CHAPTER 3: PATIENT SATISFACTION, THE ROLE
OF THE THERAPIST AND THE PLACEBO RESPONSE
3.1 Much of our evidence, including that given by
the Consumers' Association and the Patients' Association, has
suggested that patients' satisfaction with their CAM treatment
is high and is likely to account in part for a significant proportion
of the high level of CAM use. During the course of our Inquiry
the Committee met several patients of CAM practitioners (at the
Marylebone Health Centre and at the Southampton Centre for Complementary
Health Studies - see Appendices 4 and 5), all of whom expressed
high levels of satisfaction with the CAM treatment they had received.
We also received many written letters of support for CAM by patients.
We did not in fact hear directly from any patients who were unhappy
with treatment they had received from a CAM practitioner. The
high satisfaction shown by CAM patients suggests that the reasons
given (in paras 1.24-1.28) for accessing CAM are largely justified
in the event, and the conditions for which they seek help are
indeed often relieved, as Zollman and Vickers stated in an article
in the British Medical Journal last year.
3.2 During the our visit to Exeter University (see
Appendix 3), Professor Edzard Ernst referred to a project his
department had carried out, which compared satisfaction levels
with CAM to satisfaction levels with conventional medicine, amongst
arthritis sufferers who had experienced both types of treatment.
This work suggested that many CAM therapists were more friendly,
spent more time with the patient and were more forthcoming with
information on the treatment and the disease. Some patients also
perceived CAM as giving slightly more efficacious treatments.
3.3 Evidence we heard from the Consumers' Association
identified several reasons for high patient satisfaction with
CAM. They concluded that patients appreciate CAM's emphasis on
a person's overall well-being, and also suggested that the CAM
consultation may be more satisfying to patients as it is longer,
and CAM practitioners tend to have very good communication skills
which put patients at ease. The Consumers' Association had conducted
a survey in 1997 which showed that for therapies such as yoga,
aromatherapy, massage and reflexology, people experience general
life-style benefits just from the experience of taking part in
the therapy (Q 829).
3.4 Submissions from the Royal College of Physicians
(P 189) and the UK Cochrane Centre (P 223) both suggest that CAM
consultations not only take more time, but are more thorough and
more detailed than conventional medical consultations, especially
in primary care. They also tend to include active listening techniques
and demonstrate interest in the whole of the patient's life, not
just in their physical health. Such factors may well contribute
to higher levels of patient satisfaction with their treatment.
Increasing pressures on conventional medical practitioners in
an understaffed NHS are felt to be an important contributory factor.
3.5 Zollman and Vickers
gave several explanations for the popularity of CAM. It was suggested
that the "
specific effects of particular therapies
obviously account for a proportion of patient satisfaction, but
many patients also value some of the general attributes of complementary
medicine." These 'attributes' include those mentioned above
but also add: the attention to personality and personal experience,
the increased amount of patient involvement and choice, the increased
levels of hope often provided by the holistic approach, the more
human experience of healthcare (which comes from the increased
amount of touch and 'low tech' equipment used in CAM), and the
fact that CAM often specialises in dealing with ill-defined symptoms
that conventional medicine sometimes is unable, or unwilling,
to tackle. Finally they suggest that the holistic approach often
provides a means of making sense of illness in a context that
is more understandable and personally relevant to the patient.
3.6 HealthWatch (P 123) has suggested that one reason
for patient satisfaction is that most CAM practitioners work in
private practice and therefore have more time and greater resources
with which to help their patients. Several CAM practitioners and
HealthWatch (P 123) propose that CAM may function better in the
private sector, as the experience of paying for healthcare increases
patients' involvement in their own recovery and provides additional
motivation. This may lead to greater treatment compliance and
a greater degree of satisfaction.
3.7 Looked at altogether this evidence identifies
several factors considered by many to contribute to patient satisfaction
with CAM. The holistic approach of CAM, the individual emphasis,
the greater time spent on patients by practitioners, were all
very popular reasons given by witnesses for patient satisfaction.
