See, Hear, Feel

EP91: Dr. Jeremy Howick on placebo effects and empathic communication

December 06, 2023 Professor Christine J Ko, MD/ Dr. Jeremy Howick, PhD Season 1 Episode 91
See, Hear, Feel
EP91: Dr. Jeremy Howick on placebo effects and empathic communication
Show Notes Transcript

Dr. Jeremy Howick has spent his career studying evidence-based medicine as well as placebo effects. In part, this started from when he was a competitive rower, developed an allergy to a cat, and was prescribed ginger tea as a treatment. Dr. Jeremy Howick, PhD is the Director of the Stoneygate Centre for Excellence in Empathic Healthcare and a Senior Researcher at Oxford University. He is the author of Doctor You and The Philosophy of Evidence-Based Medicine as well as a book released November 14, 2023, The Power of Placebos: How the Science of Placebos and Nocebos Can Improve Health Care. He obtained his PhD from the London School of Economics. 

[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm very honored to be speaking with Dr. Jeremy Howick. Dr. Jeremy Howick, PhD is the Director of the Stoneygate Center for Excellence in Empathic Healthcare and a Senior Researcher at Oxford University. He is the author of Doctor You and The Philosophy of Evidence Based Medicine, as well as a book released November 14th, 2023, so hot off the presses, The Power of Placebos, How the Science of Placebos and Nocebos Can Improve Healthcare. He obtained his PhD from the London School of Economics and attended Dartmouth University and rowed there as an undergrad. I'll put a link to his new book in the show notes.

[00:00:42] Welcome to Jeremy. 

[00:00:43] Jeremy Howick: Hello, it's wonderful to be here with you, Christine. 

[00:00:46] Christine Ko: Thank you for spending the time. My first question would be, would you be willing to share a personal anecdote?

[00:00:52] Jeremy Howick: Absolutely. So when I was rowing, I've got an allergy to a cat. I was suffering. I couldn't sleep properly. My training was suffering. I was getting anxious. And as a last ditch effort, a last resort, I accepted my mother's suggestion to visit a traditional Chinese doctor, herbal doctor. I thought it wouldn't work, but I thought it can't hurt. I'll try it. We spent 45 minutes discussing not just allergies, but also the stresses of high level rowing and so on. At the end, the recommendation was wear a hat and scarf. Which is just common sense in the winter in Canada. And drink ginger tea. And I thought, ginger tea is not going to work. I've got these bad allergies. But I thought, it can't kill me. Billions of people drink ginger tea and they're quite healthy. So I drank it and within three days my allergies went away. And that got my geeky brain whirring. I thought, was it the ginger tea or was it the conversation? Or was it a placebo effect? And if it was a placebo effect, how would you know? How can you test ginger tea in a placebo controlled trial, which would require you to make tea that looks, smells, tastes like ginger tea, but isn't really ginger tea? That took me down a road, an academic journey, right? Spent 10 years on evidence based medicine and 10 years on the placebo effect. I've written a bunch of books and 200 publications on the way, and I've learned a bunch of stuff. But spoiler alert, I still don't know whether the ginger tea for me was a placebo or not. 

[00:02:21] Christine Ko: That's funny. It's just so hard to know these things. We try to test them with science, but it's just sometimes really hard. And we are influenced by our own experience, for sure, right? So how do you think our belief systems and context create physiologic effects in the body? 

[00:02:39] Jeremy Howick: That's a great question. I'm going to answer a slightly different one. Because that question presupposes that you can separate the beliefs from the body. But actually, the psychology and the physiology are not separable. The mind and body are not separate, and in fact, the mind and body are also connected to the external environment. It's all one big connected system. 

[00:03:02] But we can generate beliefs. I could tell you something which could cause me to have a belief which would affect my brain, my mind, and my physiology. 

[00:03:11] Christine Ko: I love it. One of the reasons I am doing this podcast is because I believe what you just said that my mind and my body aren't really separate. I think that's really not the way that I was trained, and it's not the way that I probably approach patients or even really my own life, just because of, an ingrained bias that they're separate, the mind and body.

[00:03:39] Jeremy Howick: You're right. It's important to go beyond this either or thinking. The parts are interconnected in ways which again are very deep. You know, you have your gut, people say, your gut instinct. Well, there is the enteric nervous system, which sends messages. It acts partly independently of the higher brain. People want to oversimplify things. A side effect of modern medicine is that we've oversimplified things and neglected the importance of the non-machine like aspects of the human being. 

[00:04:09] Christine Ko: I like the way you put that. I had read in Victoria Sweet's Slow Medicine that a third of patients get better on their own, a third of patients basically stay the same, and a third of patients just get worse no matter what we do. It's interesting to hear your thoughts in relation to that, because ever since I read that, I have been thinking about the fact that even with the tools of modern medicine, which are great, we don't have a lot of specific treatments for a lot of things.

