Clinician warmth and empathy

Recent research suggests that placebo effects may be mediated by the perceived warmth and competence of the clinician. Howe et al 25 found that after inducing an allergic reaction in participants, those who had both positive expectations of allergy relief and who interacted with a provider who demonstrated high warmth and high competence displayed the largest reduction in their allergic reaction (as measured by the size of the weal) compared with other groups who had negative expectations and/or providers with low warmth and competence. Similarly, in an experiment involving patients with a common cold, it was found that 48 hours after the clinical encounter, those who rated their clinician as high in empathy had higher measures of interleukin 8 (an immune biomarker) and reported that their cold lasted on average 1 day less than those who rated their clinician as low on empathy.26 Finally, in an experiment in which individuals were given either real or sham physical therapy for chronic low back pain and placed in either limited or enhanced therapeutic alliance conditions, the results demonstrated that the degree of therapeutic alliance was just as important for pain relief as whether they were receiving real or sham therapy.27

Support and patient engagement

Relatedly, the ways in which healthcare professionals support and engage with patients have been shown to contribute to placebo effects that influence clinical outcomes. A working group examining the treatment of headaches found that patients who felt that clinicians fully discussed their headache with them were 3.4 times more likely to report that their headache was resolved than patients who did not, and that this factor was the strongest predictor of resolution.28 Similarly, an experiment within a family practice indicated that the level of agreement between a patient and physician on the nature of the problem significantly predicted a decline in patient symptoms.29

In a clear investigation of how placebo effects can be generated by increased support and patient engagement in the clinical encounter, Ted Kaptchuk and colleagues conducted an experiment involving 262 patients with irritable bowel syndrome, randomised into three conditions.31 The first group received no treatment but participants were required to respond to a series of questionnaires at three points during the experiment, the second received these questionnaires as well as sham acupuncture, which was administered in a ‘business like’ interaction with the practitioner, while the third received both the questionnaires and sham acupuncture, but the latter was delivered in a ‘highly organized ritual which included an augmented patient – healer interaction that included taking medical and psychosocial histories and demonstrations of compassion, support, attentive-listening, 20 [seconds] of thoughtful silence and expressions of confidence’.30 Outcomes found that adequate relief was experienced by 28% of the first group, 44% of the second group and 62% of the third group.31 These findings offer a powerful demonstration of how incremental additions of support and engagement within the clinical encounter can lead to incremental improvements in symptom relief for patient.

This evidence demonstrates that, for certain conditions and symptoms, placebo effects mediated by the clinical encounter play a significant role in contributing to patient outcomes. In light of this, the next section offers a brief overview of the prevalence of health disparities along racial and ethnic lines, and in the following section, we examine data related to inequalities in care that correspond with the two aspects of the clinical encounter discussed above.

Clinician warmth and empathy

Warmth and empathy expressed by clinicians appear to differ across populations of patients. For example, one experiment involving independent observers who watched interactions between patients and physicians through a one-way mirror found that physicians spent more time with white patients, and scored higher on the dimensions of interviewing and empathy when they were meeting with white patients, as compared with Latino patients.40 Another study found that physicians used significantly fewer positive expressions when engaging with Latino patients as compared with non-Latino patients, but that levels of empathy were similar in both groups.41 Further investigations into inequality in the clinical encounter show that high scores on implicit racial bias, as determined by a test derived from the Implicit Association Test (IAT),ⁱⁱ correlate with lower ratings of positive affect in patients and higher ratings of clinician-dominated dialogue during the encounter.42 Another analysis of patient–physician interactions by independent coders who listened to audio recordings of patient visits found that physicians were more contentious with black patients than white patients, and guessed that black patients were less satisfied with the care they received.43 Finally, and while not a direct measure of empathy or warmth, a study by van Ryn and Burke44 found that after meeting with a number of patients and then completing short surveys about each of them, physicians were more likely to see black patients as less intelligent, more likely to engage in risky behaviour and less likely to adhere to medical advice, when compared with white patients. Physicians were also less likely to agree that black patients were ‘the kind of person they could be friends with’ in comparison with white patients.44

Support and patient engagement

Differences in support and patient engagement appear to be influenced by race and ethnicity as well. In an experiment involving patients with breast cancer, it was found that physicians spent significantly less time engaging in relationship-building behaviours with black patients as compared with white patients.45 Independent raters of audio tapes of patient visits reported that when clinicians were interacting with black patients, they engaged in 33% less patient-centred communication than when they were speaking to white patients, showed less positive affect and were 23% more verbally dominant.46 Studies have also found that when white physicians interact with black patients, they tend to engage in less shared decision making and provide less information than when they engage with white patients.47 Corroborating this evidence, Cooper-Patrick et al 48 found in a telephone survey that black patients tend to rate their medical visits as significantly less participatory than their white counterparts, while another experiment found that black patients give worse ratings for patient-centred care to clinicians with greater implicit racial biases, as measured by the IAT.ⁱⁱⁱ  ,49

Unequal distribution of placebos as an injustice

If, as we have hypothesised, health disparities along racial and ethnic lines are increasing as a result of an uneven distribution of placebo effects, as mediated within the clinical encounter, this raises the question of whether such disparities constitute an injustice. It might be granted that other contributors to health disparities, such as differences in treatment or diagnosis, can be reasonably thought of as instances of injustice, but that patients who are fortunate enough to engage with a supportive and empathic physician are merely the recipients of a lucky, therapeutic boost to their care. One might argue that the former scenario has serious repercussions for individual health outcomes and implicates the clinical competence of physicians, and so constitutes an injustice, while the latter scenario only involves different degrees of friendliness, which cannot significantly impact health outcomes and does not violate reasonable expectations of physician behaviour, and so does not constitute an injustice.

