Focus on Alternative and Complementary Therapies
www.pharmpress.com/fact
Focus Alternat Complement Ther©2005 Pharmaceutical Press
Focus Altern Complement Ther 2005; 10: 265–6
The Medical College of Ohio has recently received the largest individual gift in its history: US$1.9 million. This was given to study and teach what doctors once upon a time called ‘beside manner’, the ability to build up a good therapeutic relationship with patients.1 If ever there was an important yet under-researched subject in medicine, this must be it! Since the earliest days of medicine, the therapeutic relationship has been central to health care; it is also often referred to as the art of medicine, as opposed to the science of medicine. As the science of medicine grew stronger and stronger, the art became more and more sidelined. Today many doctors simply do not have the time for building up good understanding with their patients, or they delegate this aspect to others. I think that this is a serious mistake.
Qualities such as courtesy, respect, engagement, listening, interpersonal skills, empathy, ease of communication, friendship and trust are valued highly by patients. In fact, such factors not only influence patient satisfaction but also health outcome. In other words, a good therapeutic relationship contributes to the success of most medical treatments.
Patients instinctively seem to be aware of this. If they do not get what they want from their GP, they look for it elsewhere. The current boom in CAM is fuelled to a very large extent by exactly this phenomenon. A survey we carried out more than 10 years ago suggested that patients who, for the same complaint, use both conventional and complementary practitioners experience the therapeutic relationship as being incomparably more satisfying with the latter group compared with the former.2 Since then many studies have confirmed that patients value the caring attitude of complementary practitioners, their whole-person approach and the opportunity of getting involved in the process of care.
Building up a therapeutic relationship cannot be done in the 8 or 10 min that doctors usually have for seeing a patient. Complementary practitioners, on the other hand, have a much longer contact time with their patients than GPs. If one gave the average British GP 1 h with the average patient, they would probably run out of things to say to each other. But, for the average homoeopath, this is what it takes for a proper first consultation.
‘What people really want to see is a magician/physician. The shaman will know, better than the patient, what has been wrong so there is no need to delve into the history. With a potion or an incantation, the sickness will melt away. Failing a magical solution there could be a very private word or many more into the private doctor’s ear since the doctor’s time is at the disposal of a patient’s capacity to pay for it.’3 These words by Taylor and Moses emphasise that time is important. Unfortunately time is money – in health care like everywhere else. In many countries, CAM is largely private medicine. If one were to change this, for instance by integrating it into a busy NHS practice, its magic could easily dwindle and its success would diminish. The uncritical integration of CAM into the tough and hectic world of the NHS is problematic for this and other reasons.4
But perhaps the dichotomy of art and science or non-specific and specific effects or therapeutic relationship and evidence-based medicine is artificial, or even wrong and counter-productive. If good therapeutic relationships generate relevant health effects then these effects should be measurable. Even though it might sound odd, I can effortlessly imagine such a thing as evidence-based bedside manners. In 2001, we published a paper in The Lancet summarising 25 rigorous studies on this subject.5 The results demonstrated that ‘enhancing patients’ expectations through positive information about the treatment or the illness, while providing support or reassurance’ significantly influenced health outcomes. We concluded that ‘physicians who adopt a warm, friendly and reassuring manner are more effective’. Reading this quote again 4 years later, I feel a little embarrassed – sometimes science has the capacity for demonstrating the obvious.
As always, there is an alternative view. Writing in The Guardian, Ben Goldacre explains how doctors during the last decades have (or had to) become more and more ‘matter of fact’ with their patients.6 He continues ‘Enter the alternative therapist, who understands your problems whatever they are, who is privately employed and has time to listen, who has an answer and who gives a complicated (often wilfully obscure but always authoritative) explanation of what is going on, maintaining the power imbalance in the therapeutic relationship with his or her exclusive access to arcane knowledge. If that’s not old-fashioned medical paternalism, I don’t know what is, and the paradox is clear: while modern medicine, without even pausing to discuss the question, has championed patient autonomy and informed consent – and thrown the placebo effect out of the window – the market has shown that the old paternalism, in a new guise, is still very popular. Whether mainstream medics would want to go back to the old ways and embrace the placebo-maximising wiles of the alternative therapists is an easy question: no thanks. The didactic, paternalistic authoritative, mystifying mantle has passed to the alternative therapist, and to wear it requires one thing most doctors are uncomfortable with: dishonesty.’