However, Dr George Lewith, head of the Centre for Complementary
Health Studies in Southampton told us, during our visit, that
no empirical evidence has shown that issues such as time account
wholly for patient satisfaction. Therefore, no firm conclusions
on the reasons behind patient satisfaction with CAM can be drawn
until studies are conducted on this issue. We assume that time
is an important factor but it is also likely that quality and
not just quantity is important in relation to consultations. Although
patient satisfaction may be a component of well-being and a marker
of health itself, it is not necessarily a clear reflection of
a treatment's clinical efficacy. The placebo effect can have a
large role in patient satisfaction as can many of the factors
discussed above. The role of patient satisfaction as a component
of efficacy will be considered later in this report (see paras
4.24-4.27) as will the role of the placebo effect in CAM and conventional
medicine (see paras 3.19 - 3.34).
3.8 Some of the areas identified above as strengths
of CAM are fields which conventional medicine, as currently practised,
has difficulty in handling. Constraints on time and other pressures
on the NHS, and the reliance on drug prescribing in conventional
medicine, have eroded the time patients spend with doctors and
has tended to lead to a forced discussion of 'the problem' rather
than also embracing the context in which the problem needs to
be considered. This can lead to the patient feeling that the doctor
has not paid him or her much attention or taken time to understand
fully what is wrong with them.
3.9 The Consumers' Association suggested that one
reason patients turn to CAM is the welcome that they receive from
CAM as opposed to conventional medicine. The NHS has long waiting
lists for out-patient appointments in secondary care, and there
is a common impression among patients, even in primary care (with,
on average, seven-minute consultations throughout the NHS) that
the doctor's time is precious and must not be wasted. In comparison,
CAM therapists are numerous and often easy to access; they are
very welcoming to patients, positively encouraging long consultations.
The Consumers' Association also suggest that some CAM therapists
work in more pleasant environments, and patients appreciate the
better, and often more relaxing, quality of their surroundings.
The Consumers' Association made the point that people hate to
give up hope of getting better when they are ill; therefore if
conventional medicine fails to provide a cure, they are likely
to look elsewhere in the hope of finding a solution (Q 828).
3.10 Patients are also becoming increasingly aware
of, and concerned about, the side-effects of conventional medical
treatment, and particularly those of potent drugs. This is a problem
the Faculty of Homeopathy, which represents medical practitioners
who also practise homeopathy, told us they were very well aware
of (P 81). The risk of iatrogenic
disease is therefore another reason why patients may try to find
alternatives to conventional therapy.
3.11 It can be concluded that there are some factors
in conventional medicine that lead patients to turn elsewhere
to find the type of treatment to which they aspire. The Consumers'
Association evidence points out that it is not invariably a matter
of patients turning their back on one mode of treatment and replacing
it with another. They suggest that the Government and the NHS
are currently emphasising self-treatment of minor ailments, if
only because of the inadequate numbers of doctors in all branches
of medicine, and patients are increasingly taking on their rights
and responsibilities and are choosing treatments that they feel
are right for them. Therefore it is likely that the increased
use of CAM is a result of patients using a 'pick and mix' combination
of treatments rather than a sign of rejection of one school of
medicine for another (Q 828). The Astin Survey, discussed above
(see para 1.24) would appear to support this conclusion.
3.12 Whether this is true or not it is clear that
conventional medicine as presently practised may lack something
so that some patients are left feeling that not all their needs
have been met. This factor, coupled with developments such as
the Internet and the increased emphasis of consumer involvement
in all service areas, has led to patients being increasingly aware
of their options and responsibilities.
The Role of the Therapist
3.13 Many of our witnesses, both from conventional
and from complementary backgrounds, have suggested that the consultation
styles of CAM practitioners may play a large role in determining
patients' satisfaction with CAM treatment. Many of our witnesses
also cited difficulties with the relationship between conventional
practitioners and their patients, as well as the limited amount
of time conventional practitioners have for their patients, as
reasons why many patients are turning to CAM. However, little
work has been done on this topic.