With regard to the impact of such a scenario on clinical outcomes, as outlined in detail above, aspects of the clinical encounter that contribute to the distribution of placebo and nocebo effects can significantly influence clinical outcomes across conditions and symptoms. Research has demonstrated that saline injections delivered with positive verbal suggestions can have the equivalent impact of 6–8 mg of morphine administered surreptitiously, suggesting that placebo effects are quite powerful indeed.55 Taking this into account, an uneven distribution in placebo effects might appropriately be thought of as a freely administered treatment for certain privileged demographic groups.

The more serious objection holds that while differences in diagnosis and treatment are central to a physician’s clinical role, placebogenic aspects of the clinical encounter, such as warmth and support, are above and beyond what we require from our doctors, so any failure to express these qualities cannot constitute an injustice. However, the fact that the role of these qualities in impacting health outcomes is not widely acknowledged cannot constitute a defence; medical practice must follow the evidence. Professional medicine is concerned with the appropriate prescription and use of medications and surgical interventions: call these the ‘tools of medicine’. However, the fact that other tools, such as empathy, may not be conventionally considered part of this toolkit does not thereby constitute a justification for their not being classified as such. Rather, it merely reflects the habits and practices of orthodox medicine. Force of habit, however, is no defence against the charge of ignorance.

In these ways, we argue, the unequal distribution of placebo effects which, we argue, is likely to be contributing to systematic disparities within the delivery of patient care constitutes an injustice.

Expanding the standard of care

When medical students are taught what the standard of care is for a particular condition, they learn about which interventions are known to produce the best results, given the population they are working with and given the other risks present. What they are not typically taught is the way in which the manner they administer an intervention can impact clinical outcomes. The evidence above raises the question of whether the standard of care ought to be expanded to include not just what treatment ought to be administered, but how a treatment ought to be administered. This question brings with it a host of practical and ethical issues, including what conditions would be appropriately included in the enhanced standard of care, how to communicate with patients regarding these aspects of treatment, whether one might bill for the manner in which a treatment is delivered and whether the placebo-maximising aspects of the clinical encounter can truly be taught. While more research is surely needed before such a shift could be implemented, it is worth briefly exploring these questions.

Importantly, if the standard of care was expanded to include not just what, but how medical interventions are delivered, it would first be essential to follow the evidence in terms of what kinds of expansions would be warranted. As mentioned above, research into placebo and nocebo effects shows that some symptoms and conditions are likely to be impacted by the aspects of the clinical encounter discussed above, while others may be unresponsive. Experiences of pain are highly susceptible to placebo effects, as are some psychiatric disorders (including depression and anxiety), Parkinson’s disease and several functional somatic syndromes, so these might be better candidates for expanded treatment models than others.56 Then again, it is likely that anyone in poor health can stand to benefit from positive direct effects of therapeutic communication. While tumour growth may be unaffected by the clinical relationship, cancer-related fatigue has been shown to be responsive to placebo treatments.57

In addition if the standard of care was expanded to account for the powerful role placebo effects can play within the clinical encounter, this would raise difficult questions regarding how much the patient should be told, given that physicians cannot avoid communicating in one way or another and framing information that they provide.58 It has been observed that a tension arises between commitments to transparency that are commonly embraced within medical codes of ethics and the way in which placebo effects remain unacknowledged in the clinical setting.59 If true transparency is the goal, should patients be told that the number of minutes, smiles and tests they receive during their visit may all impact their health? Should they be informed about possible disparities in the delivery of care? Indeed, the latter question becomes even more troubling if we try to picture what transparency might look like, since telling patients that their quality of care may be undermined due to non-clinical factors like race could lead to an increase in the likelihood of nocebo effects occurring.

