I was lucky enough to spend two days attending the Placebo Symposium in Sydney in November this year – what an experience! A lineup of the cream of researchers exploring placebo and contextual responses (meaning responses) – all were excellent speakers and the focus was on both research and what this means to clinicians. If you’re keen to watch all you can for free over the next two weeks – click here: www.placebo.armchairmedical.tv.
At the end of the symposium, the speakers were asked a question by artist Eugenie Lee what subjects they would want taught if they had all the facilities and students with top class skills attending. This is what they said (it’s the Lennox Thompson translation, any mis-translations are entirely my responsibility):
- Inform students about the contextual effects of every single clinical encounter and treatment
- Help them focus on supporting patients to develop helpful expectations about treatments
- Read Stanislovski (A good doctor [healthcare professional] is about being a good actor)
- Always remember: we’re treating people not tissues
- Use words wisely (they can heal – and harm)
- Listen to your patients (and show them you’re listening)
- Interprofessionalism is a thing
- Talk with your patients not at them
- Train together with your allied health colleagues
- Ignore “placebo” or contextual effects at your peril
- “Placebo” will eventually die – but the effect of context lives on in every treatment
- Communication skills training needs more than a taste – to learn these skills takes time and intensity
- Emphasise not just empathy – but also competence – these two factors contribute enormously to the “meet the therapist moment” (generating a sense of trustworthiness)
- Introduce neurobiology from the beginning of the course
- Learn [much much much more] about pain throughout the programme – not just the neurobiological systems but the psychological and social
- Develop greater understanding of research methodologies for studying treatments and their effects
What were my take-away points from this whole conference?
As a longtime convert to Dan Moerman’s re-labeling to meaning response of what we often call “placebo effect”, the key points I took away were these (and you’ll see them pop up again and again in my blogs I’m sure):
- Every healthcare encounter involves four things: a person seeking help, a person hoping to deliver help, a treatment ritual, and a social context. These can’t be divided if we hope to understand the outcome of treatment.
- We need to understand the person seeking help – how they identify their illness, how they frame recovery, what their main concern is, and the context in which they are experiencing their illness.
- We need to understand the person hoping to deliver help – how they view their contribution, how they view the person seeking help, the way they frame their treatment, the context in which they’re given the authority to help, and how they frame recovery.
- We need to explore the treatment ritual – from the packaging, the meaning (to both parties) of the artifacts, the procedures, the words and actions – all of these have meaning, as marketing companies undoubtedly know (and exploit).
- We need to examine the social context – the communities in which we live, the way illness and wellbeing are defined, the way healing is understood, how treatments are recognised, the impact of language and interpretation of that language and the way language evolves over time, how communities view treatment seekers and treatment givers, historical understanding and how this influences who, what, why and how therapeutic interactions are enacted.
- The psychological is underpinned [as much as we can detect for now] by neurobiology, at one level of analysis. Neurobiological processes are incredibly complex and we don’t understand them very well. As we do, many of the influences decried as “woolly” or “fluffy” by some of my colleagues are, I think, going to be uncovered and found to be extraordinarily complex interactions between neurobiological systems. And yes, they will be complex – beyond most mortal’s understanding. This doesn’t mean they’re woo, or that they can be disregarded.
- A other levels of analysis, sociopsychological processes are incredibly important contributors to the way treatments are sought – and treatments have effects. This means we’re unlikely to understand them in any simplistic sense. So to deride these processes as irrelevant or “unscientific” simply because they don’t fit in with an existing model of cause and effect (particularly if they don’t fit with a simple 1+2+3=6 model) probably means there’s a lot of learning needed. Simply because an empirical basic science or RCT doesn’t show “what’s going on” does not mean the concept under study is “not science” – it just means a scientific methodology that accommodates these complexities is needed. Not everything can be reduced to an experimental design – qualitative research is valid for some very important questions.
- Communication – what and how we express meaning to another, and how this is interpreted and responded to by that other – occurs everywhere and all the time. Whether we attend to it or not. Meaning-making is something humans just do. So maybe as health professionals we should invest rather more than we do in training ourselves to be skilled at communicating. This means recording our interactions, reviewing them, getting to know the effect of what we communicate and training ourselves to be just as careful with our communication as we are with prescribing anything else. Because it could be that our communication is the most potent ingredient in our treatment.
“A good listener is not only popular everywhere, but after a while he knows something.” —Wilson Mizner