3.14 During the course of our Inquiry several witnesses
drew our attention to Complementary Medicine: A Research Perspective.
This book includes a chapter on the consultation styles of conventional
and complementary practitioners which reviews the few studies
that there are in this area.
3.15 The work of one researcher in this area, Taylor,
is reviewed in Vincent & Furnham's book. Taylor's work investigates
the changing nature of the conventional medical encounter in the
United Kingdom. Taylor suggests that in the last thirty years
the consumer movement, the increased sense of entitlement and
general demands for professional reform and accountability, have
put pressure for democratisation and attention to customer service
on the medical profession. However Taylor's work suggests the
medical profession has resisted change and that there has in fact
been a deterioration in the customer service side of the medical
encounter. Several reasons are suggested for this:
- The increased threat of malpractice suits has
made doctors more cautious and less relaxed with patients.
- There are fewer general practitioners and more
specialists so a long-term doctor-patient relationship is less
- Patients find changing doctors and getting second
opinions a struggle and so feel they have no 'exit' option within
the medical encounter.
- Patients feel doctors insist on clinical autonomy
and they perceive a refusal to share information.
- Increased administration within the health service
makes patients feel as if more attention is being paid to 'processing'
them than appreciating their individual patterns and matching
treatment to them.
- Increasing costs and rationing of services has
led to feeling that services are being withdrawn.
3.16 These factors are coupled with the fact that,
through high-profile medical advances, conventional medicine has
acquired great power, prestige and influence, leading to even
greater demand for services. This contributes to a vicious circle,
whereby patients are demanding more, and feeling as though they
are receiving less.
3.17 Vincent & Furnham's book goes on to review
the characteristics of the CAM practitioner-patient relationship.
They review the work of Kleinman
who suggests that although most CAM therapies do not share a common
theoretical basis what they do share, which distinguishes them
from conventional medicine, is an emphasis on the subjective experience
of the patient and a focus on the whole patient, not just the
disease. Kleinman suggests that there are several areas where
CAM consultation styles may prove more attractive than those of
conventional medicine. These are:
- Emphasis on overall experience of illness - CAM
therapists often take into account social issues during their
assessment of a patient, whereas some conventional medicine increasingly
focuses on the individual patient and the specific complaint and
bodily organ, or organs, involved. As patients will experience
their problem in the context of their family and work etc. and
may even see these things as the cause of their problems, they
may prefer the CAM approach.
- Simple language - The language of conventional
medicine has become increasingly technical and hard for patients
to understand. CAM practitioners are more likely to use everyday
- Lay explanations - CAM explanations for disease
are often easier for a patient to understand than the more technical
conventional medical explanations. CAM explanatory models are
also more likely to consider factors such as emotional and social
factors in disease and so will be concerned with the patient's
overall experience. This may lead to circumstances where there
is a better fit between patient's view and the views of CAM practitioners.
- Illness without pathology - Patients sometimes
feel that something is wrong but are told after a physical examination
by a conventional medical practitioner that nothing can be found
to support their claims of illness. However, in many cases they
continue to feel unwell. Complementary practitioners are often
more willing to diagnose and treat such symptoms and to provide
an explanation which will be more satisfactory for the patient.
3.18 Another study is discussed in Vincent &
Furnham's book, which shows that a doctor's consultative style
can have considerable immediate, intermediate and long-term outcomes
on patient health. Three communication variables have been found
to have importance in the consultation: creating a good interpersonal
(trusting, warm, open) relationship; the clear and comprehensible
exchange of information; and skill in making treatment-related
decisions. The study that identified these variables also identified
four major medical outcomes that these variables affect: overall
satisfaction; compliance and adherence to a treatment programme;
the recall and understanding of exchanged information; final health
status; and psychiatric morbidity.
This work suggests that the communication styles of CAM therapists,
in comparison to conventional therapists, may play a significant
role in determining patient satisfaction with CAM. There are two
important implications that arise from this. Firstly, CAM research
must take into account the potential effects of the patient-practitioner
relationship and not side-line it as an incidental factor or a
complication in research (see Chapter 7). Secondly, conventional
medicine and the NHS may learn from CAM's strengths in this area.