[00:04:39] Jeremy Howick: You're right. I mean, some people get worse no matter what you do. Some people get better no matter what you do. And in between that is where we can help them more if we focus beyond just the physical aspect, which is an important aspect, but not the only aspect. Things like empathic communication is part of that treatment. Positive communication, healing spaces, all these things which can have a measurable impact, again using hard scientific methods, randomized controlled trials, demonstrated a modest benefit. If you add them all up, you can make a real difference to people's lives.

[00:05:14] There are 48, 000 deaths by sepsis every year in the UK. Many are avoidable because they're caused by errors. And if you dig a bit deeper, what are the causes of the errors? The most common cause is... Poor communication between doctors and other health professionals and doctors and patients. Poor communication is a major cause of, not just complaints, which is more intuitively obvious, but actual medical errors. 

[00:05:44] Christine Ko: Can you talk about your personal take on the power of placebos and just flesh that out a little more?

[00:05:51] Jeremy Howick: Yes. One of the first ever systematic reviews was Henry Knowles Beecher. He was a clinician in the front lines of World War II, an American, and he was in Europe. The myth has it that he ran out of morphine, so he gave wounded soldiers saline and salt water injections, saline injections, and it worked. He found that 35 percent of the people who took placebos got better. Based on this, he said that the placebo effect is responsible for 35 percent of the cures. This was a error of reasoning. Just because someone took a placebo and got better doesn't mean it was because of the placebo. They might have got better anyways, as you mentioned before, Christine.

[00:06:33] Twenty years ago, two Danish researchers took trials that had three groups, treatment, so the real drug, placebo and no treatment. And they tried to find a difference between placebo and no treatment. They found a small difference that was statistically significant, but not, they claimed, clinically relevant. They solved Beecher's error only to create one of their own. They combined apples and oranges, any placebo for anything. So the placebo could have been reading books, sugar pill, counseling, all kinds of stuff. They mixed it all together. Their methodology was flawed. So if you take that into account, the truth is somewhere in the middle. It's not as big as Beecher said, it's not as small as the skeptics say. It's sizable for many common ailments, including pain, depression, anxiety, a length of stay in hospital, morphine use, post operative morphine use, and so on.

[00:07:27] Christine Ko: So if that has an effect somewhere in the middle, as you said, what is your recommendation on trying to harness that? 

[00:07:34] Jeremy Howick: There's two things. First of all, people think people say placebos are unethical. Because they involve deceiving patients. They say, if I give a placebo to a patient, I must lie to them and tell them, this is a real treatment. I think lying is unethical. But there's another series of trials on so called open label placebos. The doctor gives the patient a placebo, tells them it's a placebo, and it still works. So those are not unethical. Moreover, the reason the sugar pill has some effect, some modest effect for certain things, it's not because of the lactose or the sugar in the pill.

[00:08:08] It's because of the things surrounding the pill, the meaning, the positive empathic communication from the doctor, the patient's belief in the doctor's authority the surroundings, in other words, positive empathic communication, which are viewed as placebo effects.

[00:08:24] I think far from being unethical to prescribe placebos, I think it's an ethical duty. It's the doctor's duty to the four principles are beneficence, non maleficence, autonomy, and justice. Beneficence means you must help the patients. If paying attention to inducing placebo effects helps people, it's an ethical requirement, an ethical duty. And if we look at the nocebo effect, which is the negative placebo effect, that's even more powerful than the placebo effect for evolutionary reasons.

[00:08:55] We react more strongly to danger, to bad things, than to good things. We react more further in the negative direction to bad things, than in the positive direction based on good things. I guess if we were cave people, more important to remember, oh, those fruits were poison, than just to think, oh, that flower smells nice.

[00:09:13] I did a major study, 250, 000 patients, all of whom took placebos in clinical trials. Half reported at least one negative side effect, adverse event. It wasn't the sugar pill, though. It was their beliefs. When you're part of a clinical trial, they force you to read some informed consent form. They beat you over the head with all the bad things might happen. And then so you might get a headache and it might be worse because you're on the pill. Now we did some deeper misattributions, as I mentioned. They might have a headache anyways, and they misattributed it. But about a third of them were because of negative beliefs.

[00:09:49] So we've been funded by the Medical Research Council here to look into that, to make sure that the informed consent forms are honest. You shouldn't hide side effects. But you shouldn't scare people with the side effects, and you must balance it with the positive things that might happen to them. 

[00:10:03] Christine Ko: I'm glad you mentioned that, what the downside of a placebo or placebo effect is. And so you just touched on it that, especially in a clinical trial, you may be overthinking and ascribe side effects to taking, what ends up being a placebo. So that is a negative effect. And then also you mentioned earlier, some of the ethics surrounding giving a placebo. 

