structure one’s interactions to maximize the placebo response is that of the “sustained partnership” between physician and patient.²⁸ Sustained partnership consists of 6 physician characteristics:

• Interest in the whole person
• Knowing the patient over time
• Caring, sensitivity, and empathy
• Viewed as reliable and trustworthy by the patient
• Adapts medical goals of care to the patient’s needs and values
• Encourages the patient to participate fully in health decision making

These 6 elements were selected because empirical studies link them to superior health outcomes in practice settings. Relating to patients in this way leads to measurable improvements in the patient’s health and an ethically sound (as well as cost-effective) practice. Sustained partnership is a nondeceptive mode of practice, so the ethical problem created by the use of sugar pills and other dummy remedies never arises-the placebo effect is present without the placebo.²⁹

Meaning Model

The meaning model suggests that physicians will obtain the best therapeutic results if they listen carefully to patients’ accounts of their illness, offer explanations that fit with patients’ world-views, express care and concern, and help patients feel more in control of their symptoms (or of their lives, despite the persistence of their symptoms). This will happen more often if the clinician spends sufficient time with the patient, so it is not surprising that good health outcomes correlate with the length of the primary care visit.^30,31 Family physicians must act as advocates for their patients with today’s financial managers by bringing these data forcefully to the managers’ attention.

Mastery

Of the different elements of meaning, perhaps the most challenging to achieve when treating chronically ill, somatizing, or depressed patients is the heightened sense of mastery and control. Malterud³² has summarized an encounter plan to deal with one difficult population, women presenting with pelvic complaints without detectable organic cause, suggesting 4 basic questions:

• What do you most of all want me to do for you today?
• What do you yourself think is the reason for your problem?
• What do you think I should do about your problem?
• What have you found so far to be the best way to manage your problem?

Malterud points out that previous physicians, by approaching these patients in “rule out organic causes” fashion, have firmly cemented the idea of victimhood in the minds of these women. Malterud’s strategy is designed to make each encounter an exercise in seeing oneself as potentially worth listening to, potentially wise about one’s bodily needs and their management, and thus potentially powerful. Physicians can achieve progress with some of the most difficult patients when they curb the urge to supply a diagnosis and therapeutic plan before the patient has a chance to speak.

A more formal strategy has been suggested for family counseling that seems readily applicable to daily practice.³³ This entails asking at each visit, “How much is [the symptom or problem] in control of your life, and how much are you in control?” Patients can readily assign a percentage score to this variable. It is not unusual for a suffering patient to state at the first visit in which this question is asked that the problem controls 80% of his life and he feels in control of only 20%. In keeping with the mastery goal, it is critical to allow the patient, if at all possible, to choose the name of his problem. (One of my patients elected to name her complex entanglement of psychosocial stressors her “box of rocks.”) The follow-up instruction is, “Between now and the next visit, see if you can discover things that you can do, on at least some days, to make you feel more in control.” It is again desirable, unless forced, to stifle the advice-giving urge, as that can subtly undermine the patient’s sense of potential mastery.

During the next visit, the patient may report that he has discovered something that works and that he feels 25% in control of his life and the problem controls only 75%. After praising the patient for this accomplishment, your follow-up question might be, “Do you think it would be possible to try that technique even more often in the future?” or “Do you think, now that you have done such a good job of finding one thing that works, that you might think of another?” Patients may want to keep a formal written diary of their progress. By using this approach, the patient may eventually be able to report that his sense of control has risen to more than 50%. Usually that will produce a substantially improved quality of life.^34,35

Story

A further implication of the meaning model is the value of explicit “story work” with patients with chronic complex problems. Since most people attach meaning to important events in their lives by implicitly or explicitly constructing narratives about the events, story work allows the physician and patient to work together with the issue of meaning. Steps in working with the patient include:

Ask for your patient’s story about the illness or problem, including its root causes, its present effect on his life, and how he imagines the rest of life unfolding with the problem. This may be done with take-home written assignments between visits to conserve office time.

Analyze the meaning of the story with the patient, looking especially at the negatives that seem to produce unnecessary suffering, such as guilt over the presumed cause of the illness or lack of improvement in the future.

Encourage the patient to begin imaginatively constructing alternative elements to the story, especially happier endings. These are much more powerful when generated by the patient and less effective when the physician suggests them.

Work with the patient to identify changes in day-to-day activities that might reflect and further cement the reality of the revised story in the patient’s life.

A similar approach is typically employed for chronic pain patients, but it is valuable to make the story work explicit.³⁶ At the start of treatment, these patients typically see only 2 possible stories: a future in which their pain magically disappears completely or one of unremitting suffering. It may take much supportive work to facilitate the construction of an alternative story in which the patient can imagine the possibility of feeling less pain and achieving important life goals despite never being completely cured. Often the patients have been so overwhelmed by the pain experience, and the search for a cure, they have simply lost sight of those other goals; the main element of story work is getting them back in touch with those goals. Once the patient has successfully constructed that alternative story, other elements of management (long-term medication use, physical therapy, vocational rehabilitation, depression management, and so forth) often quickly fall into place.

Conclusions

From a research standpoint, many of the proposed interventions are unfortunately sloppy. One would wish to validate an empirical hypothesis such as the meaning model by distinguishing whether a better health outcome is caused by an alteration in meaning or by some other factor. The chronic pain patient who constructs a better story of ongoing life with pain is likely to be much more compliant with other therapeutic recommendations. Did the improved outcome result from the change in meaning, from greater adherence to effective modalities such as physical therapy, or both? Although progress on the research front is expected, it may well come more slowly than we would like.

But this detriment for research purposes is a plus for therapeutics. Clinicians often do not care whether a patient is feeling better because of the pill prescribed, the care and compassion shown, greater adherence, or all of them combined, as long as improvement occurs and the patient is more satisfied. The ease with which elements of the placebo response become comingled with other therapeutic endeavors makes it a more useful tool.

Because of the therapeutic usefulness of the placebo response and the way that it is intertwined with other elements of everyday practice it would seem that family practice investigators would be especially skilled at addressing the research difficulties. This review should encourage more attention to the placebo response and promote a higher priority to its research among primary care investigators and multidisciplinary research teams.

