The medical community knows perfectly well what sort of patient-care model would work better against complex diseases than the infectious-disease-inspired approach we’ve inherited. That would be one that doesn’t wait for diseases to take firm hold and then vainly try to manage them with drugs, but that rather focuses on lowering the risk that these diseases will take hold in the first place. “We need to prevent and slow the onset of these diseases,” says Blackburn. “And we know there are ways to do that.” Aside from getting people to stop smoking, the three most effective ways, according to almost any doctor you’d care to speak with, are the promotion of a healthy diet, encouragement of more exercise, and measures to reduce stress.
The evidence that these lifestyle and attitude changes have enormous impact on health is now overwhelming. Dean Ornish, a physician-researcher at the University of California at San Francisco and the founder of the independent Preventive Medicine Research Institute, has been showing in studies for more than three decades that diet, exercise, and stress reduction can do a better job of preventing, slowing, and even reversing heart disease than most drugs and surgical procedures. “They used to say I was crazy,” he told me. “Now studies have shown that angioplasty and stents don’t prolong life in patients with heart disease. And studies have shown that lifestyle changes work better than drugs in preventing the complications of diabetes.” A major 2004 study that followed 30,000 people concluded that lifestyle change could prevent 90 percent or more of all cases of heart disease.
Relieving patient stress, in particular, is looking more and more important, according to Blackburn. She earned her Nobel for her work on telomeres—the ends of the strands of DNA that make up our chromosomes. Studies by her and others have shown that stress is linked to the shortening of telomeres, and shorter telomeres are in turn linked to aging and cancer. “We tend to forget how powerful an organ the brain is in our biology,” Blackburn told me. “It’s the big controller. We’re seeing that the brain pokes its nose into a lot of the processes involved in these chronic diseases. It’s not that you can wish these diseases away, but it seems we can prevent and slow their onset with stress management.” Numerous studies have found that stress impairs the immune system, and a recent study found that relieving stress even seems to be linked to slowing the progression of cancer in some patients.
Medicine has long known what gets patients to make the lifestyle changes that appear to be so crucial for lowering the risk of serious disease: lavishing attention on them. That means longer, more frequent visits; more focus on what’s going on in their lives; more effort spent easing anxieties, instilling healthy attitudes, and getting patients to take responsibility for their well-being; and concerted attempts to provide hope. Studies have shown that when a doctor speaks to a patient about quitting smoking or losing weight, the patient is more likely to do it. A 2008 study on physician-patient relationships found that physicians deemed “exemplars” based on their reputation and awards received were likely to create an emotional bond with patients; to convey to patients that their commitment to caring for them will endure over time; and to imbue patients with “trust, hope, and a sense of being known.” Hippocrates put it this way: “It is more important to know what sort of person has a disease than to know what sort of disease a person has.”
This “healing” approach to patient care clearly isn’t found in the typical visit to the doctor’s office. Studies show that visits average about 20 minutes, that doctors change the subject back to technical talk when patients mention their emotions, that they interrupt patients’ initial statements after 23 seconds on average, that they spend a single minute providing information, and that they bring up weight issues with fewer than half their overweight patients.
Many medical students start out with a healer mentality, but few retain it. “It gets beaten out of you by the system,” says Brian Berman, noting a study showing that medical students score progressively lower on empathy tests the further they get into their training. Berman himself was a conventional M.D. until, at age 33, he took up the study of traditional Chinese medicine—which, like many alternative approaches, is largely focused on patients’ lifestyles, feelings, and attitudes, and which emphasizes stress reduction, healthier eating, and regular exercise, as well as encouraging the patient to believe in self-healing. “I saw how much more I could do to help people,” he says. “For the first time since medical school, I felt like a healer again.”
The benefits of a healing approach extend beyond the prevention of major chronic diseases to the management of many everyday maladies that plague millions of people. Amit Sood, a physician at the Mayo Clinic in Rochester, Minnesota, came to the United States from his native India to practice medicine in 1995, and he told me he was shocked at what he found. “I thought America would be a Disneyland of health,” he said. “And what I saw was patient after patient who seemed wealthy, who tested healthy, and who was completely miserable.” Aches and pains, fatigue, anxieties, lack of mobility, digestive ills—all of these problems are extremely common, and all can greatly diminish quality of life. Yet they are seldom easily diagnosable in the conventional sense—a single, identifiable pathogen is rarely responsible—and drugs and surgery can be clumsy tools for dealing with them.
Typical of people who complain of hard-to-pin-down ailments is Mary Pinkard, another patient I met at the University of Maryland Medical Center. A petite, young-looking 54-year-old, Pinkard told me about her long history of extreme fatigue, sinus discomfort, and other symptoms, which under the care of conventional physicians had resulted in three operations on her sinuses and a hysterectomy, as well as long, intense courses of antibiotics—none of it very helpful. “In 30 years, I didn’t have three months in a row of good health,” she said. She had recently started seeing Dr. Lauren Richter, an osteopath with Berman’s clinic trained in acupuncture and other alternative approaches, and told me the improvements had been dramatic. She hadn’t been sick in five months, she said, and hadn’t had to take any drugs. She declared well worth it the $2,500 she’d had to pay, out of pocket, for her treatment.
