Prof. Sven Benson: "Expectations can double the effect of pain medication"

Prof. Benson is Professor of Medical Psychology at the University of Duisburg-Essen. He holds a professorship in didactics, curricular development and communication competence in medicine. He is researching how pain and affective symptoms are influenced by psychological factors such as expectation effects (placebo and nocebo effects) and communication, as well as biological factors such as inflammatory processes.

Question: What do doctors learn from you?
Prof. Benson: The future new licensing regulations for doctors in Germany stipulate that the importance of communication in the doctor-patient relationship must be taught and practiced in a sustained manner during medical training. Communication is an essential component of any treatment. The importance of communication for the efficacy and tolerability of treatments has been demonstrated time and again, and most of the people involved are aware of this. Nevertheless, it’s important to keep reiterating the strong effect of communication, for instance when it comes to treatment expectations.

How can students learn something like that?
On the one hand, students need to learn basic information about communication, and above all carry out practical exercises, for instance on using questioning techniques. One’s own attitudes during a conversation are central. Prospective doctors need to be sensitized to this aspect and their own experiences are initiated. We also invite real patients to participate in the students’ training. In role plays and video-based practical exercises with so-called simulated or standardized patients from the Folkwangschule - a drama school - students learn how to overcome communication barriers with agitated or angry patients and how to deal with fears or language barriers in conversations, as can be the case in patients with dementia. I have often found that prior experience, such as working in emergency services, is helpful for students. One of the most difficult tasks is to communicate a serious diagnosis. How do I, as a doctor, get the important information across while at the same time providing the patient with emotional support? We offer students a safe space to practice this. We start with more everyday situations. The delivery of bad news does not necessarily mean the announcement of a cancer diagnosis, it might also be that patient has to stay in hospital for another night or that more blood needs to be taken. By drawing on everyday situations such as these, students can learn how to respond empathetically to patients' perspectives and needs. But: Practice never stops. Even in residency training, self-reflection and maintaining a patient perspective is important.

Example: What is a good or bad way to greet a new patient?
First impressions are formed very quickly, within just a few seconds, and are determined not necessarily by the first words that are spoken, but rather by the whole approach, the facial expressions, gestures, and ambience. There is no such thing as the perfect opening sentence. It starts with a question when I first enter the practice or clinic as a patient: How am I greeted by the clinic or nursing staff? A “Good morning, I’ll be right with you” can already create a positive mood. Patients arrive with very different mental states, demands, and expectations.

To what extent should or must a doctor address this?
The initial information provided is really important: Will someone explain how I get to the outpatient clinic? What will happen to me next? Will I get a leaflet, or will someone accompany me to the examination? Just think about what you would expect in a good hotel: Did you have a good journey? Can I help you with your luggage? Do you need an extra blanket? This might sound banal at first, but it signals to me as a patient that I am welcome and cared for and that I’m in good hands, both figuratively and literally.

Do you have any advice for prospective doctors?
I know it takes more time, but if you personally collect a new patient from the waiting room and accompany him or her to the treatment room, you get an immediate impression of how the patient gets up and moves around, and at the same time, you’re conveying to the patient that they’ll be looked after. Also, you should never stare at your computer screen during a conversation, even though it probably shows important information about the patient …

So how do I figure out the right choice of words for a particular patient and also what amount of detail I should provide?
When patients are talking a lot, doctors are often very quick to interrupt them. This isn’t good, but it’s certainly because time is short. Nevertheless, it’s helpful to be attentive and ask open questions, because some patients might tell you a lot of things that are not entirely relevant while actually having a different problem altogether. This is why a kind of communicative warm-up phase is important. Medical students learn to repeat to the patient what they have understood. Sometimes this is followed by the patient saying, "Doctor, I wanted to say that I also ..." This is really useful for diagnosis. Every patient has a personal assumption about what he or she subjectively has, that is, his or her very own theory of illness. Therefore, doctors should also ask: "What is your view, what is your expectation?".

What about explaining the treatment options?
As a general rule: Doctors should not take it personally or be “offended” if a patient rejects something they recommend. As an example, imagine that a tumour patient wants to stop chemotherapy. How do I react as a practitioner? I can’t say "OK, then I can't help you." Often, the reason for such decisions is a fear of severe side effects, so I have to find a good solution together with the patient, with "together" being the operative word here. We can see in such instances that the doctor’s own self-image is changing, and so too is the self-image of the patient. The patient has a right to self-determination, and this right has to be respected.