Acknowledgments

This article was partially based on some preliminary work supported by the Fetzer Institute, Kalamazoo, Michigan. The author is grateful for the suggestions of several anonymous peer reviewers for The Journal of Family Practice.

Since the placebo response was last reviewed for family physicians¹ new research has added to our basic knowledge of this phenomenon, but placebo research remains in its infancy. Outcome studies have shown how various physician behaviors and practice styles can enhance the health status of patients. Seldom, however, are these 2 bodies of research carefully integrated to show the clinician how to best use the science of the placebo response to improve patient outcomes. Such integration is possible and would be useful for family physicians.

The science of the placebo

Two recent findings highlight the continued controversy over the placebo response. The apparent importance of the placebo response was recently emphasized by the ethical debate over the use of sham surgery control groups in studies of fetal cell brain implants for intractable Parkinson’s disease.^2,3 The need for a sham group and the ethical question of whether exposing subjects to this risk is warranted arises because subjects receiving the sham procedure typically exhibit marked improvements in their Parkinson’s symptoms for up to 6 months and are indistinguishable from patients given the active treatment. This improvement does not seem to be due to either the natural history of the disease or observer bias.

However, the preliminary findings from a carefully conducted meta-analysis⁴ failed to demonstrate any consistent sizeable benefit from receiving a dummy treatment in a randomized blinded trial when another nontreatment group was included with which the sham-treatment group could be compared. These findings do not exclude the possibility that the psychosocial aspects of the physician-patient encounter may exert independent healing effects, but they do cast doubt on the placebo response as traditionally conceived-the so-called power of the sugar pill.

Although much controversy remains, the bulk of the literature supports the proposition that the placebo response is real and potentially powerful, and some of its underlying mechanisms are becoming better understood.

Definitions

Defining “placebo” and “placebo response” in a logically coherent fashion is difficult, perhaps impossible.^5,6 Terms commonly used in medical definitions, such as “inert” and “nonspecific,” range from useless to misleading. Ideally, a definition would be precise enough to clearly demarcate the phenomenon, yet open enough to include a range of possible empirical hypotheses on cause and mechanisms. Terminologic problems, among other factors, have led some thoughtful family physicians to suggest that we eliminate “placebo effect” from our lexicon.^7,8

Assuming that the placebo response falls under the general heading of psychosomatic processes, how wide a range of such processes do we want to admit under the definition? At one extreme, the placebo response can be defined in a very narrow way as bodily changes that occur following the administration of a dummy treatment. This type of placebo response is of little interest to family physicians in daily practice. This definition appeared in a recent review in which the authors claimed that there is no scientific evidence that the placebo response exists.⁹ Since they insisted on the ubiquity and robustness of psychosomatic processes generally, they leave themselves with a conundrum-why should the mind-body connection be so powerful except where it would work by giving dummy medications?

I argue for a broader definition: The placebo response is a change in the patient’s health or bodily state that is attributable to the symbolic impact of medical treatment or the treatment setting. By this definition, a placebo response would be predicted whenever a conscious patient engages in any form of medical encounter (or self-treatment activity). But the definition explicitly excludes from consideration mind-body changes that are not directly related to medical treatment. This definition highlights why family physicians should be particularly interested in the placebo response. Also, since bodily change can be negative as well as positive (nocebo effects),¹⁰ it warns us that if we fail to understand the placebo response, we may unwittingly do harm. For example, a frequently quoted study¹¹ showed that expressing diagnostic uncertainty regarding common nonspecific symptoms can adversely affect symptom resolution.

Frequency of Placebo Responses

The first modern review of the placebo effect made the often-repeated claim that an average of approximately one third subjects will respond to placebos.¹² It was later shown that this average, even if accurate, masks an extremely wide variation in placebo response rates among studies.¹³ Roberts and colleagues¹⁴ recently reviewed the original uncontrolled trials of therapies introduced with great fanfare in past years and now universally dismissed as medically useless. They found a 70% average rate of “excellent” and “good” responses to those treatments before properly designed double-blind trials were conducted. They concluded that in settings of heightened expectancy, the placebo response rate could be much higher than previously thought.

Attention has recently turned to meta-analyses of the placebo response.^9,13,14 One sophisticated analysis of placebo-controlled studies with more than 2 arms suggests that so-called “nonspecific” effects may be substantial and may be either synergistic or antagonistic toward “specific” effects, so the merely “additive” model of the placebo and drug effects, implicit in the design of most randomized controlled trials, is overly simplistic.¹⁵

Hypothetical Models

According to a meaning model,¹⁶ a positive placebo response is most likely to occur when the meaning of the illness experience is altered in a positive direction. A positive change in meaning occurs when one or more of 3 things happens: The patient feels listened to and receives a satisfactory, coherent explanation of his illness; the patient feels care and concern from those around him; and the patient feels an enhanced sense of mastery and control over his symptoms. Because the meaning that we attach to events in our lives often hinges on the stories we construct about those events, this model helps explain the importance of narrative in medicine.^17,18

Support for this model comes from several directions. In a psychology laboratory, a group of subjects told about the potentially healthful effects of brief hand immersion in ice water had better pain tolerance than a group briefed on the dangers of cold immersion, and both groups were significantly different from control subjects given a neutral message.¹⁹ In clinical research, the informed consent process is often thwarted by the “therapeutic misconception,” the tendency of subjects to believe that they are getting medical care aimed at their personal medical problems despite being told that their treatment is selected by the research protocol.²⁰ The therapeutic misconception might enhance the placebo response and make it more difficult to show that an active drug is superior to placebo.

Placebo-Prone Personalities

Much of the early literature on the placebo response was devoted to identifying a “placebo personality type,” in the vain hope that such subjects could be eliminated from clinical trials so as not to confuse the results with placebo responses. In general, this early literature^21,22 concluded that no such personality type exists and that the placebo response is more a contextual situational phenomenon than an enduring personality trait.

One important exception to this general conclusion is highlighted in a superb recent review of the placebo literature. Fisher and Greenberg²³ argue that the “acquiescent” personality type is more likely to experience positive placebo responses. At first misunderstood as passivity, the label “acquiescent” is now better understood as an active coping mechanism. This type of person deals with adversity by developing positive relationships with others and using them as a healing resource. This suggests the importance of continuity of care and effective interpersonal relationships in producing positive placebo responses as part of daily practice.

