Doctors who have a better bed side manner have healthier patients.^1,2,3 This may be due to better communication between a doctor and a patient and/or improved cooperation. It may also be that a good relationship results in a patient who reports embellished improvement on questionnaires.

Another explanation may be that a positive interaction with a doctor may induce confidence that a cure will happen resulting in the patient’s brain producing chemicals that reduce stress and mitigate things like pain or anxiety.

Similar to hypnotherapy, psychotherapy, the placebo effect and alternative medicine the doctor-patient relationship may be a non-pharmacologic intervention that can effect brain chemicals causing an improvement in conditions that respond to compensatory brain mechanisms.

There are many factors that go into making a good doctor-patient relationship, just as there are many factors that make for good hypnotherapy, psychotherapy, placebo effect, and alternative therapy. These non-pharmacologic aspects of therapy can improve outcomes in multiple ways but we are now learning that they can also work through compensatory changes in brain chemistry. These therapies can cause improvement in general health and a few specific conditions such as pain, nausea, and some psychiatric conditions.

How can a relationship alter brain chemicals?

Could there be a metaphysical explanation? Perhaps, your “Qi” has become balanced.

Could there be a spiritual explanation? Perhaps, your life force is connected to the one and only true God.

Maybe doctors that have a good bedside manor are better endowed with some mystical life force that flows through them? Perhaps, the “laying on of hands” needs to be done by a doctor who is better connected to the universal force that binds the galaxy.

All of these may seem like reasonable explanations depending on your orientation but they are all explanations that were made after the fact. There was an observation that a relationship precedes a medical improvement, then various rational explanations were made up. This is an example of a logical fallacy called a post hoc rationalization.

This type of thinking may not be logical but it is the primary way that Homo sapiens think. It is actually a smart way to think if accurate premises are not available. If you must guess, then a post hoc rationalization can provide a probability of an accurate explanation. Of course, it can also result in an explanation that is just plain bat shit crazy. The weird thing is that either way it gives you a sense in your gut that it is logical.

Here is a brief neuroscience video that will help you understand how humans think when they believe stuff that is bat shit crazy.

The Neuroscience of Belief

When there is an observation that can’t be explained and you want to know the truth you start by asking a question, not making a statement. Therefore, I would ask, “What is the mechanism of action by which the doctor-patient relationship causes a better or worse outcome?

Certainly, there is evidence that improved communication results in improved medication compliance, improved follow-up and improved healthy behavior etc.⁴ But…Does a good doctor-patient relationship also result in alterations in brain chemicals that can ameliorate certain specific conditions and generally improve over-all health?

Also,

Can the mystical claims we so often hear actually work in the same way?

Humans are given to fanciful explanations when they simply don’t have a clue about how or why an observation exists. The other day my friend Bob said, “Acupuncture may not be scientific but it does work. It has been around for thousands of years! Furthermore, Qi is real and you can not prove that it isn’t.”

I bit my tongue but was thinking, “Might there be another explanation that is more amenable to scientific inquiry?”

My scientific education taught me to disconnect my brain from the innate way it was programmed. I was taught to not think like a human. I was taught that when there is an observation that can’t be explained it is because we have yet to discover the explanation. I was also taught that it is not logical to say, “We don’t understand, therefore there must be a  mystical explanation.”

The physician-patient relationship is an important influence on health outcomes ⁴ but it is hard to conclude exactly which factors contribute the most. The research is in it’s infancy but I believe it is leading us to conclude that there is evidence to suggest that you can effect mechanisms that involve brain chemicals through non-pharmacologic means.

I want to walk you through my reasoning in order to conclude that a social relationship interaction can change brain chemicals in a manner that can mitigate certain conditions and improve general health and well being.

Q: In addition to the doctor-patient relationship, are there other examples of non-pharmacologic therapies that effect outcomes?