It is important to note that many practising medical practitioners
possess and are taught exactly those communication skills and
appreciation of the emotional and social factors which cause or
influence disease, but may be prevented from deploying these skills
fully because of pressures and constraints of time. It is widely
accepted that some of the most intractable problems which patients
present to doctors, often expressed as "illness without pathology"
(see above), have a psychological or social basis of which the
patient (and sometimes the doctor) may not be fully aware, or
which they may be unable to acknowledge.
3.19 Psychological factors not only play an important
role in giving rise to symptoms but also in determining a patient's
response to a treatment. Studies have shown that patient expectations
concerning a treatment, patients' experience of the treatment
and patients' attitudes towards their healthcare provider can
all affect the impact a treatment has. Such factors as these can
all be brought together under the term 'the placebo effect'. The
placebo effect has been described as the therapeutic impact of
'non-specific' or 'incidental' treatment ingredients, as opposed
to the therapeutic impact that can be directly attributed to the
specific, characteristic action of the treatment. However, the
placebo effect has often in the past had a negative stigma attached
to it, and has often been considered either as a nuisance which
hampers research, a sign of patient neuroticism, or a sign of
3.20 The placebo effect is known to permeate all
areas of healthcare. Professor Tom Meade of the Royal Society
articulated this for us: "...we all recognise the strong
placebo effect in, probably, all aspects of medical treatment,
whether they are conventional or not" (Q 155). However, it
has been suggested by some of our witnesses that the placebo effect
may be responsible for much of the apparent benefit of CAM therapies
which have no other understandable mechanism of action through
which they may affect the body. Before considering this further
it is worth considering the complicated history and definition
of the placebo effect. Only recently has it begun to be considered
in a more positive light.
3.21 The placebo effect is nothing new, nor are attempts
to enhance its effect unconventional. In fact the history of conventional
medicine has largely been the history of the placebo effect. Vincent
& Furnham's book also has a chapter on this subject, written
by Phil Richardson who reviews some interesting studies. Most
medicines used by doctors up until the 20th Century are now known
to be inert, but they were often of exotic origin and thus were
often perceived as having magical properties. Even today part
of the conventional doctor's armoury may include inert capsules
and sugar pills. In fact one study showed that 80 per cent of
US hospital clinicians admitted to the occasional use of placebo
medicines in routine clinical practice (Gray & Flynn, 1981).
The reasons these doctors gave for this practice were concerned
with deflecting the focus of the demanding patient and proving
that the symptom thereby reduced was psychogenic and not of organic
3.22 However, some would argue that these reasons
demonstrate only a limited knowledge of relevant empirical findings.
All treatments, physically active or otherwise, have a psychological
impact when administered to a conscious patient. It is possible
that this psychological effect should not be considered as a nuisance
that hampers research or some kind of fraud, but an essential
element of any holistic therapy. It could even be suggested that
the placebo effect is a legitimate form of psychotherapy.
3.23 Many studies have been conducted where placebo
treatments have been compared to no-treatment controls. Evidence
from a wide range of studies indicates that placebo therapies
in the context of conventional medicine can provide some relief
from a huge range of conditions including allergies, angina, asthma,
some forms of cancer, cerebral infarction, depression, diabetes,
epilepsy, multiple sclerosis, ulcers and warts. Placebo responses
have also been found to vary enormously from 0 -
100 per cent even for the same condition.
3.24 In the past the placebo effect has often had
negative connotations as a worthless by-product of a treatment,
notable only in that it complicates research design. As more evidence
on this subject becomes available it may be considered that the
term placebo effect is unhelpful because it embraces a number
of disparate phenomena that are poorly understood. Evidence from
placebo studies has provided ammunition to contradict the claim
that the placebo effect can be attributed to the patient's wish
to please the doctor by reporting symptom relief. Research shows
the placebo effect has a measurable effect on objective measures
such as blood pressure, post-operative swelling and gastric mobility
In addition, there is increasing evidence of a neuro-effector
mechanism ("mind over matter") which can influence significantly
the immune system. In drug action trials there are sometimes even
difficulties in differentiating placebos from the active agents
that they are being compared with; several studies have shown
parallel time-effect curves and dose-response relationships.