Theories of Placebo Action

Experimental data currently support 2 general theories about the placebo response: expectancy and conditioning.^22,24 The first proposes that bodily changes occur to the extent that the subject expects them to; the second, that bodily changes occur when the subject is exposed to a stimulus that has been linked in the past to active processes that produce the change.

A classic study of expectancy²⁵ showed subjects unable to distinguish the pharmacologic properties of amphetamines and chloral hydrate when they had no expectancy cues for the drugs they were receiving. A recent study of conditioning²⁶ showed that young asthmatics, exposed over time to a vanilla aroma at the same time as they used their metered dose inhalers, demonstrated objective bronchodilation when later exposed only to the vanilla.

We may view these theories, taken in conjunction with the meaning model, as complementary not competing. Conditioning theory may explain how the past experiences of the patient affect the meaning attached to present events, while expectancy focuses on how the patient’s thoughts of the future may influence therapeutic outcomes.

Biochemical Mediators

Neither expectancy nor conditioning theory explains the process by which the altered meaning in the patient’s mind causes a change in bodily status. The complete answer to the neuroanatomy and biochemistry of the placebo response is unknown. The most interesting research has focused on 3 pathways: endorphins, cathecholamines and cortisol, and psychoneuroimmunology. All are capable of altering bodily symptoms, and all are known to be connected intimately with the individual’s emotional and cognitive state.

An elegant, recent, 12-armed trial conducted in a psychology laboratory²⁷ compared 2 aspects of placebo response to pain: expectancy versus conditioning, and conditioning with morphine versus conditioning with ketorolac. The results showed that placebo analgesic effects produced by expectancy could be reversed by naloxone, suggesting that these might be endorphin mediated. Similarly, placebo conditioning with morphine could be reversed by naloxone, but the placebo response was not naloxone-reversible when ketorolac was used as the initial stimulus. The authors concluded that the biochemical pathway for placebo conditioning might depend on the biochemical pathway activated by the active drug.

Future Research Directions

My brief review suggests a number of requirements for advancing knowledge of the placebo response. The greatest advances will come from multidisciplinary research teams set up to integrate qualitative measures of meaning and perception with quantitative measures of biochemical mediators and bodily change.

Intriguing studies conducted in psychology laboratories²⁷ must be replicated and expanded in the less controlled environment of clinical practice.

Creative use of brain imaging techniques, such as positron emission tomography and functional magnetic resonance imaging may be used to identify which neuroanatomical centers’ activation correlates with placebo responses.

Carefully designed meta-analyses may increase our understanding of selected facets of the placebo response.

Integrating Science and Practice

The [ Figure] suggests how the scientific elements reviewed here can be interwoven into a causal account of the placebo response that can guide physician behavior. Although all elements are of interest for research, the meaning model is most helpful for suggesting therapeutic interventions, since it describes those parts of the process that the physician can most easily influence.

Practice implications

This review suggests a number of therapeutic strategies for office practice that many sensitive and astute clinicians are already using. The available evidence suggests that although we do not fully understand why or how these strategies work, they are relatively inexpensive and notably nontoxic, so no barriers exist to their employment.

Although the focus here is on specific techniques, the importance of the background rituals of medical practice, such as listening to the heart with a stethoscope and writing a prescription, should not be forgotten. History and culture have imbued these rituals with multiple layers of meaning, and their simple predictability may bring great comfort to a frightened patient.

Sustained Partnership

Perhaps the best single concept of how to structure one’s interactions to maximize the placebo response is that of the “sustained partnership” between physician and patient.²⁸ Sustained partnership consists of 6 physician characteristics:

• Interest in the whole person
• Knowing the patient over time
• Caring, sensitivity, and empathy
• Viewed as reliable and trustworthy by the patient
• Adapts medical goals of care to the patient’s needs and values
• Encourages the patient to participate fully in health decision making

These 6 elements were selected because empirical studies link them to superior health outcomes in practice settings. Relating to patients in this way leads to measurable improvements in the patient’s health and an ethically sound (as well as cost-effective) practice. Sustained partnership is a nondeceptive mode of practice, so the ethical problem created by the use of sugar pills and other dummy remedies never arises-the placebo effect is present without the placebo.²⁹

Meaning Model

The meaning model suggests that physicians will obtain the best therapeutic results if they listen carefully to patients’ accounts of their illness, offer explanations that fit with patients’ world-views, express care and concern, and help patients feel more in control of their symptoms (or of their lives, despite the persistence of their symptoms). This will happen more often if the clinician spends sufficient time with the patient, so it is not surprising that good health outcomes correlate with the length of the primary care visit.^30,31 Family physicians must act as advocates for their patients with today’s financial managers by bringing these data forcefully to the managers’ attention.

Mastery

Of the different elements of meaning, perhaps the most challenging to achieve when treating chronically ill, somatizing, or depressed patients is the heightened sense of mastery and control. Malterud³² has summarized an encounter plan to deal with one difficult population, women presenting with pelvic complaints without detectable organic cause, suggesting 4 basic questions:

• What do you most of all want me to do for you today?
• What do you yourself think is the reason for your problem?
• What do you think I should do about your problem?
• What have you found so far to be the best way to manage your problem?

Malterud points out that previous physicians, by approaching these patients in “rule out organic causes” fashion, have firmly cemented the idea of victimhood in the minds of these women. Malterud’s strategy is designed to make each encounter an exercise in seeing oneself as potentially worth listening to, potentially wise about one’s bodily needs and their management, and thus potentially powerful. Physicians can achieve progress with some of the most difficult patients when they curb the urge to supply a diagnosis and therapeutic plan before the patient has a chance to speak.

