|
Novel experiment illuminates the importance of the
doctor-patient relationship, provides the first data
into the underlying neurobiology of the caregiver.
A patient’s relationship with his or her doctor has
long been considered an important component of
healing. Now, in a novel investigation in which
physicians underwent brain scans while they believed
they were actually treating patients, researchers
have provided the first scientific evidence
indicating that doctors truly can feel their
patients’ pain – and can also experience their
relief following treatment.
Led by researchers at Massachusetts General Hospital
(MGH) and the Program in Placebo Studies and
Therapeutic Encounter (PiPS) at Beth Israel
Deaconess Medical Center/Harvard Medical School, the
new findings, which appear online today in Molecular
Psychiatry, help to illuminate one of the more
intangible aspects of health care – the doctor/patient
relationship.
“Our findings showed that the same brain regions
that have previously been shown to be activated when
patients receive placebo therapies are similarly
activated in the brains of doctors when they
administer what they think are effective treatments,”
explains first author Karin Jensen, PhD, an
investigator in the Department of Psychiatry and the
Martinos Center for Biomedical Imaging at MGH and
member of the PiPS. Notably, she adds, the findings
also showed that the physicians who reported greater
ability to take things from the patients’
perspective – that is, to empathize with patients’
feelings – experienced higher satisfaction during
patients’ treatments, as reflected in the brain
scans.
“By demonstrating that caring for patients involves
a complex set of brain events – including deep
understanding of the patient’s facial and body
expressions, possibly in combination with the
physician’s own expectations of relief and feelings
of reward – we have been able to elucidate the
neurobiology underlying caregiving,” adds senior
author Ted Kaptchuk, director of the PiPS and
associate professor of Medicine at Harvard Medical
School. “Our findings provide early evidence of the
importance of interacting brain networks between
patients and caregivers and acknowledge the doctor/patient
relationship as a valued component of health care,
alongside medications and procedures.”
Previous investigations have demonstrated that a
brain region associated with pain relief (right
ventrolateral prefrontal cortex, VLPFC) and a region
associated with reward (rostral anterior cingulate
cortex, rACC) are activated when patients experience
the placebo effect, which occurs when patients show
improvement from treatments that contain no active
ingredients. The placebo effect accounts for
significant portions of clinical outcomes in many
illnesses – including pain, depression and anxiety.
Although behavioral research has suggested that
physicians’ expectations influence patients’
clinical outcomes and help determine patients’
placebo responses, until now little effort has been
directed to understanding the biology underlying the
physician component of the clinical relationship.
Jensen and her colleagues hypothesized that the same
brain regions that are activated during patients’
placebo responses – the VLPFC and rACC – would
similarly be activated in the brains of physicians
as they treated patients. They also hypothesized
that a physician’s perspective-taking skills would
influence the outcomes.
To test these hypotheses, the scientists developed a
unique equipment arrangement that would enable them
to conduct functional magnetic resonance imaging (fMRI)
of the physicians’ brains while the doctors had
face-to-face interactions with patients, including
observing patients as they underwent pain treatments.
The experiment included 18 physicians (all of whom
had received their medical degree within the last 10
years and represented nine separate medical
specialties). Two 25-year-old females played the
role of “patients” and followed a rehearsed script.
The experiment called for the participating
physicians to administer pain relief with what they
thought was a pain-relieving electronic device, but
which was actually a non-active “sham” device.
To ensure that the physicians believed that the sham
device really worked, the investigators first
administered a dose of “heat pain” to the
physicians’ forearms to gauge pain threshold and
then “treated” them with the fake machine. During
the treatments, the investigators reduced the heat
stimulation, to demonstrate to the participants that
the therapy worked. The physicians underwent fMRI
scans while they experienced the painful heat
stimulation so that investigators could see exactly
which brain regions were activated during
first-person perception of pain.
In the second portion of the experiment, each
physician was introduced to a patient and asked to
perform a standardized clinical examination, which
was conducted in a typical exam room for
approximately 20 minutes. (The clinical exam was
performed in order to establish a realistic rapport
between the physician and patient before fMRI
scanning took place, and was comparable to a
standard U.S. doctor’s appointment.) At this point
the physician also answered a questionnaire, the
Interpersonal Reactivity Index, used to measure the
participant’s self-reported perspective-taking
skills.
During the third step, says Jensen, the physician
and patient were led into the scanner room. “The
physician went inside the scanner and was equipped
with a remote control that could activate the
‘analgesic device’ when prompted,” she explains.
Mirrors inside the scanner enabled physicians to
maintain eye contact with the patient, who was
seated on a chair next to the scanner’s bed and
hooked up to both the thermal pain stimulator and
the pain-relieving device.
Then, in a randomized order, physicians were
instructed to either treat a patient’s pain or to
press a control button that provided no relief. When
physicians were told not to activate pain relief,
the “patient” exhibited a painful facial expression
while the physicians watched. When the physicians
were instructed to treat the patients’ pain, they
could see that the subjects’ faces were neutral and
relaxed, the result of pain relief. During these
doctor-patient interactions, fMRI scans measured the
doctors’ brain activations.
Following the scanning session, the physicians were
removed from the scanner and told exactly how the
experiment had been performed, says Jensen. “If the
physician did not agree with the deceptive component
of the study, they were given the opportunity to
withdraw their data. No one did this.”
As predicted, the authors found that while treating
patients, the physicians activated the right VLPFC
region of the brain, a region previously implicated
in the placebo response. Furthermore, Jensen adds,
the physicians’ ability to take the patients’
viewpoints correlated to brain activations and
subjective ratings; physicians who reported high
perspective-taking skills were more likely to show
activation in the rACC brain region, which is
associated with reward.
“We already know that the physician-patient
relationship provides solace and can even relieve
many symptoms,” adds Kaptchuk. “Now, for the first
time, we’ve shown that caring for patients
encompasses a unique neurobiology in physicians. Our
ultimate goal is to transform the ‘art of medicine’
into the ‘science of care,’ and this research is an
important first step in this process as we continue
investigations to find out how patient-clinician
interactions can lead to measurable clinical
outcomes in patients.”
In addition to Jensen and Kaptchuk, study coauthors
include MGH and PiPS investigators Jacqueline Raicek,
Alexandra Cheetham, Rosa Spaeth, Amanda Cook, Randy
L. Gollub, and Jian Kong; Predrag Petrovic of the
Karolinska Institute, Stockholm, Sweden; and Irving
Kirsch of the PiPS. This study was funded, in part,
by the Swedish Society for Medical Research and the
Swedish Council for Working Life and Social
Research, Osher Center for Integrative Medicine
(Karolinska Institute) and by NIH grants from the
National Center on Complementary and Alternative
Medicine (K24AT004095; P01 AT003883; R21AT004497;
R01AT006364; R01AT005280), the National Institute on
Drug Abuse (R03AT218317); and the National Center
for Research Resources (M01-RR-01066 and UL1
RR025758-01; and P41RR14075).
For more information
Massachusetts General Hospital
(MDN)
|
