The ultimate communication challenge

As experienced practitioners, Drs. Pollard and Nowak have seen many changes in veterinary medicine over the years. New surgical and medical treatments have replaced others once considered the gold standard. Recommended protocols regarding what vaccines with which to vaccinate which animals for which diseases and when have gone through multiple transformations and adaptations. Microorganisms once believed to cause certain diseases have received new names or been reduced from causal to contributory status.

All of these shifts created communication challenges for the practitioners that taught them the value of educating their clients regarding the dynamic, imprecise nature of veterinary science in a manner that didn’t undermine their clients’ faith in it. The veterinarians also recognized that quality communication and the mutual respect for and rapport with their clients and patients this fostered made it much easier for them to make such transitions than it was for those who lacked this skill.

“But that was a walk in the park compared to what lies ahead,” grumbled Dr. Pollard good-naturedly as he tossed several publications on the table at the local coffee shop where the friends periodically met. “Looks like it’s time to add pointy hats with stars and crescent moons to our professional wardrobes.”

Intrigued, Dr. Nowak scans the collection of academic studies and articles written for the general public about two phenomena, the effects of which practitioners undoubtedly encounter in their work even though they rarely if ever acknowledge these: the placebo and nocebo effects. Historically, the term “placebo effect” arose as a result of studies conducted by the 18th century German physician, Franz Mesmer. He maintained that illness somehow was related to a blockage in some unidentified but universal body fluid. To prove this, he used magnets to redirect this flow in subjects with a variety of symptoms (e.g., unusual body sensations, syncope, vomiting distress, convulsions) who responded to the treatment which they claimed left them with a profound sense of well-being.

Mesmer referred to this relationship between a universal body fluid, magnetic therapy, and health as “animal magnetism” and it eventually caught the attention of politician, writer, and quasi-scientist Benjamin Franklin and French chemist Antoine-Laurent Lavoisier. To prove or disprove Mesmer’s claim, they replicated one of his sessions and asked subjects to embrace magnetized trees. These subjects also fainted or trembled. But because the researchers actually had not magnetized the trees, everyone realized that something else had caused these reactions. This “something else” later became known as the placebo effect. Ultimately the phenomenon became associated with feeble-mindedness, quack medicine, and charlatans. Nonetheless, evidence of the placebo effect persisted even in the realm of medical research conducted with strict adherence to the Scientific Method.

However the availability of sophisticated technology that now permits scientists to explore how placebos affect the brain has made this subject one of the hottest areas in medical research. In addition to governments understanding and properly using this phenomenon as a legitimate way to reduce healthcare costs, the placebo effect so predictably affects a certain percentage of subjects in drug testing that it has gained the attention of the pharmaceutical industry as well.

For veterinarians, a proxy placebo effect (sometimes called the caregiver placebo effect) has been demonstrated in parents and children and owners and their animals. In these situations, parents or owners may facilitate the healing process simply by feeling confident about the treatment.

“But how can this be?” asks Dr. Nowak.

Studies demonstrate that thinking about one’s treatment and response to treatment affect different parts of the brain than medications designed to treat one’s illness. For example, research conducted by Tor D. Wagner and his team at the University of Colorado at Boulder over the past decade indicates that expecting to get an analgesic and receiving one reduced people’s self-reported pain. However expectation of pain relief increased activity in the prefrontal cortex and reduced it in areas associated with emotion. Meanwhile the analgesic (in this case remifentanil) affected the pain-processing areas of the brain. Because the latter occurred later than the former, the researchers theorized that awareness of the placebo effect could be used to enhance the efficacy of analgesics.

Meanwhile other, concurrent studies yielded good news/bad news results of relevance to practicing physicians and veterinarians. When Ted J. Kapchuck, director of the Program in Placebo Studies at Beth Israel Deaconess Medical Center in Boston, and Harvard researcher and psychologist Irving Bosh treated asthmatic patients with albuterol or saline inhalers, sham acupuncture, or nothing, the respiratory scores of those receiving albuterol increased by 20% compared to 7% for those receiving the placebos. But when all patients were asked to rank their respiratory discomfort on a scale of 0 to 10, all except those who received no treatment reported a 50% improvement. This further supported the notion that medical treatments consist of placebo and medical components that affect difference parts of the brain. A similar study of subjective — owner and veterinarian — and objective — force plate gait analysis — evaluations in lame dogs with osteoarthritis showed a similar effect (1).

“But what difference does it make?” persists Dr. Nowak. “I have no intention of lying to my clients about what kind of medication I’m dispensing. That’s unethical.”

Dr. Nowak raises a critical point regarding the practitioner’s role in this process, one researchers also consider vitally important. But while practitioners may blanch at the thought of giving a client a harmless nostrum in place of a drug, many routinely state their expectations regarding how prescribed treatments will affect patients before the fact. Nor is there any shortage of support from the manufacturers of such products to fuel this kind of communication.

To sort out how this affects the healing process, in another study Kapchuck and his team divided 262 patients with irritable bowel syndrome (IBS) into 2 groups: those who received placebo acupuncture and those who were put on a waiting list. Those in the sham acupuncture group additionally were divided into 2 more groups: those who received minimal doctor-patient communication and those who received attention, empathy, and interaction with the clinician prior to treatment. Of those put on the waiting list who had no interaction with the practitioner, 28% reported that their bowel symptoms improved. Among those who experienced minimal communication with the clinician, 44% reported significant improvement. And among those who received quality clinician interaction, 62% said they felt better.

In a subsequent study by this same group, functional MRI scans of physicians who believed they were offering a patient effective pain-relief showed changes similar to those experienced by patients expecting this in previous experiments. That is, the brain changes associated with this empathetic connection made physicians as well as their patients feel better. These results have led researchers to postulate that teaching practitioners to successfully communicate empathy to their patients (and those patients’ caregivers) would result in an effective placebo effect that could enhance treatment benefits and possibly even reduce the amount necessary to achieve the desired results.

But even though Drs. Pollard and Nowak find these results intriguing, the “deception thing” continues to bother them.

Kapchuck et al (2) also recognized this problem and to eliminate this factor, in another study they gave 40 patients with IBS medication they truthfully described as “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes”. Following 3 weeks of twice daily medication, the patients reported increased feelings of well-being and less severe symptoms than those who received no treatment.

Although veterinary practitioners possessing or willing to gain quality empathetic communication skills conceivably could add this component to their treatment protocol (if they are not subconsciously using it already), there is a problematic side of this phenomenon. In 2012, a review of clinical trials by Winfried Hauser of the Technical University of Munich indicated that placebos also caused half the negative effects as the actual drug, a phenomenon he called the nocebo effect. Hauser maintained, and studies on the positive effects of the placebo effect appear to support this, that this stems in part from the warnings physicians give patients regarding possible negative side-effects of impending treatments. He does not suggest that clinicians ignore these effects, but rather that they become more mindful of how they communicate these to patients and caregivers.

How the placebo and nocebo effects play out in clinician-client-patient interactions depends on qualities that some practitioners may consider elusive or have chosen to dismiss as inconsequential: the combination and empathy and the communication skill that permits the clinician to share just the right amount of the right information at the right time in the right manner. This can be learned. But before that can occur, practitioners first must choose whether they prefer to function as conduits of their prescribed treatments or acknowledge their role as active participants in the healing process.