MDNews - Greater Boston

E VEN THOUGH RESEARCHERS don't fully understand how expectations and beliefs regarding the effi cacy of a therapy converge to infl uence functional improvements, it's clear that physicians should take note of how expectations can translate into better outcomes. Karin Jensen, PhD, research fellow in the Department of Psychology at Harvard Medical School, explains that expectations patients form before undergoing treatment can affect a broad spectrum of conditions, even those for which it would seem impossible. "When researchers perform sham surgery — just opening up the body and stitching it back again, without doing anything — that seems to have a huge impact on recovery," Jensen says. "Expectations seem to have a role even in the hardest outcomes." Physician Importance One thing is certain: For any kind of expectation effect to occur, patients must fi rst be aware of possible benefi ts or complications associated with a treatment. Physician expertise is paramount when it comes to shaping those expectations. CAN THE POWER OF POSITIVE THINKING REALLY AFFECT A MEDICAL OUTCOME? A GROWING BODY OF LITERATURE SAYS IT CAN. By Michael Ferguson Mind over Mat ter: A Different Perspective Even though patients should be actively engaged in directing courses of treatment, physician expertise should carry appropri- ate weight, according to S. Jay Jayasankar, MD, consultant in Orthopaedic Surgery at Massachusetts General Hospital. "It's an unequal relationship, so we don't want to [aim somewhere] in between the two people's expectations, but rather toward the physician's," explains Dr. Jayasankar, who also authored an article for the American Academy of Orthopaedic Surgeons examining the impact of patient expectations. "[Because it's an] uneven relationship, there is a fiduciary responsibility that is much greater on the physician — making sure that he or she takes care of the patient as a fi duciary, and not just simply as an equal within a contract." In fact, confi dence in physicians' expertise reinforces positive patient expectations. To this point, a 2007 study published in the Journal of General Internal Medicine demonstrated clinically signifi cant improvements in patients who had high expectations of quick recoveries for their therapeutic treatments for acute lower back pain. Participants were divided into two groups: One group was given usual care as determined by a physician, and the other was given usual care with the option of choosing additional acupuncture, chiropractic care or massage. The study suggests that confi dence in a physician's plan can signifi cantly sway a patient's functional recovery. All patients carried generally high expectations for functional recovery, but patients whose care was determined solely by physicians demonstrated nearly double the improvement of the other group at fi ve-week follow-up, and even greater difference after 12 weeks. Conscious and Unconscious Impact Jensen led a study that examined how placebo and nocebo activate outside of conscious awareness. Published in a 2012 issue of the Proceedings of the National Academy of Sciences of the United States of America, the study shows that cues associated with pain relief can activate responses without patients being aware of their exposure to them. Think of the conditioned response people have to a car horn. There isn't a conscious process to determine the source of the noise, what it might mean and what action should be taken, but people still jump out of the way when they hear the noise, Dr. Jayasankar explains. Cognitive neuroscientists have studied such fear and reward responses for a long time, Jensen notes. The brain makes adap- tive responses — jumping out of the way of a car after hearing its horn — remarkably quickly. Her study took this idea and applied it to placebo theory, shifting traditional understanding of the phenomenon. "Before we wrote the article, people hadn't thought about placebos in the same way," Jensen says. "But I think of placebos as being a safety cue or cue of a reward." Her study shows the importance of nonverbal cues. Eye contact, posture and tone of voice can all convey positive or negative information the brain unconsciously processes and translates into a corresponding expectation. The Ethical Challenge If cultivating positive expectations improves outcomes, how can physicians do so without overstepping ethical boundaries? Dr. Jayasankar emphasizes getting real with patients. "The goal in doing that is to make the expectation realistic, and that's a challenge in itself because we're all prone to highlight or lowlight various things," he says. To illustrate this point, Jensen hypothesizes a medication having a 95 percent chance of successfully quelling painful symptoms and a 5 percent chance of causing side effects that reduce quality of life. The physician's task is to present the whole picture, while emphasizing the medicine's positive effects. Doing so might increase the chance of a positive outcome. Conversely, even mentioning the risk of negative side effects might cause patients to dwell on the pos- sibility and increase the likelihood they will suffer from side effects. Jensen notes it's a diffi cult balance. "It's hard because we don't really want to deceive patients by saying something is great, or this pill is really going to make you bet- ter," she says. "Physicians have the responsibility to inform patients about side effects and their limitations, and to be transparent about whatever knowledge [they] have." Physicians can frame their recommendation of a medicine in such a way as to provide a full picture of its benefi ts and shortfalls, while accentuating the positive elements and hopefully generating positive expectations. To keep patients from dwelling on the 5 percent chance their medication will cause signifi cant side effects, physicians can tell them there's a 95 percent chance they will suffer no unwanted side effects, thereby maintaining focus on the benefi ts the medication will likely bring. ■ CORE CORE SPECI A L FE AT UR E 1 0 | Greater Boston MD NEWS ■ M D N E W S . CO M

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