Besides the medicines they dispense and the procedures they perform, physicians wield two more powerful tools for healing: their empathy and their confidence in their ability to provide relief. When they employ these powers in the exam room, physicians may kickstart a placebo response in patients. And a patient's belief that she will feel better can be an important spur to making it so.
There's no billing code for these medical powers, so one might well ask, are they real? A new study says they are and shows them at work in the brains of practicing physicians.
Researchers at Massachusetts General Hospital and Harvard Medical School in Boston devised a novel way to capture the mind-set of a physician treating a "patient" (who was, unknown to the physician-subjects, an actor) for a bout of experimentally induced pain.
Their study was published this week in the journal Molecular Psychiatry.
The experiment used a "thermal pain stimulator," which delivered a spot of heat that ranged from uncomfortable to painful to the inner arm of 18 physician subjects. Researchers then demonstrated to the physician-subjects a device that, when used alongside the pain stimulator, could provide relief. (While the pain stimulator was real, the "analgesia" device was a fake: The researchers ensured that the subjects thought it would work by dialing down the pain stimulator when the painkilling device was being demonstrated.)
The 18 physician-subjects, who came from a wide range of specialties and were on average almost four years out of medical school, then performed a 20-minute clinical examination on a "patient." Immediately following, each physician-subject entered a functional Magnetic Resonance Imaging (fMRI) scanner, which would track his or her brain response during another round of pain-induction and pain-plus-analgesia induction.
The next part was tricky, since few physicians interact with their patients while the doctor is lying down and the patient is sitting. Researchers seated the "patient" at the foot of the scanner and transferred the pain stimulator and the analgesia device from the doctor's arm to the patient's arm. The physician-subject was given the controls for both while his or her brain was being scanned. (From here on out, it was all acting. When the doctor was asked to administer pain or the pain reliever, the "patient" responded with a facial expression meant to convey pain or equanimity. The machines were actually turned off.)
When the physician-subjects "delivered" pain to their patients without an analgesic, the experimenters observed high activity in areas of the brain that had become active when the physicians themselves experienced pain. But the exercise also activated an area in both hemispheres called the temporoparietal junction, which has been associated in past research with moral decision-making and altruism.
When the physician-subjects thought they were administering pain relief, researchers saw high activity in areas that became active when the physicians themselves experienced the effects of the (sham) analgesia device. But they also saw high activity in the anterior insula, a brain region associated in past research with empathy for another's pain. And they detected clear evidence that delivering relief from pain was highly relieving, or rewarding, for the physician-subject: a key node in the brain's reward-related circuitry, the ventral striatum, showed greatly increased activity when the doctor believed he or she was providing pain relief.
Among the physician-subjects who had ranked higher on a scale of "perspective taking" (the skill of putting onself in another's shoes), researchers saw higher levels of brain activity in those nodes of the reward- and empathy-related networks.
It gives a new twist to the expression "physician, heal thyself." Perhaps those who perform best at healing others are the ones who feel that pain themselves and are confident that it can be overcome.