The Mayo Clinic’s Sood, after seeing how dissatisfied American patients were with their costly, state-of-the-art health care, reacquainted himself with the traditional medicine of his childhood, and now runs a stress-reduction program loosely based on meditation techniques. “Awareness and stress management are key to resilience and the ability to self-regulate health,” he says. Many of the large companies that contract with the Mayo Clinic to provide executive-wellness programs have been so taken with Sood’s program that they’ve asked him—to no avail—to be accessible to them through the clinic full-time.
Steven Novella calls the notion that alternative care’s benefits are rooted in closer practitioner-patient interactions the “touchy-feely defense.” Novella is a highly respected Yale neurologist, and the editor of Science-Based Medicine, an influential blog that has tirelessly gone after alternative medicine. I met with him in his home outside New Haven, Connecticut, where he argued that claims about the practitioner-patient relationship are only intended to draw attention away from the fact that randomized trials have by and large failed to show that alternative treatments work better than placebos. And while he concedes that sham treatments can give patients a more positive attitude, which can confer real health benefits, he is adamant that providing sham treatments at all—essentially fooling patients into believing they’re being helped—is highly unethical. “Alternative practitioners have a big advantage,” says Novella. “They can lie to patients. I can’t.”
Yet on its own terms, this argument is not as cut-and-dried as it first appears. “Mainstream medicine uses the placebo effect all the time,” says Ted Kaptchuk, a Harvard researcher who studies the impact of placebos. “Doctors don’t tell you the drug they’re giving you is barely better than a placebo. They all spin.” To be approved by the FDA, a drug has to do better than a placebo in studies—but most approved drugs do only a little better, and for many drugs the evidence is mixed. A number of studies have indicated, for example, that most antidepressants don’t do better than placebos, but patients filled more than 250 million prescriptions for them in 2010. The vast majority of drugs don’t work in as many as 70 percent of patients, according to an estimate from within the pharmaceutical industry. One recent study concluded that 85 percent of new prescription drugs hitting the market are of little or no benefit to patients.
Of course, whether doctors or alternative practitioners are really “lying” when they ply patients with drugs or homeopathic remedies is a matter of judgment—we can’t know how much any individual caregiver believes in these treatments, although a noteworthy 2008 survey found that about half of U.S. physicians admit they routinely prescribe treatments they don’t think are likely to be of direct physical benefit. Regardless, notes Kaptchuk, patients absolutely end up feeling better, and often testing healthier, when they get these noneffective treatments, thanks to the placebo effect. “Knowing that you’re getting a treatment,” he says, “is a critical part of the ritual of seeing any kind of practitioner.”
Many studies have proved that sham-treatment rituals can do as well as drugs and surgery in relieving symptoms of many common and debilitating ailments. A 2002 study found that sham knee surgery involving an incision but nothing else did as much to relieve arthritis as the standard real procedure, and a 2009 study found that the same was true of a common back operation for osteoporosis. A 2008 British Medical Journal study by Kaptchuk and several colleagues showed that patients receiving sham treatment for irritable bowel syndrome—which is one of the 10 disorders that most frequently bring patients to doctors and which has been estimated to cost the U.S. up to $30 billion a year—did as well as patients typically do on the standard drug for the disorder. A 2001 study showed that in patients suffering from Parkinson’s disease, a condition marked by the brain’s diminished ability to produce dopamine, a placebo treatment caused dopamine production to surge. A German Medical Association study this year found that 59 percent of patients with stomach discomfort were helped by sham treatments.
“Placebos have a stronger impact and are more complex than we realized,” German Medical Association Director Christoph Fuchs stated upon the study’s release. “They are hugely important in medicine today.” Studies by Kaptchuk and others have even shown that patients still get a beneficial placebo effect when practitioners are honest but optimistic with patients about the placebo—saying something along the lines of “We know of no reason why this should work, yet it seems to work with many patients.” Sure enough, it often does.
Studies have also shown that alternative treatments such as acupuncture tend to produce a larger placebo effect than merely handing out sugar pills, presumably because alternative treatments involve more ritual, and thus further raise patients’ expectations. In other words, alternative practitioners tend to do a better job at “selling” the placebo effect.
One might argue that a system of care that merely delivers a powerful, relatively safe placebo for many conditions—without side effects—has at least something to commend it, when compared with the system of care we actually have today. Yet to focus on alternative medicine’s placebo effect ignores what may be its largest benefit—its adherence to a “healing” model of patient care.