A more formal strategy has been suggested for family counseling that seems readily applicable to daily practice.³³ This entails asking at each visit, “How much is [the symptom or problem] in control of your life, and how much are you in control?” Patients can readily assign a percentage score to this variable. It is not unusual for a suffering patient to state at the first visit in which this question is asked that the problem controls 80% of his life and he feels in control of only 20%. In keeping with the mastery goal, it is critical to allow the patient, if at all possible, to choose the name of his problem. (One of my patients elected to name her complex entanglement of psychosocial stressors her “box of rocks.”) The follow-up instruction is, “Between now and the next visit, see if you can discover things that you can do, on at least some days, to make you feel more in control.” It is again desirable, unless forced, to stifle the advice-giving urge, as that can subtly undermine the patient’s sense of potential mastery.

During the next visit, the patient may report that he has discovered something that works and that he feels 25% in control of his life and the problem controls only 75%. After praising the patient for this accomplishment, your follow-up question might be, “Do you think it would be possible to try that technique even more often in the future?” or “Do you think, now that you have done such a good job of finding one thing that works, that you might think of another?” Patients may want to keep a formal written diary of their progress. By using this approach, the patient may eventually be able to report that his sense of control has risen to more than 50%. Usually that will produce a substantially improved quality of life.^34,35

Story

A further implication of the meaning model is the value of explicit “story work” with patients with chronic complex problems. Since most people attach meaning to important events in their lives by implicitly or explicitly constructing narratives about the events, story work allows the physician and patient to work together with the issue of meaning. Steps in working with the patient include:

Ask for your patient’s story about the illness or problem, including its root causes, its present effect on his life, and how he imagines the rest of life unfolding with the problem. This may be done with take-home written assignments between visits to conserve office time.

Analyze the meaning of the story with the patient, looking especially at the negatives that seem to produce unnecessary suffering, such as guilt over the presumed cause of the illness or lack of improvement in the future.

Encourage the patient to begin imaginatively constructing alternative elements to the story, especially happier endings. These are much more powerful when generated by the patient and less effective when the physician suggests them.

Work with the patient to identify changes in day-to-day activities that might reflect and further cement the reality of the revised story in the patient’s life.

A similar approach is typically employed for chronic pain patients, but it is valuable to make the story work explicit.³⁶ At the start of treatment, these patients typically see only 2 possible stories: a future in which their pain magically disappears completely or one of unremitting suffering. It may take much supportive work to facilitate the construction of an alternative story in which the patient can imagine the possibility of feeling less pain and achieving important life goals despite never being completely cured. Often the patients have been so overwhelmed by the pain experience, and the search for a cure, they have simply lost sight of those other goals; the main element of story work is getting them back in touch with those goals. Once the patient has successfully constructed that alternative story, other elements of management (long-term medication use, physical therapy, vocational rehabilitation, depression management, and so forth) often quickly fall into place.

Conclusions

From a research standpoint, many of the proposed interventions are unfortunately sloppy. One would wish to validate an empirical hypothesis such as the meaning model by distinguishing whether a better health outcome is caused by an alteration in meaning or by some other factor. The chronic pain patient who constructs a better story of ongoing life with pain is likely to be much more compliant with other therapeutic recommendations. Did the improved outcome result from the change in meaning, from greater adherence to effective modalities such as physical therapy, or both? Although progress on the research front is expected, it may well come more slowly than we would like.

But this detriment for research purposes is a plus for therapeutics. Clinicians often do not care whether a patient is feeling better because of the pill prescribed, the care and compassion shown, greater adherence, or all of them combined, as long as improvement occurs and the patient is more satisfied. The ease with which elements of the placebo response become comingled with other therapeutic endeavors makes it a more useful tool.

Because of the therapeutic usefulness of the placebo response and the way that it is intertwined with other elements of everyday practice it would seem that family practice investigators would be especially skilled at addressing the research difficulties. This review should encourage more attention to the placebo response and promote a higher priority to its research among primary care investigators and multidisciplinary research teams.

Acknowledgments

This article was partially based on some preliminary work supported by the Fetzer Institute, Kalamazoo, Michigan. The author is grateful for the suggestions of several anonymous peer reviewers for The Journal of Family Practice.

In a rigorously conducted qualitative study in this issue of the Journal, Robert Bartz¹ provides a glimpse into the practice of a family physician caring predominantly for urban Native Americans. We read the physician’s thoughts about treating some of her patients with diabetes, and in one case we learn the parallel thoughts of the patient. The study, limited as it admittedly is, gives us much to ponder as we face the challenges of teaching and practicing culturally sensitive and culturally competent medical care.²

In his abstract, Bartz states that “biopsychosocial models of disease may conflict with patient-centered approaches to communication.” I would propose instead that the 2 models are somewhat different in focus and ought to be viewed as complementary.

The biopsychosocial (BPS) model was originally proposed as a scientific paradigm³ and as such, aims to be ethically neutral to the extent that any scientific model or theory can be. The BPS model teaches us that if we want to understand diabetes among Native Americans, we need to understand the social and cultural environment and the psychological impact that environment has on the individual, just as much as we would need to study the genetics and the biochemistry of the disorder in that population. This model goes on to suggest that in caring for any patient with diabetes, we ought to inquire into the psychological, social, and cultural factors in that person’s life, as well as examine the retina and monitor glycohemoglobin levels.

The BPS model, as a scientific paradigm, speaks peripherally to the issue of physician-patient communication, but solely in instrumental fashion, similar to the utilitarian approach that Bartz’s physician, Dr M, seems to adopt. That is, since science begins with accurate observation, scientific medical practice must begin with an accurate and thorough history. But the patient will, as a rule, provide a detailed, thoughtful, and accurate history only when the physician enters into an open, interested, and facilitative relationship with the patient. That sort of communication becomes a critical scientific tool, without which medical work could proceed no further.⁴

Various patient-centered methods, such as the model of sustained partnership, constitute different model types.^5,6 Unlike the BPS model, they include both scientific and ethical aspects, and claim to help integrate those 2 elements of good medical practice. In an extreme case, a physician could use the BPS model as a superior way to manipulate or coerce patients, since knowing more about the patients’ emotions, cultures, and so on could render them more vulnerable to the physician’s machinations. The patient-centered models suggest that the physician ought to use this integrated knowledge of the patient as a whole person within a particular ethical framework that respects the patient’s basic rights and dignity, and takes very seriously the patient’s own life goals and projects.