[00:10:29] Jeremy Howick: That's right. It's an ethical duty for doctors to induce placebo effects. Usually it's just positive empathic communications that is an ethical duty. It's also an ethical duty to avoid avoidable nocebo effects because right now, again, the ethics of informed consent is focused exclusively on the need to inform patients about the bad things that might happen, but it's also an ethical duty to inform them of the good things.

[00:10:51] Christine Ko: You've mentioned several times empathic communication. Can you talk a little bit about the importance of the therapeutic interaction between healthcare practitioners and patients?

[00:11:02] Jeremy Howick: Yes. Empathic communication improves patient outcomes improves practitioner outcomes and improves patient safety because again, poor communication, including lack of empathic communication, increases medical complaints and medical errors. When doctors take a bit more time, but it doesn't always take more time, to express empathy, which means demonstrating understanding, and importantly, therapeutic action, this reduces patient pain by 10%. Improves patient satisfaction by 10%. It can reduce the amount of morphine required after surgery. It improves doctor job satisfaction. This is counterintuitive. People think if I'm empathic, I'll get burned out. That might happen in some cases, but the evidence clearly shows an inverse relationship. And the reason is that a doctor who's empathic, who cares about their patients, they see the benefit they're having. They can feel it. This creates this positive mission of helping people, which creates resilience. And when I teach this I give Victor Frankl. He was tortured in World War II by the Nazis. And he said, if you have a why, you can deal with almost any how. 

[00:12:16] And empathic communication can be taught. 

[00:12:18] Christine Ko: Empathic communication can be taught. 

[00:12:20] Jeremy Howick: Yeah. 

[00:12:21] Christine Ko: Yeah? Do you have recommendations on how to learn empathic communication? 

[00:12:26] Jeremy Howick: We teach it in our center, of course, and we're changing the medical school, in fact, to ensure that future doctors are more empathic. At the moment, empathy declines throughout medical school because of what's called a hidden curriculum. Poor role models, stress, et cetera. And stress just shuts people down, makes it impossible to relate to other people. We're focused on survival, not relating. Empathic communication can be taught via, empathic communication skills, making sure you understand the whole patient, not just their symptoms, but why their symptoms are bothering them, what they're seeking to get out of the consultation, and demonstrating that you're trying to understand.

[00:13:04] Here's one example. If a surgeon stands up or sits down, but in both cases, spends the exact same time, say one minute. And then the patient's asked, how long did the surgeon spend with you? The patient raised the time as longer when the surgeon sits down. Although objectively it was the same. So these kinds of things, they seem simple, but they have a measurable effect on the patient and practitioner outcomes. 

[00:13:29] Christine Ko: Yes. Yeah, I've heard that Mary Dahm, who was on this podcast earlier, had mentioned that about just sitting down, which doesn't take any more time, really at all does have a very much a positive effect on that empathic or positive communication aspect. Are there any other simple tips like that, that you can share?

[00:13:53] Jeremy Howick: Yes, I'm actually writing a paper about it, so I'll share it in advance. It's not even off the press. And most of these are evidence based. So one is, always sit down, don't stand up. Another one is... If you're a family physician, instead of summoning the patient via a megaphone or the receptionist, walk into the waiting room, introduce yourself by name, and walk beside the patient back to the consultation room.

[00:14:16] This will give you invaluable diagnostic information. Another one is counterintuitive. Don't cut the patient off. When the patient gets cut off, first of all, people think, oh, if I don't cut them off, they're going to talk for hours. They don't. It's averaging at 70 seconds, then they'll stop by themselves.

[00:14:33] And the opposite happens when you cut them off, they want longer. They never feel satiated, satisfied. Don't cut them off. Another one is introduce yourself by name, which is part of going to meet and greet them. In other words, give a message of realistic hope. Don't promise them the world if they have a terrible prognosis.

[00:14:51] But even if you can't think of something positive to say, you just say, I'm gonna do my best to take good care of you. That can activate the body's inner pharmacy literally to produce calming hormones, endorphins and so on, make them feel at ease.

[00:15:06] So those are just a few things people can do. Then there's of course more complicated behavioral techniques we can teach as well. But anything with body language, by definition, doesn't take more time, necessarily.

[00:15:17] Christine Ko: Yes. I recently spoke to someone else who emphasized how 70 plus percent of communication is really nonverbal. And just being more aware of our nonverbal communication shouldn't really take much time once we're aware of it.

[00:15:31] Do you have any final thoughts? 

[00:15:33] Jeremy Howick: Just that I very much enjoyed this, you asking all the great questions, and I hope that your listeners learn something, are inspired to engage in getting involved in positive empathic communication via the science of placebos. It applies not just for doctor to patient communication but also doctor to doctor and person to person. You can apply it in your life. 

[00:15:54] Christine Ko: Thank you so much for spending the time with me. 

[00:15:56] Jeremy Howick: Thank you, Christine.