Healthy Conversations
(now titled The Talking Cure)
We know that the doctor-patient relationship is changing. Sources of health information have multiplied and the GP’s monopoly on knowledge is wobbling. But as we move from paternalism to ‘patient-centred’ how should we think about professionalism and expertise? What are the advantages and challenges of patients and the public playing a more active role in their own healthcare? As the questions patients ask of their doctors become more complicated, how do conversations with doctors need to change?
‘Complements’ and sweet talk
at 3:10pm on Tuesday, 22nd April 2008Dr. Edzard Ernst, a prominent professor of alternative medicine, is interviewed in today’s Independent talking about his new book, Trick or Treatment. From what I gather, it gives alternative medicine a bit of kicking, demonstrating its ineffectiveness when subjected to randomised controlled trials.
Two interesting points strike me about the article.
The first is that whilst Dr. Ernst is very critical about the complementary medicine industry, he doesn’t shy away from criticising mainstream medicine too. In fact he singles out mainstream medicine’s lack of interaction as a large factor driving people to alternative medicine;
"Mainstream medicine is pretty awful, too. Doctors lack empathy and time. There is plenty of evidence that people using alternative medicine don't even expect effective treatment – they are just looking for a therapeutic relationship. They are not getting it from their GP, so they look for it elsewhere."
This relationship is often overlooked in policy conversations and healthcare debates, even though as Dr.Ernst highlights it’s at the heart of good healthcare. Our upcoming report, The Talking Cure (formally Healthy Conversations), examines precisely this issue, looking at the importance of the relationship between health professionals and patients. You can find out more here.
The second point of interest is Dr.Ernst’s findings that complementary therapies can have a strong placebo effect. For example, the interview sites four wheelchair users getting up and walking under the influence of a healer (or so they thought, it was actually an actor/voice recording).
This got me thinking about what we consider to be legitimate effects. Why isn’t a placebo benefit considered a legitimate product of the alternative treatment? We know that placebos work in some circumstances. Yet the essence of a placebo is that you don’t know it’s a placebo. Inherent in this is some form of deception, whether it’s by a doctor or an alternative therapist. If the narrative of complementary medicine allows people to heal, is not valid? Does it not serve its purpose, if its purpose is to be a necessary disguise for a placebo?
If I understand the views of philosophers such as Richard Rorty correctly (and I may well not have), a ‘pragmatic’ philosophical approach argues that a belief is a device for understanding the world, to be shed when no longer useful. Science is not therefore a mirror of a true nature but a language through which to understand the world. If that’s the case how do we manage issues like alternative therapy, which science tells us is false, but still appears to benefit people?
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Comments
On this post, first, I don't understand why Prof Ernst separates out "effective treatment" from "therapeutic relationship". Is a relationship therapeutic if it's not effective (as judged by the patient)? And can't all treatments' effectiveness be modified by how therapeutic the relationship is? I think he demonstrates old style thinking. EVERY doctor-patient relationship should be therapeutic, and "effective" in patient terms is not the same as "effective" in experimental trial terms. The latter suggests a treatment can be demonstrated to have a particular effect. The former is a judgement only the patient can make. A painkiller may be shown to be effective in a trial but when swallowed by a patient may not relieve pain.
The second issue is the placebo one. This is SUCH a misunderstood phenomenon. You'd think placebo was some kind of con trick, or some kind of illusion. It isn't. What is termed the placebo effect is a real effect. BP actually can be reduced with a "placebo" antihypertensive. Depression can actually be relieved by a "placebo" antidepressant. A better term would be the "self-healing" effect. This would capture it's REAL nature and would, as you suggest, serve its purpose. (In fact, the so called placebo effect is indivisible from the "specific" effect of a drug in any single patient - there's no way to tell how much of an individual patient's improvement comes from the one effect or the other)
I've discussed this idea that the professional's judgement is superior to the patient's (which Prof Ernst repeatedly claims to be the case) here.