Relationships between healthcare providers and their patients built on trust and empathy do more than put patients at ease, they actually change the brain’s response to stress and increase pain tolerance, according to a research team at Michigan State University. While these findings were widely hailed in news reports, there were important limitations of this study and the results must be considered preliminary.
Writing online ahead of print in the journal Patient Education and Counseling, lead researcher Issidoros Sarinopoulos, PhD and his team note that this was the first study to look at the patient-centered consultation from a biological perspective, demonstrating that there is a neurobiological rationale for advocating that this type of relationship benefits patients [Sarinopoulos et al. 2012]. For their study, female patients were randomly assigned to one of two types of 20-to-25 minute interviews with a physician before undergoing functional magnetic resonance imaging (fMRI) brain scans:
- One group of subjects was assigned to a patient-centered interview approach in which physicians addressed any and all concerns of participants regarding the procedure and asked open-ended questions allowing participants to talk freely about their jobs, home life, and psychological and social factors affecting their health.
- The remaining randomly-assigned subjects experienced a clinician-centered interview; that is, participants were asked only specific questions to gather clinical information, such as their medical history, current symptoms, and what medications they were taking.
To verify that the patient-centered differed from clinician-centered interview, the researchers rated the interviews and also administered a questionnaire to patients assessing their satisfaction with the provider–patient relationship. Patients’ brains were then scanned as they received mild but painful electric shocks and also viewed pictures of either the interviewing physician or control images of unknown physicians. The scans measured activity in the anterior insula — a part of the brain that makes people aware of pain — in anticipation of the shocks and when they actually occurred.
As expected, those who had undergone the patient-centered interview reported greater satisfaction and confidence in their physician in the post-interview questionnaire. Along with that, the brain scans revealed that patients who had experienced the patient-centered interview showed less activity in the anterior insula when they were looking at a photo of the interviewing physician than when the person in the photo was unknown. Participants also self-reported less pain when the photos showed the known and trusted physician.
The researchers conclude that their study demonstrates that a patient-centered interview approach helps to establish a positive practitioner-patient relationship, which in turn reduces pain-related neural responses in the brain. If confirmed by further research, these results support the wider clinical use of this empathetic approach when interacting with patients in pain.
COMMENTARY: This was an important experiment for helping to establish a neurobiological basis behind the case for empathizing with patients in pain — getting to know them on a personal level and building trust. The patient-centered consultation encompassed 4 key areas: 1) establishing rapport with the patient, 2) encouraging patient disclosure of emotional cues and concerns, 3) the practitioner’s expression of empathy, and 4) positive reappraisal of patient concerns. Variations of these themes are typically taught during medical training; however, whether or not most practitioners have the luxury of a 20-to-25 minute consultation, as in this study, to establish such rapport with all patients during everyday clinical encounters is questionable.
Another important limitation of this study is that there were only 9 total subjects: all were female, mean age 49 years, and prospective participants with prominent pre-existing pain symptoms had been excluded. During lengthy fMRI scans, each subject underwent 72 trials, with half presenting pain stimuli and the remainder no pain for comparison; while this facilitated numerous data-points for analysis, the very small number of subjects overall qualifies the design as, at most, a pilot study.
The researchers concede that their findings are preliminary and need replication in a much larger sample. The present study also does not suggest how strong or persistent the effects may be from a single patient-centered consultation or how many interviews over what period of time would be needed to affect a desirable neurobiological profile. Furthermore, based merely on this study, the results cannot be applied to patients with chronic pain who may have altered neurobiological status as a result of their conditions.
This study by Sarinopoulos et al. focused on the insular cortex (see figure), which is active during emotional stress and plays a role in the anticipation and experience of pain. It is one part of a network of brain regions comprising the limbic system and other structures that are important for the perception, interpretation, and response to pain stimuli. As noted in a prior UPDATE article [here], chronic pain can alter chemical, functional, and structural neurobiology in ways that might impact a patient’s quality of life as well as their cognitive and emotional stability on a day-to-day basis. The role of practitioner-patient relationships for influencing better patient outcomes in this context is still unknown, and this current study does not address those concerns.
It seems reasonable that focusing solely on the physical dimensions of a patient’s pain establishes only a part of the clinical profile. While this is necessary, taking the time to also let patients tell their story in an unfettered way may help to establish better rapport and result in more satisfying interactions. Whether or not this relationship actually helps to ameliorate chronic pain and/or aids other outcomes needs further investigation.
REFERENCE: Sarinopoulos I, Hesson AM, Gordon C, et al. Patient-centered interviewing is associated with decreased responses to painful stimuli: An initial fMRI study. Patient Educ Couns. 2012; online ahead of print [abstract here].
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