The Sacred Nature of the Doctor-Patient Relationship

Mark Gignac, ND, FABNOSeattle Cancer Treatment and Wellness Center

OncANP ConferenceFebruary 2015

Looks good on paper…

• US and Canadian law considers the doctor-patient relationship fiduciary

• Physicians are expected and required to act in their patient’s best interests, even when those interests may conflict with their own

• What is in the patient’s best interests?

• Who determines this?

What is a Patient?

“one who suffers”

Latin – patiens (to suffer, endure)

Greek – páskhein (to suffer)

Person receiving tx

Who is the Person “who suffers”?

What is a Doctor?

What is a “Real” Doctor?

Whose Doctor is it anyways?

Vis Medicatrix Naturae The Healing Power of Nature

“Nature is the best physician” -Hippocrates (460-370 BC)-

Nature - derived from Latin word natura • birth, essential qualities, innate disposition

Natura – from the Greek word physis• essence or principle of growth • life’s internal principle of organization

milieu intérieur – environment within“the terrain is everything!”

Claude Bernard – 1865

HomeostasisNamed by Walter B. Cannon in 1926

The Wisdom of the Body (1932)

“All that I have done thus far in reviewing the various protective and stabilizing devices of the body is to present a modern interpretation of

the natural vis medicatrix.”Walter B. Cannon, PhD

Walter B. Cannon, LJ Henderson and the Organic Analogy

Osiris 1987;3:165-192

“What we observe is not Nature itself,

but nature exposed to our line of questioning”

-Werner Heisenberg-

Asclepius

• “God” of Medicine in Greek mythology

• Son of Apollo

• Raised and mentored by Chiron in the Art of Medicine

“the measure of all things…”

Current Scientific Worldview

• Reductionism• Scientific Materialism

Francis Crick (1995)The Astonishing Hypothesis

Stephen Hawking (2010)The Grand Design

Evolution of Medicine (1)

0. Superstition

1. Mechanical • reductionistic/deterministic (body as

machine)

2. Mind-Body • “mind” (thoughts, feelings, beliefs) has

causal powers solely within the individual

3. Non-Local • Consciousness/mind (2) can produce

positive or negative effects within and between persons

History of Present Illness

• Imhotep (2600 BCE)

• Hippocrates (460-370 BCE)

• Renaissance (1350-1550)

• Scientific Revolution (1543-1727)

• Descartes (1596-1650) - mind/brain – body split

• Biomedical Revolution (body as machine)

• Freud and Psychosomatic Medicine (1)

• Mind-Body Medicine

Brief History of Mind-Body Medicine

1890 - Ian Pavlov (classical conditioning) • Dogs - bell ringing + food = salivation

1926 - Serge Metalnikov (Pasteur Institute)• Skin scratching guinea pigs + injection of bacteria

= immune response

1974 - Robert Ader, PhD• Taste aversion experiment with saccharine and

Cytoxan in rats (1) (2)

1985 - Candace Pert, PhD• Neuropeptide-specific receptors present on cell

walls of both brain and immune system (3)

Voodoo DeathWalter B. Cannon

Amer Anthropol 1942;44(2):169-181

Psychogenic death by “the fatal powers of the imagination”

For a voodoo death to become a reality, the following must happen:

1. Belief (victim must believe in harm caused)

2. Attitude of helplessness is essential

3. Social Pressure and reinforcement

StressHans Selye, MD (1907-1982)

• Effects of General Adaptation Syndrome first discussed by Selye in 1936A Syndrome Produced by Diverse Nocuous Agents

Nature 1936;138(3479:38

• First used the term Stress in 1950 (1)

• First to discuss the HPA AxisPhysiology and Pathology of Exposure to Stress

H. Selye 1950 (1025 pg)

• Bad stress = Distress / Good stress = Eustress

When Stress can make you sick

1. Loss of control or predictability2. Absence of outlets of frustration3. Absence of social support4. Perception of events worsening

Manipulation of any of the psychological variables can result in dramatic changes in physiologic and pathophysiologic responses in animals exposed to identical physical stressors (1)

Placebo Response – An Inconvenient Truth

• First documented medical use (1785)

Thought to bring only comfort

• First placebo controlled trial in 1801 (1)

• 1955 – Henry Beecher reviewed 15 placebo controlled trials – ave 35.2% (2)

• Walter Kennedy – Nocebo Response “placebo’s evil twin” (3)

In 1807 Thomas Jefferson, recording what he called “the pious fraud,” observed that,

“one of the most successful physicians I have ever known has assured me that he used more

bread pills, drops of colored water, and powders of hickory ashes, than all other

medicines put together.”

The Writings of Thomas Jefferson (edited by PL Ford, version 9) New York: GP Putnam’s 1898

Language and CultureMedicine or Poison?