Prof. Benson, a not too small percentage of patients do not take the drugs that have been prescribed to them. What can be done about this?
It starts with communication when prescribing a new drug. "Let me prescribe you something ..." is not a good enough explanation. You need to explain the impacts, but also the benefits and the mechanisms of action, because patients aren’t always consciously aware of the symptoms of their disease. High blood pressure is a good example of this, because the patient doesn’t notice any difference whether they’re taking blood pressure medication or not - at least not at first. So here, you need to clearly explain the long-term benefits of the treatment. But pharmacists also have an important role to play here and can have a great influence regarding placebo and nocebo effects, which isn’t possible if patients use an online pharmacy. But in the case of chronic diseases such as rheumatism or diabetes, specialist assistants are also important and long-term contacts, providing consultations and discussions. Good information materials can be helpful if a patient wants to read up on something at home. As practitioners, we should not leave the patient to search for competent information alone on the internet.

Cooperation and collaboration: For a patient to cooperate in what can sometimes be a lengthy therapeutic endeavour, trust is needed. How can trust be built?
Doctors should broach any problems or issues, be able to listen, and for example if a patient has forgotten to take a medication, offer solutions and show understanding for shortcomings. The worst thing is if the patient is afraid to tell their doctor the truth, for instance if they haven’t been taking a medication because they’re scared of side effects. An offer to talk, whatever the situation may be, is therefore extremely important. Reproaching the patient, on the other hand, is completely counterproductive. Studies have shown that digital services such as apps can be a useful addition, for instance for oncology patients. They can serve to regularly monitor a patient’s condition, or act as a reminder. There are lots of good new types of support for communication that will certainly be used more and more in the future for other diseases as well.

Let's move on to the expectation effect: To what extent do placebo and nocebo effects account for the outcome of a treatment?
We have impressive data documenting the expectation effect. This effect isn’t a minor one, like for example the last one percent that makes a painkiller more effective. It’s actually very substantial. Expectation effects can double, or massively reduce, the effect of pain medication, for instance. This also applies to side effects of medications.

Is it possible for patients to do something wrong? Do you have any examples of things practitioners have told you?
As a patient, I should never even think that I might be doing something wrong. For most people, a visit to the doctor is an unusual situation: you’re agitated, not as focused as usual, all kinds of thoughts and fears are swimming around in your head. So what can I do as a patient to make sure I’m satisfied with how the conversation goes? Consider in advance what is important to you, what you definitely want to say, make notes, take a trusted person with you. Of course, you need to think about the time factor. That's why preparation is good. When you’re agitated, you might forget important things and be annoyed with yourself afterwards because you didn’t directly ask about something or other.

If I feel that the chemistry between myself and the doctor just isn’t right, what should I do?
Well, look at it this way: In the case of psychotherapy, which can last for many months, it’s common to have a trial session to test it out. If you break your leg, you can get by without chemistry. The relationship with the family doctor is crucial, and for any chronic illness it makes sense for the patient to find the care that is truly the most appropriate and trustworthy. And if you don’t feel it fits, you should change it.

How can doctors deal with very anxious patients?
The level of information you provide is very important. Some patients don’t want to be given detailed information, they block it out, and in that case you should only explain the most important things if possible. Often, though, questions and information can help the patient to deal with their fears. Take colonoscopy as an example: Patients often have misgivings and inhibitions about this, so it can be helpful to ask what specific fears a patient has about the procedure. Some patients might be worried that the laxative they need to take in advance might be unpleasant and unmanageable, or that they will have to expose themselves during the examination. Such worries can often easily be discussed and dispelled. Again, information materials, including videos, are good here.

In all honesty, a visit to the doctor can be unsettling for lots of patients and for many reasons. It might be because you don’t know exactly how an examination will proceed, or that you’re scared about the results. We’ve all heard frightening tales from the people around us, and the Internet is full of other people’s emotionally disturbing experiences. All of this generates - entirely understandably - agitation, fears and worries. That's why it’s so important to be empathetic and open towards patients and to allow them to discuss their concerns. And it’s why I'm glad that communication will be given greater and appropriate importance in the training of medical students in the years to come, because this will contribute to achieving the best possible care and treatment for patients.