My hero – Michael Balint – was aware of the power of words in his classic ‘The Doctor, his Patient and the Illness.’  He discusses patients with medically unexplained symptoms. This constellation is the subject of a study in which CLAHRC WM and the WM-AHSN are collaborating.
One tricky issue concerns getting patients off the diagnostic treadmill without annoying them by implying that the symptoms originate in their mind. When I was in practice I used to say that medically unexplained does not mean the symptoms are not real – I suffered headaches and they were real enough, for all that I did not have any specific disease. Now, writing in JAMA, Arthur Barsky makes a further helpful suggestion. He advises clinicians to tell patients about the nocebo effect. Tell patients that their beta-blocker might cause erectile dysfunction, for example, and you will cause more erectile dysfunction than if the topic is not mentioned – 32% if they are warned instead of 13% if they are not. Likewise, patients who have lower back pain and are randomised to receive MRI suffer more pain, more visits and more disability than those randomised to no imaging. The author argues that explaining that the mind is quite capable of amplifying symptoms will help patients understand that symptoms can be amplified as a result of anxiety and that more testing is likely to make matters worse.
The findings do create something of a dilemma for patients and their doctors with respect to information disclosure when people are offered a chance to participate in trials. On the one hand, it is unethical not to tell patients about potential side effects, while on the other the probability of those very side-effects is increased by disclosing that they may occur. The author suggests an interesting way out – he suggests that the clinician should seek permission not to disclose the details of symptoms that are known to be labile and that do not threaten life and limb.
The deeper message from this paper is the focus on the importance of words in clinical consultations. They really do matter, but there can be a clash between words that please and words that are honest.
— Richard Lilford, CLAHRC WM Director
- Balint M. The Doctor, his Patient, and the Illness. Lancet. 1955; 265(6866): 683-8.
- Balint M. The Doctor, his Patient, and the Illness. 2nd Edinburgh: Churchill Livingstone, 2000.
- Barsky AJ. The Iatrogenic Potential of the Physician’s Words. JAMA. 2017; 318(24): 2425-6.
- Cocco G. Erectile dysfunction after therapy with metoprolol: the Hawthorne effect. Cardiology. 2009; 112(3): 174-7.
- Lilford RJ. Ethics of clinical trials from a Bayesian and decision analytic perspective: whose equipoise is it anyway? BMJ. 2003; 326: 980-1.