Randomized controlled trials, the medical world’s gold standard for assessing the efficacy of treatments, cannot really test for this effect. Such studies are perfect for testing pills and other physically administered treatments that either have a direct physical benefit or don’t. (In its simplest form, a controlled study randomly assigns patients to receive either a drug or the equivalent of a sugar pill. If the real thing doesn’t bring on more improvement than the placebo does, the drug is a washout.) But what is it that ought to be tested in a study of alternative medicine? To date, the focus has mostly been on testing the physical remedies by themselves—divorced from any other portion of a typical alternative-care visit—with studies clearly showing that the exact emplacement of needles or the undetectable presence of special ingredients in homeopathic water isn’t really having any significant physical effect on the patient.
But what’s the sham treatment for being a caring practitioner, focused on getting a patient to adopt healthier attitudes and behaviors? You can get every practitioner in each of the study groups to try to interact in exactly the same way with every patient and to say the exact same things—but that wouldn’t come close to replicating what actually goes on in alternative medicine, where one of the main points is to customize the experience to each patient and create unique bonds. “We have to be careful about allowing presumed objective scientific methods to trump all aspects of human experience,” says Clifford Saron, a neuroscientist at the University of California at Davis who studies the effect of meditation on the brain. “Instead, science has to learn to listen in a sophisticated way to what individuals report to us, and relate those findings to other kinds of knowledge obtained from external measurements.”
The University of Maryland’s Berman suggests that other types of studies may do a much better job of demonstrating what alternative approaches can or can’t accomplish. He’s undertaking “cluster care” studies, for example, which attempt to carefully compare how patients fare at different care facilities, and he thinks these studies might offer convincing proof that with certain types of patients, integrative clinics can get better outcomes than their mainstream counterparts. Steven Novella decries such suggestions. “The randomized controlled trial has been the standard of evidence in medicine for a long time,” he told me, “and it’s nonsense to claim that we have to lower our standards just to find some way to justify alternative medicine. It’s just a fallback position for the alternative-medicine community, after its complete failure to prove its treatments work in good studies.”
And yet the question of whether the benefits of the “touchy-feely” aspects of alternative medicine can be proved in randomized trials seems strangely beside the point. That’s because just about everyone in medicine, including hard-core critics like Novella and Steven Salzberg, already believes that a more caring practitioner who takes more time and bonds better with patients is an enormous boon to health. “Of course it benefits patients to have a practitioner who spends more time with them, and listens more carefully to them,” says Novella. He agrees that a caring, bonding practitioner is more likely to get patients to adopt healthier lifestyles, and that these changes lead to better health. And he agrees that many patients do feel better when practitioners actively try to help them deal with vague, hard-to-diagnose complaints such as pain and fatigue, instead of telling them that there’s no diagnosis or effective treatment.
But like most alternative-medicine critics, Novella claims that these aspects of a better patient-practitioner relationship should not be uniquely associated with alternative medicine. Instead, these critics say, we should look to our doctors to be the nurturing caregivers who take the time to listen to us, bond with us, and guide us toward healthier lifestyles and lower levels of stress. “I try to do that with my patients,” Novella told me. Does he think most doctors do? “No,” he said, after a moment. “I have the luxury of taking time with my patients because I’m at an academic medical center. There are things in the system that have to be fixed before most doctors could do that too.”
Every single physician I spoke with agreed: the current system makes it nearly impossible for most doctors to have the sort of relationship with patients that would best promote health. The biggest culprit, they say, is the way doctors are reimbursed. “Doctors are paid for providing treatments, not for spending time talking to patients,” says Victor Montori, an endocrinologist at the Mayo Clinic. A medical system that successfully guided patients toward healthier lifestyles would almost certainly see its cash flow diminish dramatically. “Last year, 75 percent of the $2.6 trillion the U.S. spent on health care was for treating chronic diseases that, to a large degree, can be prevented or reversed through lifestyle change,” says Dean Ornish of UCSF. Who (besides patients) has an incentive to make changes that would remove that money from the system?
With systemic costs in mind, it doesn’t even really make sense to ask physicians—who, after all, spend hundreds of thousands of dollars and a decade of their lives becoming trained in anatomy, biochemistry, high-tech diagnosis, pharmacology, and more—to spend long blocks of time bonding with patients. Other sorts of professionals could be better at the healing, bonding, and placebo-selling part, and for less money. These might include behavioral-medicine therapists, social workers, nurse practitioners, or even some entirely new sort of practitioner specially trained for the task—and working alongside or under the direction of a conventional physician, who could continue to focus on quickly prescribing conventional tests, drugs, and surgeries when they were specifically called for.
Of course, the result wouldn’t be much different from what one already encounters in an integrative clinic like Berman’s. If an alternative practitioner is also an M.D. or works in conjunction with one, it’s hard to see what’s being risked. The biggest catch is likely to be that insurance won’t cover most visits, leaving many patients with the difficult choice of paying out of pocket or seeing a covered doctor who doesn’t have much time for them.
Rather than going ballistic when they hear that patients believe themselves to benefit under the care of alternative practitioners, argues the Mayo Clinic’s Victor Montori, doctors ought to be praising, or at the very least tolerating, alternative medicine for the way it plugs gaping holes in modern medicine. “Who cares what the mechanism is?” he says. “The patient will be healthier.”