Perspectives in Biology and Medicine

Over 200 years ago, doctors' most effective tools were typically not found in their medical bags. Indeed, most treatments in the history of medicine have, until relatively recently, caused more harm than good. Prior to the biomedical revolution in the late 19th century, doctors' most reliable and effective instruments of healing were their skills of communication with patients and an aptitude for a positive and supportive bedside manner. Bearing out this portrait of medicine, Thomas Jefferson, writing in 1807, noted 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 powers of hickory ashes, than of all other medicines put together" (qtd. in De Craen et al. 1999, 511). Jefferson referred to these skills of beneficent persuasion as a "pious fraud." Exactly one hundred years later, in 1907, Mark Twain drew similar observations: "Physicians cure many patients with a bread pill; they know that where the disease is only a fancy, the patient's confidence in the doctor will make the bread pill effective."

Two major developments would downgrade the value of the interpersonal, doctor-patient relationship in professional medicine. The first development was the biomedical revolution. A wave of scientific medical success stories during the latter half of the 19th century would lead to a substantially more effective and reliable treatments and techniques than doctors had ever before employed. Encompassing a range of significant developments for public health and medical [End Page 349] care, the biomedical revolution included the emergence of the germ theory of disease, the use of anesthetics and antiseptics in surgery, and the development of vaccines. One consequence of these developments was the incorporation of determinedly scientific tools and training into biomedical education and clinical practice, with the result that the value of interpersonal, healing relationships between doctors and patients was devalued. In keeping with this idea, the Father of Modern Medicine, Canadian physician William Osler (1849–1919), acclaimed for putting medicine on a scientific footing and reforming medical education, taught that the temperament of the physician ought to be one of "detached concern." Emphasizing the medical virtue of "Aequanimitas," Osler placed a premium on scientific objectivity and a composed, steady, "clinical" demeanor in all patient interactions.

The second major development that indirectly devalued interpersonal doctor-patient interactions occurred in the mid- to late-20th century: the emergence of the randomized controlled trial (RCT). The goal of RCTs is to evaluate whether a drug or intervention is effective. Patients are randomly allocated to one of two groups: the "verum" or treatment that is under scrutiny, and a control group. The control group may receive no treatment or a placebo: the placebo is intended to serve as a yardstick; the goal is to eliminate all of the therapeutic "noise" that can arise when patients enroll in clinical trials, including any salubrious effects of healing rituals, medical paraphernalia, or the positive effects of interacting with health-care practitioners, as well as the natural progression of illness.

Even when the placebo pill or treatment is a sham, patients may experience health benefits from their participation in clinical trials. However, RCTs—the gold standard of clinical research—seek to determine whether the treatment under scrutiny is effective over and above any positive effects of participating in trials, and of receiving placebo interventions. They therefore aim to eliminate the effects of human interactions, thus indirectly (and perhaps ironically) further discrediting, or at least distracting from, the potential therapeutic value of doctor-patient interactions, including factors associated with the context of care.

However, somewhat paradoxically, RCTs have also helped identify the importance of placebo effects in such a way as to make them a respectable subject for study. The same experimental design of the typical RCT, which is used to test for the effectiveness of an innovative treatment, can be likewise deployed to the comparison of a placebo and a no-treatment group. One goal associated with this research is to harness the significant medical effects of the social practices of doctor-patient interactions to improve patient...