One physician’s approach

How does Dr M stack up in relation to these various models? I ask this question not to criticize Dr M, who deserves great praise for having dedicated her career to the care of an underserved population and for trying hard to understand the lives of her patients. But Dr M may serve as an exemplary representative of a physician who does things that all of us do in our own practices, even when caring for patients of similar cultural backgrounds, so the analysis of her methods may be of general benefit.

First, it is worth noting that while Bartz describes Dr M as having a “sophisticated biopsychosocial approach,” her own description shows at least one way that this is not true. Many of her patients came to her wanting to talk about stress, and Dr M agreed that under the BPS model there was a direct relationship between emotional stress and the course of diabetes. But then her “medical perspective” caused her to “[direct] the patient away from problems like stress and toward issues like exercise, diet, and medications.” If the result was a group of patients with well-controlled diabetes, no one could criticize Dr M’s strategy. But she admitted that too often the result was a series of time-consuming repeat visits with the patient being no more compliant with the medical regimen at the end than he or she had been at the start. Apparently Dr M never asked herself whether talking to her patients more about stress and less about diet, exercise, and pills would actually in the end have been a more efficient way to secure their sympathetic cooperation and their compliance.

Turning next to patient-centered care, Dr M’s most important deviance from ideal practice seems to be what Bartz describes as her adoption of an instrumental rather than a dialogic mode of discourse. This is illustrated best in Table 5, a transcript of an encounter with Patient C. Patient C has just given Dr M a gift: She has admitted openly that she has never taken any of the oral medication for diabetes that Dr M prescribed. Admittedly, most of us do not especially enjoy receiving this type of information from our patients and are at least momentarily at a loss for words when it happens, but it is a gift nonetheless. It usually takes patients a lot of courage to admit this, and the disclosure often signals a heightened level of trust in the relationship on the patient’s side. If the physician responds appropriately, she may learn critical new facts about the patient’s belief system, and a much more effective and collaborative treatment plan may then emerge.

How does Dr M respond to Patient C? She very appropriately and wisely asks why, and the patient responds with a pivotal further disclosure: “Because I’m scared.” Dr M then charges on: “You know, that’s interesting that you are scared to take the medicine. Some people are scared not to take their medicine; they worry that if they don’t take it they might get sicker.”

This depicts the instrumental mode that infects most of us at least some of the time, and some of us almost all the time. Dr M has very little curiosity about what scares Patient C. Instead she is simply looking for the best angle to preach to the patient about why compliance with the prescribed regimen is so important. This robs Dr M of any opportunity to explore the fears in detail and perhaps do something positive to reassure Patient C.

Somewhat surprisingly, given the way that Dr M has snubbed her, Patient C actually makes another effort to tell her story and describes how the medicine man told another patient with diabetes not to take her medicine. But this hint that the patient is seeking a way to treat diabetes that is perhaps more in concert with traditional tribal practices is unheeded by Dr M, who simply rejects the idea that a medicine man would tell a patient with diabetes not to take medicine.

A sustained partnership with a diabetic patient requires finding out the patient’s goals and preferences, warning the patient of possible mismatches between their personal agendas and what is known medically about the optimal management of diabetes, and finally trying to negotiate a treatment plan that will best preserve the patient’s other life commitments and sense of autonomy, while at the same time preventing complications in both the short and long term. But to do this requires, first of all, that the physician be sufficiently curious about the patient’s life goals and beliefs. Dr M seems notably lacking in this curiosity. She just knows that if a patient has diabetes, the most important things in that patient’s life become proper diet, exercise, and compliance with medications. If the patient does not happen to think this way, then Dr M does not really want to know why. She will simply spend each visit continuing to repeat why she is right and the patient is wrong. The reasons not to practice this way, sadly, are the same as why (as the popular saying has it) a person should not try to teach a pig to sing—it does not work, and it annoys the pig. An additional reason, as Dr M’s own case proves, is that it also annoys the physician.

A physician does not have to engage in a so-called cross-cultural medical practice to run into these issues. I have plenty of these sorts of problems trying to provide good care for my white, middle-class patients with diabetes. Actually, to be more accurate about it, every encounter with a patient is a cross-cultural exercise. But the need to embrace both the BPS model and a sustained partnership model are driven home by dramatic examples from practice among patients whose belief systems are even more clearly at odds with the medical mindset. A recent book⁷ describing a case of epilepsy in a Hmong child, leading eventually to a near-persistent vegetative state, is illustrative. The author began by asking who was to blame: Did stubborn, ignorant parents engage in noncompliance amounting to medical neglect, as it seemed to the competent and caring physicians? Or did the child in fact get sicker each time the Western medicines were employed and seem to improve only when traditional Hmong remedies were given, as the parents insisted? In the end, the author concluded that the question of blame is unanswerable, but much could be done to prevent such an impasse from occurring.

Success stories

The following are 2 minor success stories from practice among Southeast Asian patients.

A middle-aged Hmong male (from a community that avoids all contact with Western medical institutions whenever possible) had severe, recurrent right-upper-quadrant pain. A Western physician diagnosed gall bladder disease and recommended cholecystectomy. The patient underwent a healing ceremony in which a shaman bestowed magical powers on water that was then used to cleanse the abdomen. When the pain persisted after the ceremony, the patient accepted the conclusion that the pain was not of spiritual origin and consented to surgery. He had an unremarkable postoperative course and reported that he was cured of the pain.⁷

An older woman from Southeast Asia (ethnicity not further specified) presented to the intensive care unit with hemorrhage into a highly anaplastic carcinoma of the liver that had previously proved unresponsive to radiation or chemotherapy. She requested aggressive life-prolonging therapy, which seemed totally unrealistic to the medical staff, and consideration was given to denying her request on the grounds of medical futility. Further discussion with the patient revealed that she fully accepted her terminal prognosis. Her religious beliefs convinced her, however, that if she died during the present lunar cycle, a curse would fall on her family for the next 5 generations. She requested aggressive therapy only to the extent that it could help her survive a few more days until the change in the lunar cycle. Once this request was understood in context, the staff agreed and were able to keep her alive for the requested period.⁸

These success stories depend in large part on someone having sufficient curiosity to want to know why the “other” is acting in a seemingly inexplicable manner. Dr M, sadly, has a lot of labels to pin on her noncompliant patients, but very little curiosity about them.