Relationship between language and disease

• Illness as a distinct entity rather than aspect of bodily function

• Use of nouns rather than verbs to express illness

Language as illusion

• Tumor is only a side effect of cancer, not its cause

• Removing the gross physical manifestation of disease. Is this a cure?

Cancer as Metaphor (1,2)

• War is the dominant metaphorWinning the war, loosing the battle, instinct to fight, therapeutic armamentarium, magic bullet…

• Benefits and limitations

• Conceptual weakness

“Beliefs are contagious”-Bertrand Russell-

Meme – unit of cultural info that propagates from one mind to another analogously to the way in which a gene propagates from one organism to another• Word coined by Richard Dawkins

The Selfish Gene (1976)

Culture Bound Syndromes (DSM V) (1)

• Combination of psychiatric and somatic sx’s• Only found within a specific culture (ex. Susto)• No objective structural or biochemical

alterations

Cognitive Dissonance

• 1957 – Leon Festinger, PhD

• Denial

• Confirmation bias

• Mental stress or discomfort experienced by an individual who holds two or more contradictory beliefs, ideas, or values at the same time, or is confronted by new information that conflicts with existing beliefs, ideas, or values

Factors common to all successful healing encounters

…from Shaman to 21st century Oncologist

1. Generation of Hope

2. Shared belief system

3. Emotionally charged, confiding relationship

Persuasion and HealingJerome Frank, MD, PhD (1961)

The Doctor, His Patient and The Illness (1957)

-Michael Balint, MD-

“The most powerful therapeutic tool the doctor possesses is him/herself”

• Medical degree in hungry in 1918• PhD in Biochem while working in lab of Otto

Warburg while also working half-time at the Berlin Insitute of Psychoanalysis

• 1968 – President of British Psychanalytical Society

“Besides the materia medica, the patient’s mind, cognitions, and emotions play a central

part as well in any therapeutic outcome..”

“It is not surprising that a crucial element that triggers the placebo response comes from the

very special social encounter between the patient and his/her doctor.”

Placebo and the New Physiology of the Doctor-Patient Relationship

Physiol Rev 2013;93(3):1207-1246

“Words are powerful tools in the doctor’s armamentarium, having both healing as well as harming effects. Doctors need to be conscious

about the choice of their words.”

“Creative psychopharmacotherapy involves personalization and maximization of the placebo

response and minimization of the nocebo response in order to increase treatment effectiveness and treatment efficacy.”

Qualitative study of Nocebo Phenomenon (NP) involved in doctor-patient communication

Int J Health Policy Manag 2014;3(1):23-27

“Healing is not a relationship between an expert and a problem. It is the outcome of

the meeting of two whole people who recognize the potential in their

relationship to exceed the limitations of both science and disease.”

-Rachel Naomi Remen- 2008

“One of the essential qualities of the clinician is interest in

humanity, for the secret of the care of patients is in caring for the

patient” (1)

-Francis Peabody, MD-JAMA 1927;88:877-882

“The physician’s duty is to cure occasionally, relieve often, console

always”-Hippocrates-

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“It is more important to know what sort of person has a disease than to know what

sort of disease a person has”-Hippocrates-

“The physician should not treat the disease, but the patient who is suffering

from it”-Maimonides- (1135-1204)

“The practice of medicine is an art,based on science”

William Osler, MD

“Spirituality is a set of beliefs and attitudes that give meaning and purpose to life through a sense of connectedness to self, others, the

natural environment, a higher power and/or supernatural forces. These beliefs and attitudes

empower and transcend the self and are embodied in feelings, thoughts, experiences and

behaviors.”

Int J Gyn Cancer 2005;15:755-761 (1)

“The world is full of suffering but it is also full of the overcoming of it”

-Helen Keller-

Hope appears in Greek mythology as the story of Zeus, Prometheus and Pandora

What is false hope?

“Why should we try to authorize hope according to the statistics….?

WHY?Personal thoughts and reflections…

Existential distress. Why me? Why now?

Schrodinger’s Paradox• Life evolves to higher and higher orders of

complexity. This seems to violate the 2nd Law of Thermodynamics

• What is Life (1944)

Ilya Prigogine, PhD – captivated by the problem of explaining how ordered structures (biological systems) develop from disorder

Health as Expanding ConsciousnessMargaret Newman, RN, PhD

• Health is a unitary pattern that encompasses both disease and non-disease

• Disease / disruption can be seen as part of the self-organizing process leading to higher consciousness

• Importance of “meaning”

The Evolving Self (1982)Robert Kegan, PhD

• The disease process may represent a loss of meaning in the service of a new higher meaning

• Disease process can be seen as an attempt to make more meaning

The Wounded Healer

“The doctor is effective only when he himself is affected. Only the wounded physician heals”

-Carl Jung, MD-

• Greek myth of Chiron• Accidentally inflicted with a

permanent wound• By way of overcoming the pain of

his wounds, Chiron became the compassionate teacher of healing