NCCIH Research Blog

The COVID-19 crisis has rapidly altered the nature of the patient–health care provider interaction. To mitigate disease transmission, many appointments have shifted from in-person to telemedicine. Clinicians have also had to wear protective gear, which has changed rituals and communication styles during patient encounters. These developments prompt us to reflect on the relationship between patients and their health care providers, including integrative medicine practitioners, and how their interaction and context impact health outcomes.

The patient-provider relationship is a complex, multifaceted framework whose components include expectancy, perceptions, beliefs, conditioning, practitioner attention, support, rituals, placebo effects, and communication styles. The National Center for Complementary and Integrative Health (NCCIH) Strategic Plan for 2016 to 2020 included an objective to conduct basic and clinical research to understand the role of nonspecific effects and whether they can enhance pain management. NCCIH remains interested in funding research in this realm.

Among the Center’s grantees in this field is Vitaly Napadow, Ph.D., L.Ac., an investigator at Massachusetts General Hospital who used a novel magnetic resonance imaging (MRI)–based approach to image the brains of patients with fibromyalgia and their acupuncturists during treatment. NCCIH’s summary of the study notes that harmony in both behavior and brain circuitry may contribute to pain relief associated with the patient-clinician interaction. Such effects may be mediated through brain regions involved in empathy and theory of mind (i.e., inferring the mental state of others). Also, greater concordance (or synchrony) between patient and practitioner in the brain’s temporoparietal junction was associated with stronger pain relief. Each group’s scores of therapeutic alliance—the working relationship or positive social connection between a patient and a practitioner—were higher when the practitioner had provided consultation before the procedure, compared with a simple introduction.¹ 

NCCIH has also supported research at Harvard University’s Program in Placebo Studies & Therapeutic Encounter, led by its director, Ted J. Kaptchuk. One of the innovative lines in Professor Kaptchuk’s research has been “open-label placebos”—i.e., inert substances prescribed transparently to patients, with no concealment or deception. Some small pilot or feasibility trials conducted by his group found such placebos brought significant symptom relief in irritable bowel syndrome, chronic low-back pain, migraine, cancer-related fatigue, and osteoarthritis knee pain.²  

Another NCCIH grantee, Alia Crum, Ph.D., of Stanford University, received an NIH High-Risk High-Reward Research grant to investigate how changes in mindsets—the lenses through which information is perceived, organized, and interpreted—can impact health outcomes through behavioral, psychological, and physiological mechanisms. Dr. Crum’s work is, in part, inspired by research on the placebo effect. In one of her recent papers, she and her colleagues constructed a framework for providers to boost placebo responses in the patient-provider interaction using nondeceptive and ethically appropriate strategies.³ 

As we continue to fund research on the patient-provider relationship, we hope it will result in practical considerations for all health care providers. I encourage investigators who are interested in conducting research in this realm to contact NCCIH program staff to discuss their potential projects before they apply for funding.

For More Information

• View a brief Q&A with Professor Kaptchuk about placebos, the placebo effect, and the therapeutic encounter.
• View a presentation at NCCIH by Dr. Crum on her research. 

¹ Ellingsen D-M, Isenburg K, Jung C, et al. Dynamic brain-to-brain concordance and behavioral mirroring as a mechanism of the patient-clinician interaction. Science Advances. 2020;6(43):eabc1304.

² Kaptchuk TJ, Hemond CC, Miller FG. Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice. BMJ. 2020;370:m1668. 

³ Howe LC, Leibowitz KA, Crum AJ. When your doctor “gets it” and “gets you”: the critical role of competence and warmth in the patient-provider interaction. Frontiers in Psychiatry. 2019;10:475.