As Engel⁴ would remind us, the activity of science starts with curiosity. Most of us ended up going into the medical profession because as children we loved to take things apart and put them back together. (Or, in some cases, we just loved to take things apart.) Curiosity was probably the first impulse that prompted us toward a medical career. The first step in becoming excellent patient-centered and culturally competent physicians might be as simple as recapturing that basic sense of why we became physicians in the first place.

In a rigorously conducted qualitative study in this issue of the Journal, Robert Bartz¹ provides a glimpse into the practice of a family physician caring predominantly for urban Native Americans. We read the physician’s thoughts about treating some of her patients with diabetes, and in one case we learn the parallel thoughts of the patient. The study, limited as it admittedly is, gives us much to ponder as we face the challenges of teaching and practicing culturally sensitive and culturally competent medical care.²

In his abstract, Bartz states that “biopsychosocial models of disease may conflict with patient-centered approaches to communication.” I would propose instead that the 2 models are somewhat different in focus and ought to be viewed as complementary.

The biopsychosocial (BPS) model was originally proposed as a scientific paradigm³ and as such, aims to be ethically neutral to the extent that any scientific model or theory can be. The BPS model teaches us that if we want to understand diabetes among Native Americans, we need to understand the social and cultural environment and the psychological impact that environment has on the individual, just as much as we would need to study the genetics and the biochemistry of the disorder in that population. This model goes on to suggest that in caring for any patient with diabetes, we ought to inquire into the psychological, social, and cultural factors in that person’s life, as well as examine the retina and monitor glycohemoglobin levels.

The BPS model, as a scientific paradigm, speaks peripherally to the issue of physician-patient communication, but solely in instrumental fashion, similar to the utilitarian approach that Bartz’s physician, Dr M, seems to adopt. That is, since science begins with accurate observation, scientific medical practice must begin with an accurate and thorough history. But the patient will, as a rule, provide a detailed, thoughtful, and accurate history only when the physician enters into an open, interested, and facilitative relationship with the patient. That sort of communication becomes a critical scientific tool, without which medical work could proceed no further.⁴

Various patient-centered methods, such as the model of sustained partnership, constitute different model types.^5,6 Unlike the BPS model, they include both scientific and ethical aspects, and claim to help integrate those 2 elements of good medical practice. In an extreme case, a physician could use the BPS model as a superior way to manipulate or coerce patients, since knowing more about the patients’ emotions, cultures, and so on could render them more vulnerable to the physician’s machinations. The patient-centered models suggest that the physician ought to use this integrated knowledge of the patient as a whole person within a particular ethical framework that respects the patient’s basic rights and dignity, and takes very seriously the patient’s own life goals and projects.

One physician’s approach

How does Dr M stack up in relation to these various models? I ask this question not to criticize Dr M, who deserves great praise for having dedicated her career to the care of an underserved population and for trying hard to understand the lives of her patients. But Dr M may serve as an exemplary representative of a physician who does things that all of us do in our own practices, even when caring for patients of similar cultural backgrounds, so the analysis of her methods may be of general benefit.

First, it is worth noting that while Bartz describes Dr M as having a “sophisticated biopsychosocial approach,” her own description shows at least one way that this is not true. Many of her patients came to her wanting to talk about stress, and Dr M agreed that under the BPS model there was a direct relationship between emotional stress and the course of diabetes. But then her “medical perspective” caused her to “[direct] the patient away from problems like stress and toward issues like exercise, diet, and medications.” If the result was a group of patients with well-controlled diabetes, no one could criticize Dr M’s strategy. But she admitted that too often the result was a series of time-consuming repeat visits with the patient being no more compliant with the medical regimen at the end than he or she had been at the start. Apparently Dr M never asked herself whether talking to her patients more about stress and less about diet, exercise, and pills would actually in the end have been a more efficient way to secure their sympathetic cooperation and their compliance.

Turning next to patient-centered care, Dr M’s most important deviance from ideal practice seems to be what Bartz describes as her adoption of an instrumental rather than a dialogic mode of discourse. This is illustrated best in Table 5, a transcript of an encounter with Patient C. Patient C has just given Dr M a gift: She has admitted openly that she has never taken any of the oral medication for diabetes that Dr M prescribed. Admittedly, most of us do not especially enjoy receiving this type of information from our patients and are at least momentarily at a loss for words when it happens, but it is a gift nonetheless. It usually takes patients a lot of courage to admit this, and the disclosure often signals a heightened level of trust in the relationship on the patient’s side. If the physician responds appropriately, she may learn critical new facts about the patient’s belief system, and a much more effective and collaborative treatment plan may then emerge.

How does Dr M respond to Patient C? She very appropriately and wisely asks why, and the patient responds with a pivotal further disclosure: “Because I’m scared.” Dr M then charges on: “You know, that’s interesting that you are scared to take the medicine. Some people are scared not to take their medicine; they worry that if they don’t take it they might get sicker.”

This depicts the instrumental mode that infects most of us at least some of the time, and some of us almost all the time. Dr M has very little curiosity about what scares Patient C. Instead she is simply looking for the best angle to preach to the patient about why compliance with the prescribed regimen is so important. This robs Dr M of any opportunity to explore the fears in detail and perhaps do something positive to reassure Patient C.

Somewhat surprisingly, given the way that Dr M has snubbed her, Patient C actually makes another effort to tell her story and describes how the medicine man told another patient with diabetes not to take her medicine. But this hint that the patient is seeking a way to treat diabetes that is perhaps more in concert with traditional tribal practices is unheeded by Dr M, who simply rejects the idea that a medicine man would tell a patient with diabetes not to take medicine.

