A Psychiatrist at Large

The brain, behavior, and everything in between.

Faith in Psychiatry

Believe it or not.

Vincent van Gogh - Old Man in Sorrow
Vincent van Gogh - Old Man in Sorrow
Wikipedia Commons
Est autem fides credere quod nondum vides; cuius fidei merces est videre quod credis.

Faith is to believe what you do not see; the reward of this faith is to see what you believe.

St. Augustine

In response to one of my prior posts one of my readers commented that “in [the] American society doctors are treated like prophets and religious deities.”

This got me thinking, as my experience as a practicing physician in this country has been quite unlike being treated as a god or a prophet.

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Let me set some facts straight.

I am a foreign medical graduate. As such, before coming to the US, I was used to a degree of implicit respect from my patients, which is the norm in other parts of the word. Also, while my European medical background prepared me for the overall practice of medicine in the US, it did leave out a couple of important things. Specifically, it was during my US internship when, for the first time in my professional life, I was exposed to learning about malpractice suits and defensive medicine, learned that physicians fall under one of the many categories of health care practitioners, and heard about patients “firing” their doctors.

Elsewhere the doctor-patient relationship is not just another business contract, essentially no different than the contract that a customer makes with his car mechanic or plumber or traveling agent etc. Elsewhere, the physician is not just another contractor or consultant but has a special role as someone whose intimate knowledge of one’s body and mind lessens one’s pain or nurses one back to health. This implies a certain “magic” to seeing the doctor that often results in the patient’s feeling better the moment they see their physician, which “magic” is both palpable in the medical examination room and acknowledged by the society at large. That is why being a doctor, in many places around the world, tends to have a special social status, even when doctors are not as financially prosperous as other professionals in the same society.

In the Western culture we tend to forget that healing was once part of a sacred relationship between the healer, the sufferer and a god whose discontent with the sinner was the proximate cause of his illness. A healer was then a hierophant and mediator of one’s relationship with God. And to this day, tribal societies see their healers as working with one’s spirit or soul. Arguably this sacred dimension might be at the origin at the “magic” that we now call a placebo effect.

Regardless of its origins the placebo effect turns out to be an essential ingredient in any healing process. 

At the same time it turns out the quality of the physician-patient relationship is the main predictor of the placebo response. What does that mean? The better the relationship is the higher the chance that the patient will feel better (as a result of an enhanced placebo response). It is important to understand that good doctoring will invariably increase placebo effect, while bad doctoring will invariably results in worse outcomes because of the lack of a placebo effect.

In other words, as doctor but also, and this is the most important part of this argument, as a patient, you would want the placebo effect on your side.

Unfortunately, in this day and age, when the divine is no longer part of the allopathic physician toolkit, when a medical malpractice suit can be started anytime by anyone, when patients or rather “medical customers” or “clients” engage in business medical contracts with doctors or rather “medical health care practitioners” who tend to practice defensive medicine, the odds are set against a placebo response.

It is a paradox, as the safeguards put in place to improve the quality of medical care actually hinder the changes of a good placebo response and thus result in poorer outcomes.

Which brings me to my final points.

Psychiatrists and their medications are commonly criticized for the high rates of placebo response as indicative of a lack of true biological effect for commonly prescribed psychotropics. An alternative explanation is that psychotropic medications are prescribed by psychiatrists, a category of physicians who might have a better chance of eliciting a strong placebo response because of a unique set up (longer appointments) and  professional skills that result in better engaging their patients.

We don’t know which explanation is true. But the consequences following these opposite explanations are far reaching: while the former explanation would be a reason for concern, the latter would be a reason for study and emulation.

Finally, a word of advice for the patient in all of us: the better doctor for you is the one that’s going to make your placebo response go way up. Thus the better doctor is not the one with a ton of diplomas on his walls but the one that you feel you can trust and connect with.

© Copyright Adrian Preda, M.D.

Adrian Preda, M.D., is an Associate Professor of Psychiatry and Human Behavior at the UC Irvine School of Medicine.

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