Translating these findings into improved outcomes in practice will not be an easy task. In fee-for-service models of healthcare, where clinicians are reimbursed for components of treatment piece by piece, it may even be considered necessary to bill for placebo-maximising aspects of the clinical encounter in order to see them implemented in practice. This could bring about a bizarre reality in which clinicians are reimbursed $20 for shaking hands with a patient, $30 for 20 s of thoughtful silence and $50 for a short conversation about the weather. These may seem laughable, but some evidence suggests that paying for such improvements within the clinical encounter may come out on top within a cost–benefit analysis. As mentioned above, it has been found that better communication skills and an increase in emotional support can lead to significant reductions in postsurgical days spent in the hospital.11 12

Another question arises in terms of whether the aspects of the clinical encounter that make a real difference are aspects that can readily be taught to clinicians. While some factors, such as the length of time spent with a patient, may be easy to increase, others, it might be argued, such as the degree of empathy expressed and the participatory style of communication, are harder to teach. However, there is encouraging evidence that short training interventions can significantly improve physicians’ communication skills and perceived levels of empathy among patients.60 Indeed, it was the introduction of short courses which focused on teaching surgeons to increase patient empowerment and communicate better that led to the reductions in days spent at the hospital mentioned above. These findings suggest that, at least to a certain degree, placebo-maximising behaviours may both be teachable and, in the long term, increasingly feasible in clinical encounters. Perhaps more important, however, is eliminating the behaviours that lead to differential treatment of minority patients in the first place.

Reducing implicit bias

As noted, an abundance of research shows that patients from racial and ethnic minority groups are vulnerable to inferior care. A wealth of indirect evidence suggests that these differences in care are likely to be, at least in part, the result of implicitly held biases related to race and ethnicity.38 While most physicians are unlikely to explicitly report biases towards minority groups, like the rest of the population, most display substantial implicit biases grounded in racial and ethnic stereotypes, and at least sometimes, these biases appear to correlate with clinical decision making.61 Evidence also suggests that reliance on stereotypes tends to increase with cognitive load, suggesting that healthcare professionals, who are typically engaging in many tasks while under time pressures, are more likely than others to fall back on such stereotypes while making decisions or interacting with patients.62 Some have also hypothesised that the culture of medicine may exacerbate tendencies to frame one’s experience through stereotypes, either through derogatory humour63 or through the ‘ethical erosion’ that happens to medical students during their training.64 Unfortunately, the nature of these implicitly held biases, as unconscious and automatic beliefs, poses a significant challenge in terms of both their identification and reduction.38 65

Fortunately, a growing literature from social psychology has been exploring techniques for reducing implicit racial biases, although methodological weaknesses and a lack of randomised control trials suggest that conclusions from this realm of research should be approached tentatively. Despite these shortcomings, a review of this literature suggests that counteracting racial bias among healthcare providers should involve strategies that illuminate what underlies biases, motivate practitioners to reduce them, emphasise partnership within the clinical context, encourage confidence related to interacting with patients from different ethnic or racial groups, and help providers to experience empathy in both its cognitive and emotional dimensions.65 Research has also found that requiring students to take the IAT and reflect on their own biases and incorporating curricula related to health disparities and minority health into medical school can be effective in reducing implicit biases.66 Techniques that have shown promise outside of the clinical context include repeated exposures to counter-stereotypes67 and increased contact with those who are the target of one’s biases.68 Unfortunately, the long-term effects of these training interventions are not known.

Another important area of related research explores the impact of racial concordance on patient experiences. Some evidence from this realm suggests that when patients and clinicians are of the same race, patient visits are longer, satisfaction is higher, more positive affect is expressed, and patient and clinician assessments of pain are more closely aligned.69 70 These outcomes align well with the aspects of the clinical encounter that contribute to placebo effects discussed above, suggesting that perhaps a way to increase placebo effects in minority populations is to increase the number of racially concordant patient–physician relationships. However, the experiments measuring the impact of racial concordance mentioned above did not examine health outcomes, and a recent meta-analysis suggests that there is inconclusive evidence for the claim that racial concordance has a positive effect on clinical outcomes.71 It is likely that more research is needed before any efforts are made to match skin tones or ancestry within clinical settings, especially given the unintended effect of perpetual racial segregation this could lead to.^v

Other forms of inequality

While the discussion above has focused on inequality in relation to race and ethnicity, there are countless other individuals who face stigma, discrimination and bias within healthcare settings.

Differences in patient weight, mental health, substance use, socioeconomic status, age, gender identity, sexuality, attractiveness, criminal records, HIV status, street involvement and marriage status, among other factors, all contribute to experiences of discrimination and differences in treatment within clinical settings.63 72–84 This suggests that individuals from any of these groups may be less likely to experience placebo effects during healthcare interactions, further increasing inequality in health outcomes along countless other dimensions. In addition, for those patients among whom two or more of these identities intersect, negative experiences within healthcare may be even more likely.

The ubiquity of discrimination within healthcare settings is alarming and raises pressing questions related to justice. In thinking through the possibility of implementing strategies to increase placebo effects within the clinical encounter, arguably the greatest priority should be given to those who are most vulnerable to stigmatisation within healthcare settings. Concerns arise, however, regarding whether flagging patients at risk for discrimination and intentionally treating them differently is the right solution to reduce the effects of stigma. The many forms in which bias appears within clinical settings is an important issue however, and the way in which it may be directly contributing to an increase in health disparities by way of placebo effects has, to date, been overlooked. Further investigation into the ways in which this occurs, the extent to which it occurs and the ways in which we can ameliorate its effects, we argue, should be a research priority.