A sustained partnership with a diabetic patient requires finding out the patient’s goals and preferences, warning the patient of possible mismatches between their personal agendas and what is known medically about the optimal management of diabetes, and finally trying to negotiate a treatment plan that will best preserve the patient’s other life commitments and sense of autonomy, while at the same time preventing complications in both the short and long term. But to do this requires, first of all, that the physician be sufficiently curious about the patient’s life goals and beliefs. Dr M seems notably lacking in this curiosity. She just knows that if a patient has diabetes, the most important things in that patient’s life become proper diet, exercise, and compliance with medications. If the patient does not happen to think this way, then Dr M does not really want to know why. She will simply spend each visit continuing to repeat why she is right and the patient is wrong. The reasons not to practice this way, sadly, are the same as why (as the popular saying has it) a person should not try to teach a pig to sing—it does not work, and it annoys the pig. An additional reason, as Dr M’s own case proves, is that it also annoys the physician.

A physician does not have to engage in a so-called cross-cultural medical practice to run into these issues. I have plenty of these sorts of problems trying to provide good care for my white, middle-class patients with diabetes. Actually, to be more accurate about it, every encounter with a patient is a cross-cultural exercise. But the need to embrace both the BPS model and a sustained partnership model are driven home by dramatic examples from practice among patients whose belief systems are even more clearly at odds with the medical mindset. A recent book⁷ describing a case of epilepsy in a Hmong child, leading eventually to a near-persistent vegetative state, is illustrative. The author began by asking who was to blame: Did stubborn, ignorant parents engage in noncompliance amounting to medical neglect, as it seemed to the competent and caring physicians? Or did the child in fact get sicker each time the Western medicines were employed and seem to improve only when traditional Hmong remedies were given, as the parents insisted? In the end, the author concluded that the question of blame is unanswerable, but much could be done to prevent such an impasse from occurring.

Success stories

The following are 2 minor success stories from practice among Southeast Asian patients.

A middle-aged Hmong male (from a community that avoids all contact with Western medical institutions whenever possible) had severe, recurrent right-upper-quadrant pain. A Western physician diagnosed gall bladder disease and recommended cholecystectomy. The patient underwent a healing ceremony in which a shaman bestowed magical powers on water that was then used to cleanse the abdomen. When the pain persisted after the ceremony, the patient accepted the conclusion that the pain was not of spiritual origin and consented to surgery. He had an unremarkable postoperative course and reported that he was cured of the pain.⁷

An older woman from Southeast Asia (ethnicity not further specified) presented to the intensive care unit with hemorrhage into a highly anaplastic carcinoma of the liver that had previously proved unresponsive to radiation or chemotherapy. She requested aggressive life-prolonging therapy, which seemed totally unrealistic to the medical staff, and consideration was given to denying her request on the grounds of medical futility. Further discussion with the patient revealed that she fully accepted her terminal prognosis. Her religious beliefs convinced her, however, that if she died during the present lunar cycle, a curse would fall on her family for the next 5 generations. She requested aggressive therapy only to the extent that it could help her survive a few more days until the change in the lunar cycle. Once this request was understood in context, the staff agreed and were able to keep her alive for the requested period.⁸

These success stories depend in large part on someone having sufficient curiosity to want to know why the “other” is acting in a seemingly inexplicable manner. Dr M, sadly, has a lot of labels to pin on her noncompliant patients, but very little curiosity about them.

As Engel⁴ would remind us, the activity of science starts with curiosity. Most of us ended up going into the medical profession because as children we loved to take things apart and put them back together. (Or, in some cases, we just loved to take things apart.) Curiosity was probably the first impulse that prompted us toward a medical career. The first step in becoming excellent patient-centered and culturally competent physicians might be as simple as recapturing that basic sense of why we became physicians in the first place.

In a rigorously conducted qualitative study in this issue of the Journal, Robert Bartz¹ provides a glimpse into the practice of a family physician caring predominantly for urban Native Americans. We read the physician’s thoughts about treating some of her patients with diabetes, and in one case we learn the parallel thoughts of the patient. The study, limited as it admittedly is, gives us much to ponder as we face the challenges of teaching and practicing culturally sensitive and culturally competent medical care.²

In his abstract, Bartz states that “biopsychosocial models of disease may conflict with patient-centered approaches to communication.” I would propose instead that the 2 models are somewhat different in focus and ought to be viewed as complementary.

The biopsychosocial (BPS) model was originally proposed as a scientific paradigm³ and as such, aims to be ethically neutral to the extent that any scientific model or theory can be. The BPS model teaches us that if we want to understand diabetes among Native Americans, we need to understand the social and cultural environment and the psychological impact that environment has on the individual, just as much as we would need to study the genetics and the biochemistry of the disorder in that population. This model goes on to suggest that in caring for any patient with diabetes, we ought to inquire into the psychological, social, and cultural factors in that person’s life, as well as examine the retina and monitor glycohemoglobin levels.

The BPS model, as a scientific paradigm, speaks peripherally to the issue of physician-patient communication, but solely in instrumental fashion, similar to the utilitarian approach that Bartz’s physician, Dr M, seems to adopt. That is, since science begins with accurate observation, scientific medical practice must begin with an accurate and thorough history. But the patient will, as a rule, provide a detailed, thoughtful, and accurate history only when the physician enters into an open, interested, and facilitative relationship with the patient. That sort of communication becomes a critical scientific tool, without which medical work could proceed no further.⁴

Various patient-centered methods, such as the model of sustained partnership, constitute different model types.^5,6 Unlike the BPS model, they include both scientific and ethical aspects, and claim to help integrate those 2 elements of good medical practice. In an extreme case, a physician could use the BPS model as a superior way to manipulate or coerce patients, since knowing more about the patients’ emotions, cultures, and so on could render them more vulnerable to the physician’s machinations. The patient-centered models suggest that the physician ought to use this integrated knowledge of the patient as a whole person within a particular ethical framework that respects the patient’s basic rights and dignity, and takes very seriously the patient’s own life goals and projects.

One physician’s approach

How does Dr M stack up in relation to these various models? I ask this question not to criticize Dr M, who deserves great praise for having dedicated her career to the care of an underserved population and for trying hard to understand the lives of her patients. But Dr M may serve as an exemplary representative of a physician who does things that all of us do in our own practices, even when caring for patients of similar cultural backgrounds, so the analysis of her methods may be of general benefit.

