Are We Missing the Most Important Aspect of Health Care?

Physician Danielle Ofri argues that honest conversation is the most powerful mechanism for healing. 

Danielle Ofri was confused the first time she heard the term ‘expired.’ The first-year medical student envisioned her family’s shabby air mattress used for camping trips in the Catskill Mountains. The revelation took a moment.

Now a veteran physician at New York’s Bellevue hospital, Ofri laughs at her earlier ignorance. Language, and more importantly communication, is at the center of her new book, What Patients Say, What Doctors Hear (Beacon Press). How doctors and patients interact plays a greater role in medicine than we might believe.

As the medical industry strives for a virtual world in which diagnoses are made and prescriptions rendered on a smartphone app, Ofri argues that successful conversation is the primary driver of healing. Sadly dialectics remain a longstanding elephant in the office: doctors enter with opinions, patients their own, the ticking clock on the wall in plain view of both parties.

This creates resentment in the patient, who, as it turns out, is interrupted by the doctor within twelve seconds on an average visit. Likewise the physician quickly grows impatient due to noncompliance: 50-75 percent of subjects do not adhere to physician advice. A vicious cycle commences in which neither side feels heard. Healing becomes difficult when anxiety rests at the foundation of this relationship.

This particular exchange is often fraught with problems from the beginning. A perpetual fear of litigation on one side and long wait times and snap judgments on the other create an insurmountable gulf. Marriage counselors recognize that by the time a couple seeks guidance it’s often too late. No comparable therapy exists for a patient that wants to break up with their doctor (or vice-versa).

Yet this mysterious distance is avoidable. Ofri writes that talking through emotional challenges alleviates tension for both parties. When physicians avoid the psychological and emotional aspects of illness the risk of nonadherence to medications triples. Factor in particularly stressful situations—unemployment, housing issues, romantic quandaries—and that risk is six-fold higher.

An inability to quantify conversation seems embedded in a system in which blood pressure and cholesterol levels are promptly displayed. But it’s not. One Canadian study showed that electrical stimulation for back problems resulted in a 45 percent reduction in pain. The other group received a sham treatment but talked extensively with their therapist. The result was 55 percent pain reduction.

It comes down to time. Doctors get caught on clinical hamster wheels; patients demand prompt answers to complex problems. Ofri believes this is mitigated when both parties take a deep breath. As she writes, “effective communication needn’t take an unconscionably long time; it just needs full and intense focus.”

Ofri’s narrative is not factual alone. Her personal experiences of bias, uncertainty, fear, and confusion are woven into the fabric of this challenging tale. She openly discusses her unconscious intolerance of obesity, avoidance of junkies, ethnic favoritism, the sheer emotional and cognitive magnitude of dealing with death and suffering on a daily basis. In the process she humanizes her profession, an essential step in reversing favoritism and bigotry in hospitals and clinics.

Delivering a death sentence, Ofri promises, does not become easier with practice. She’s broken down in tears on more than one occasion regardless of how together she tries to remain. She’s misread charts on long shifts and missed clear signs of domestic abuse. For an entire year she never realized one particularly challenging patient who never took the proper medication was illiterate.

Yet she argues that you can’t be a good doctor with a lousy bedside manner. Empathy matters. Spending six figures on an education makes some feel mighty, though research knocks such an attitude down. A study conducted at Waterbury Hospital in Connecticut revealed that while 73 percent of patients knew they had one primary care doctor during their visit, only 18 percent could name them. Incredibly, two-thirds of doctors believed their patients knew their name.

What if expectations shift? One of the most illuminating aspects of Ofri’s book is that expectations can be as influential as medication. The placebo effect works on such a premise. What we believe about a drug or doctor can actually block the biological effect of a pharmaceutical. This knowledge potentially shifts the patient-doctor relationship—so long as both parties recognize and act as if they’re in a relationship.

Which of course requires empathy. Ofri’s most potent revelation resides in its simplicity: the patient is not the same as the illness. In one racially-motivated study nurses offered less pain medication to African Americans than to white patients when instructed to use their best clinical judgment. When told to envision how pain affected their patients’ lives, dosages were more judicial. When they imagined feeling their suffering nurses complied with the Golden Rule.

My watch is currently telling me to take a minute to breath. Soon it might send my vitals to the team at UCLA, which would then text me should they notice worrisome discrepancies. A refill, diagnosis, even a kind word about my day might follow. Yet it could never replace the pantomimes and personality of a real human being. As Ofri argues in her insightful book, this remains the most important aspect of medicine. 


Derek's next book, Whole Motion: Training Your Brain and Body For Optimal Health, will be published on 7/4/17 by Carrel/Skyhorse Publishing. He is based in Los Angeles. Stay in touch on Facebook and Twitter.

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The study's senior author and Integrative Physiology Professor Christopher Lowry described this fat as "one of the main ingredients" in the "special sauce" that causes the beneficial effects of the bacterium.

The finding goes hand in hand with the "hygiene hypothesis," initially proposed in 1989 by the British scientist David Strachan. He maintained that our generally sterile modern world prevents children from being exposed to certain microorganisms, resulting in compromised immune systems and greater incidences of asthma and allergies.

Contemporary research fine-tuned the hypothesis, finding that not interacting with so-called "old friends" or helpful microbes in the soil and the environment, rather than the ones that cause illnesses, is what's detrimental. In particular, our mental health could be at stake.

"The idea is that as humans have moved away from farms and an agricultural or hunter-gatherer existence into cities, we have lost contact with organisms that served to regulate our immune system and suppress inappropriate inflammation," explained Lowry. "That has put us at higher risk for inflammatory disease and stress-related psychiatric disorders."

University of Colorado Boulder

Christopher Lowry

This is not the first study on the subject from Lowry, who published previous work showing the connection between being exposed to healthy bacteria and mental health. He found that being raised with animals and dust in a rural environment helps children develop more stress-proof immune systems. Such kids were also likely to be less at risk for mental illnesses than people living in the city without pets.

Lowry's other work also pointed out that the soil-based bacterium Mycobacterium vaccae acts like an antidepressant when injected into rodents. It alters their behavior and has lasting anti-inflammatory effects on the brain, according to the press release from the University of Colorado Boulder. Prolonged inflammation can lead to such stress-related disorders as PTSD.

The new study from Lowry and his team identified why that worked by pinpointing the specific fatty acid responsible. They showed that when the 10(Z)-hexadecenoic acid gets into cells, it works like a lock, attaching itself to the peroxisome proliferator-activated receptor (PPAR). This allows it to block a number of key pathways responsible for inflammation. Pre-treating the cells with the acid (or lipid) made them withstand inflammation better.

Lowry thinks this understanding can lead to creating a "stress vaccine" that can be given to people in high-stress jobs, like first responders or soldiers. The vaccine can prevent the psychological effects of stress.

What's more, this friendly bacterium is not the only potentially helpful organism we can find in soil.

"This is just one strain of one species of one type of bacterium that is found in the soil but there are millions of other strains in soils," said Lowry. "We are just beginning to see the tip of the iceberg in terms of identifying the mechanisms through which they have evolved to keep us healthy. It should inspire awe in all of us."

Check out the study published in the journal Psychopharmacology.