3.25 Studies in this area clearly show that the psychological
impact of any treatment is potentially great. Comparing placebo
groups to no-treatment groups does not rule out the possibility
that the placebo effect is due to data distortion on the part
of therapists, or even the possibility that results are affected
by patients with high expectations or a desire to please the doctor.
This is because it is very hard to blind patients to the simple
fact that they are receiving treatment. However this does not
explain changes in objectively measured physiological processes,
and thus it seems there is a psychologically-mediated physical
effect of most treatments.
3.26 Many studies in this area have looked into whether
there are particular patient variables that increase the likelihood
that an individual will exhibit the placebo effect. Although such
studies have looked into a multitude of factors including sociological
factors such as age, gender, ethnicity, educational level and
intelligence, and personality factors such as extroversion and
suggestibility, they have yielded weak and inconclusive results.
It seems that placebo responders cannot be characterised by this
type of variable. In fact evidence shows that people who are placebo
responders on one occasion may not be on the next: thus it is
not an enduring trait. Awareness of the fact that any patient
may benefit from the placebo effect might do much to de-stigmatise
it as a sign of patient neuroticism.
3.27 There has also been research on which therapies
produce the strongest placebo effect. More serious or invasive
procedures do seem to have greater placebo properties, with placebo
surgery yielding very high positive response rates. Treatments
that employ sophisticated technical equipment also enhance the
placebo effect. Research on therapist variables has shown that
those therapists who exhibit greater interest in their patients,
greater confidence in their treatments and higher professional
status, whatever their background of training, all appear to promote
stronger placebo responses in their patients. This work does not
entirely support the view that CAM's effects may be due to the
placebo effect. CAM is not generally highly invasive, nor does
it tend to involve highly sophisticated technical equipment. However,
CAM therapists do seem to exhibit great interest in their patients
and confidence in their treatments. It is also possible that the
almost "magical" approach of some complicated and unusual
therapies may have a similar effect to highly sophisticated technologies
in inducing wonder in patients.
3.28 It is important to consider the possible modes
of action through which the placebo effect may operate. Professor
Patrick Bateson, Vice President of the Royal Society, explained
how psychological factors might affect physical health: "...when
somebody suffers chronic stress, bereavement or loses a job, under
those conditions they are much more prone to disease and more
likely to get cancer, and it is now believed that this is because
of suppression of the immune system, which is constantly cleaning
up bacteria and viruses and also cleaning up cells which are cancerous
cells. So if you do the opposite of that and give a patient some
reassurance, and if they are given a treatment which they believe
in, then this will enhance the immune response - it will remove
the stress which is causing the immune response to be suppressed
- and so that may be one rather powerful mechanism by which the
placebo effect works" (Q 155). However it is widely accepted
that the exact mechanisms of action are as yet not well understood.
Professor Timothy Shallice of the Academy of Medical Sciences
was one of several witnesses who acknowledged this gap in our
knowledge: "We would agree that the placebo effect is not
fully understood, but this is because essentially the higher cognitive
functions in general are not very well understood and the placebo
effect operates through belief and a whole series of mechanisms
on the body in general through the central nervous system"
3.29 Despite a lack of understanding of the exact
mechanisms through which the placebo effect may operate, research
clearly shows that the effect exists and can have a significant
impact on health. This work has important implications for anyone
who has identified a therapy which appears to be efficacious but
which does not have a clearly identified mode of action and it
is important that all research on such therapies takes account
of the placebo effect.
3.30 Research in this area, and evidence we have
heard, suggests that it may be over-simplistic, when evaluating
physical treatment methods, to ask whether the treatment is a
placebo or not. The more pertinent question will often be: "In
what proportion may the effects of this treatment be accounted
for by psychologically-mediated, as opposed to direct physically-mediated,
In the absence of direct evidence from placebo-controlled double-blind
it is proper to regard any new or unusual form of treatment as
potentially a form of psychotherapy. This is the reason why the
debate over the need for randomised controlled trials has become
a central debate in the CAM world
3.31 We have also considered the implications of
finding that any particular CAM therapy relies largely on the
placebo effect and has little or no treatment-specific effect.