First, it is worth noting that while Bartz describes Dr M as having a “sophisticated biopsychosocial approach,” her own description shows at least one way that this is not true. Many of her patients came to her wanting to talk about stress, and Dr M agreed that under the BPS model there was a direct relationship between emotional stress and the course of diabetes. But then her “medical perspective” caused her to “[direct] the patient away from problems like stress and toward issues like exercise, diet, and medications.” If the result was a group of patients with well-controlled diabetes, no one could criticize Dr M’s strategy. But she admitted that too often the result was a series of time-consuming repeat visits with the patient being no more compliant with the medical regimen at the end than he or she had been at the start. Apparently Dr M never asked herself whether talking to her patients more about stress and less about diet, exercise, and pills would actually in the end have been a more efficient way to secure their sympathetic cooperation and their compliance.

Turning next to patient-centered care, Dr M’s most important deviance from ideal practice seems to be what Bartz describes as her adoption of an instrumental rather than a dialogic mode of discourse. This is illustrated best in Table 5, a transcript of an encounter with Patient C. Patient C has just given Dr M a gift: She has admitted openly that she has never taken any of the oral medication for diabetes that Dr M prescribed. Admittedly, most of us do not especially enjoy receiving this type of information from our patients and are at least momentarily at a loss for words when it happens, but it is a gift nonetheless. It usually takes patients a lot of courage to admit this, and the disclosure often signals a heightened level of trust in the relationship on the patient’s side. If the physician responds appropriately, she may learn critical new facts about the patient’s belief system, and a much more effective and collaborative treatment plan may then emerge.

How does Dr M respond to Patient C? She very appropriately and wisely asks why, and the patient responds with a pivotal further disclosure: “Because I’m scared.” Dr M then charges on: “You know, that’s interesting that you are scared to take the medicine. Some people are scared not to take their medicine; they worry that if they don’t take it they might get sicker.”

This depicts the instrumental mode that infects most of us at least some of the time, and some of us almost all the time. Dr M has very little curiosity about what scares Patient C. Instead she is simply looking for the best angle to preach to the patient about why compliance with the prescribed regimen is so important. This robs Dr M of any opportunity to explore the fears in detail and perhaps do something positive to reassure Patient C.

Somewhat surprisingly, given the way that Dr M has snubbed her, Patient C actually makes another effort to tell her story and describes how the medicine man told another patient with diabetes not to take her medicine. But this hint that the patient is seeking a way to treat diabetes that is perhaps more in concert with traditional tribal practices is unheeded by Dr M, who simply rejects the idea that a medicine man would tell a patient with diabetes not to take medicine.

A sustained partnership with a diabetic patient requires finding out the patient’s goals and preferences, warning the patient of possible mismatches between their personal agendas and what is known medically about the optimal management of diabetes, and finally trying to negotiate a treatment plan that will best preserve the patient’s other life commitments and sense of autonomy, while at the same time preventing complications in both the short and long term. But to do this requires, first of all, that the physician be sufficiently curious about the patient’s life goals and beliefs. Dr M seems notably lacking in this curiosity. She just knows that if a patient has diabetes, the most important things in that patient’s life become proper diet, exercise, and compliance with medications. If the patient does not happen to think this way, then Dr M does not really want to know why. She will simply spend each visit continuing to repeat why she is right and the patient is wrong. The reasons not to practice this way, sadly, are the same as why (as the popular saying has it) a person should not try to teach a pig to sing—it does not work, and it annoys the pig. An additional reason, as Dr M’s own case proves, is that it also annoys the physician.

A physician does not have to engage in a so-called cross-cultural medical practice to run into these issues. I have plenty of these sorts of problems trying to provide good care for my white, middle-class patients with diabetes. Actually, to be more accurate about it, every encounter with a patient is a cross-cultural exercise. But the need to embrace both the BPS model and a sustained partnership model are driven home by dramatic examples from practice among patients whose belief systems are even more clearly at odds with the medical mindset. A recent book⁷ describing a case of epilepsy in a Hmong child, leading eventually to a near-persistent vegetative state, is illustrative. The author began by asking who was to blame: Did stubborn, ignorant parents engage in noncompliance amounting to medical neglect, as it seemed to the competent and caring physicians? Or did the child in fact get sicker each time the Western medicines were employed and seem to improve only when traditional Hmong remedies were given, as the parents insisted? In the end, the author concluded that the question of blame is unanswerable, but much could be done to prevent such an impasse from occurring.

Success stories

The following are 2 minor success stories from practice among Southeast Asian patients.

A middle-aged Hmong male (from a community that avoids all contact with Western medical institutions whenever possible) had severe, recurrent right-upper-quadrant pain. A Western physician diagnosed gall bladder disease and recommended cholecystectomy. The patient underwent a healing ceremony in which a shaman bestowed magical powers on water that was then used to cleanse the abdomen. When the pain persisted after the ceremony, the patient accepted the conclusion that the pain was not of spiritual origin and consented to surgery. He had an unremarkable postoperative course and reported that he was cured of the pain.⁷

An older woman from Southeast Asia (ethnicity not further specified) presented to the intensive care unit with hemorrhage into a highly anaplastic carcinoma of the liver that had previously proved unresponsive to radiation or chemotherapy. She requested aggressive life-prolonging therapy, which seemed totally unrealistic to the medical staff, and consideration was given to denying her request on the grounds of medical futility. Further discussion with the patient revealed that she fully accepted her terminal prognosis. Her religious beliefs convinced her, however, that if she died during the present lunar cycle, a curse would fall on her family for the next 5 generations. She requested aggressive therapy only to the extent that it could help her survive a few more days until the change in the lunar cycle. Once this request was understood in context, the staff agreed and were able to keep her alive for the requested period.⁸

These success stories depend in large part on someone having sufficient curiosity to want to know why the “other” is acting in a seemingly inexplicable manner. Dr M, sadly, has a lot of labels to pin on her noncompliant patients, but very little curiosity about them.

As Engel⁴ would remind us, the activity of science starts with curiosity. Most of us ended up going into the medical profession because as children we loved to take things apart and put them back together. (Or, in some cases, we just loved to take things apart.) Curiosity was probably the first impulse that prompted us toward a medical career. The first step in becoming excellent patient-centered and culturally competent physicians might be as simple as recapturing that basic sense of why we became physicians in the first place.