A: Yes, there are several other examples of non-pharmacologic therapies that have been shown to improve clinical outcomes.²¹ 1. Hypnotherapy, 2. Psychotherapy, 3. The placebo effect, 4. Complimentary and alternative medicine, 5. Yoga, 6. Meditation, and 7. Lifestyle.

Q: What do these therapies share in common? (hint: This is a key question.)

A: They all involve a relationship that assists an individual in doing species-specific behavior such as when a psychotherapist helps a depressed patient to re-engage with social relationships. (Any member of any species is the most happy and healthy when doing the species-specific behavior that its species evolved to do^5,6 and humans now live in a world where it is easy to not be doing this.)

Q: Is there any type of brain activity that correlates with clinical improvement when these therapies are used?

A: Yes, when these therapies are used we can look at functional brain images and see areas of the brain that appear to regain function in a manner that is similar to what happens when a patient is treated with medications that improve the same conditions.^7,8,9,10,11

Q. Is there evidence that the doctor-patient relationship effects physiology in this way?

A. Yes.²⁵

Q: Does this work for any condition?

A: No, only for conditions that can be effected by compensatory neuro-chemical responses.

Q: What are the conditions that can be improved through non-pharmacologic means?

A: Pain,^10,11,12,14 nausea,¹³ insomnia,^19,20 Parkinson’s disease,¹⁴ general health and well being,^17,18 depression,^14,15 obsessive-compulsive disorder,¹⁶ anxiety,¹⁵ and, of course, psychosomatic conditions.

Caveat:

A psychosomatic illness is one in which a patient is complaining of symptoms but there is no physical illness.The doctor must recognize and address the patient’s psychological problem in order for the symptoms to go away. Interestingly, the symptoms usually go away with only a psychological intervention. All of the non-pharmacologic interventions mentioned here work very well for most psychosomatic illness. It is estimated that 25-50% of patients who present to a family physician have psychosomatic conditions.³⁰ This may explain why non-pharmacologic therapies and especially complimentary approaches can be effective for a lot of people. I suggest that when a psychosomatic illness improves there might be a change in brain chemicals.

Q: So, a non-pharmacologic intervention can cause changes in neuro-chemistry in a similar way to medications and these changes can change a persons behavior and improve symptoms such as pain, nausea and depression?

A: Yes.

Q: What chemicals are we talking about?

A: Endorphins, monoamines (such at serotonin, norepinephrine and dopamine), heterocyclic amines (such as histamine), hormones (such as oxytocin), possibly some immune agents and others.

Q: Is there evidence that these chemicals are performing due to a non-pharmacologic stimulus?

A: Researchers have found that these chemicals can respond in a compensatory manor to social cues or to the above listed relationship behaviors.^10-16,22-25

Q: What specific types of relationship interaction between a doctor and a patient might produce such a result?

A. The human brain is pre-programmed to respond to social cues.²⁶ Studies have shown that within a doctor-patient relationship details that increase the relationship’s effect on outcome include eye contact and touch.²⁷ There is even evidence to suggest that your doctor needs to stop looking at the computer screen so much while he is talking to you.²⁸

Q: Can this mechanism fix everything?

A: Although there is some evidence that secondary symptoms like pain, nausea, and psychiatric conditions can be ameliorated, there is no evidence that this process can treat any primary disease process such as infection, cancer, broken bone, auto-immune condition, anatomical defect, or genetic disorder.

Q: Can a non-pharmacologic intervention cause a patient’s symptoms to become worse?

A: Yes.²⁹

I think there still needs to be a lot more research in this area. It is my conclusion from the current research that the following statement is likely to be accurate.

“The doctor-patient relationship can ameliorate pain, nausea and psychiatric conditions. General health can also be improved which can secondarily help when a patient is battling something like an infection or a cancer.”

Thus, certain specific behaviors in a relationship can have a positive or negative effect on a clinical outcome through real physiologic mechanisms.

Morgan Levy, MD

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