Several of our witnesses have suggested this is a very important
question. Professor Tom Meade of the Royal Society summed up this
sentiment: "I think the important question is that if a CAM
is claiming that it has a specific value for a particular condition,
then it does have to be able to show that there is a treatment-specific
effect over and above the placebo effect. I think that is important
because, first of all, a lot of CAM is practised in private practice
at the moment, and people
are entitled to know how they are
spending their money. I think it is also important from the health
service's point of view, as various trusts and general practitioners
take CAMs up in increasing numbers (Q 155).
3.32 If a treatment makes people feel better, whether
that be through treatment specific effects or the placebo effect,
then it could be considered as being worthwhile. In fact, as the
placebo effect is not just an imagined experience but can positively
improve objective biological measures of health, then a treatment
which enhanced such an effect could even be considered worth attaining
in its own right. As well as stressing the need to prove treatment-specific
effects Professor Patrick Bateson, giving evidence with Professor
Tom Meade for the Royal Society, acknowledged that sometimes the
placebo effect may be worth attaining in its own right.
3.33 However, the idea that the placebo effect might
be something worth using as a treatment was not a majority opinion,
and Professor Timothy Shallice of the Academy of Medical Sciences
suggested that there is probably little justification for supporting
the wider advocacy of any technique that relies on the placebo
effect within the NHS "
since it depends so critically
on the particular beliefs of that particular person at that particular
time" (P 1403).
3.34 Professor Peter Lachmann of the Academy of Medical
Sciences elaborated on why treatments which work through the placebo
effect are not worth using as a treatment: "
it is not
surprising that therapies which have no pharmacological basis
but which affect mental state can stimulate the secretion of endogenous
opioids and other mediators that affect lymphocytes because they
also carry the relevant receptors. The fact remains that methods
of doing just this (for example jogging) are not used for treating
visceral diseases, nor are similar claims made for them. That
immune cells can be affected by neurological mechanisms is neither
unconventional nor terribly surprising" (Q 1413).
16 Zollman, C. & Vickers, A. (1999) 'ABC of Complementary
Medicine: Complementary Medicine & the Patient'. British
Medical Journal; 319 (1999) 1486-1489. Back
Resch, K., Hill, S. & Ernst, E. (1997) 'Use of Complementary
Therapies by Individuals with Arthritis'. Clinical Rheumatology;
Zollman, C. & Vickers, A. (1999) (Op.cit.). Back
The Oxford English Dictionary defines iatrogenic disease as "Med.
(of an illness or symptoms) induced in a patient as a result of
a physician's words or action". Back
Vincent, C. & Furnham, A. Complementary Medicine: A Research
Perspective (Chichester; Wiley & Sons; 1997) 119-121. Back
Kleinman, J. (1980) as cited in: Vincent, C. & Furnham,
A. (1997) (Op.cit.). Back
Ong, de Haes and Lammes, (1995) as cited in: Vincent, C.
& Furnham, A. (1997) (Op.cit.). Back
Gray & Flynn (1981) as cited in: Vincent, C. &
Furnham, A. (1997) (Op.cit.). Back
Ross & Olson (1982) as cited in: Vincent, C. &
Furnham, A. (1997) (Op.cit.). Back
Richardson (1989) as cited in: Vincent, C. & Furnham,
A. (1997) (Op.cit.). Back
Ross & Olson (1982) as cited in: Vincent, C. &
Furnham, A. (1997) (Op.cit.). Back
Richardson, P. (1997) as cited in Vincent, C. & Furnham,
A. (Op. cit.). Back
Trials in which neither the practitioner nor the patient are aware
of which treatment is being administered. In single-blind trials
only the patient is unaware of which treatment is being administered. Back