Fabrizio Benedetti - The Patients Brain: The neuroscience behind the doctor-patient relationship

The Patients Brain
The neuroscience behind the doctorpatient relationship

The Patients Brain
The neuroscience behind the doctorpatient relationship

Fabrizio Benedetti, M.D.

Professor of Physiology and Neuroscience

Department of Neuroscience

University of Turin Medical School

and

National Institute of Neuroscience

Turin, Italy

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To the memory of my mother

Contents

There is a vast amount of literature on what has often been called doctorpatient relationship, patientprovider interaction, therapistpatient encounter, and such like. This special, and indeed intriguing, social interaction has been analysed from different perspectives, so that today the medical, psychological, social, philosophical, and even socioeconomical and health-policy literature is full of accounts and essays that deal with this topic. Needless to say, this literature has provided valuable information to physicians, health professionals, psychologists, philosophers, and policymakers. Basically, what has emerged in the course of the years is that not only should health professionals develop and take care of their own technical skills, but that they also should strengthen their social skills in order to better interact with their patients. This might seem quite obvious indeed, nonetheless a large amount of scientific investigation has provided compelling evidence that not only is a good doctorpatient relationship desirable because politeness is better than rudeness, but also because the former may have beneficial effects on health, whereas the latter may lead to negative outcomes.

With the recent advances of neuroscience, I believe we are today in a good position to also describe and discuss the biological mechanisms that underlie the doctorpatient relationship. No attempt of this kind has been made thus far and the task is not an easy one. Many neuroscientific facts must be put into the context of the clinical setting, routine medical practice, social issues, and psychological theories, in order to provide evidence that the doctorpatient relationship can indeed be approached in neurobiological terms.

Neuroscience is a very broad discipline, and actually many sub-disciplines do exist, like molecular and cellular neuroscience, as well as cognitive neuroscience. Social and cognitive neuroscience are in a good position to tackle the doctorpatient relationship from a biological perspective, for many neurobiological underpinnings of complex social interactions have been unravelled in recent years and many neuroscientific hypotheses have been put forward. For example, we now know that different physiological and biochemical mechanisms take part in complex functions, like trust, hope, empathy, and compassion, which are all key elements in the therapistpatient encounter. If on the one hand the patient must trust and hope, on the other hand the therapist must be empathic and compassionate.

Neuroscientific facts should also be put into an evolutionary context. Neuroscience investigates biological systems, and any simple or complex neurobiological system is a product of evolution which has emerged in animals and humans with a precise and specific purpose. For example, brain circuits subserving trust have emerged in the course of evolution in order to strengthen social interactions. Trustworthy behaviour is a prosocial behaviour, and if the patient who seeks relief does not trust therapists and therapies, the doctorpatient encounter has no meaning to exist at all. Therefore, an evolutionary understanding of why and how these social mechanisms have emerged and have evolved is of paramount importance. They give us insights into the evolutionary emergence of altruism and subsequent medical care.

In this book I propose to give scientific facts on the most recent discoveries and advances of neuroscience that can explain both the biological systems involved in the doctorpatient interaction and their evolutionary meaning. The basic concept is that from a neuroscientific perspective, I aver, the doctorpatient relationship can be subdivided into at least four steps. The first is feeling sick, a key starting point that triggers the subsequent behaviour. Neuroscience has a lot to say about feeling sick. It involves sensory systems and cortical areas that generate conscious awareness, and indeed the perception of a symptom, like pain, is the product of bottom-up processes and top-down modulation. The second step is seeking relief, a kind of motivated behaviour which is aimed at suppressing discomfort. This behavioural repertoire is not very different from the one aimed at suppressing hunger or thirst, and the brain reward circuits are of great importance in this regard. The third step is meeting the therapist, a special and unique social encounter whereby the therapist represents the means to suppress discomfort. Here many intricate mechanisms are at work, such as the patients trust and hope and the therapists empathy and compassion. Neuroscience is beginning to understand these complex functions and, interestingly, not only can we study the patients brain but we can also have a look into the doctors brain, in which many regions are responsible for empathic and compassionate behaviour. Finally, the fourth step is receiving the therapy, the final act of the doctorpatient interaction. The mere ritual of the therapeutic act may generate therapeutic responses (placebo responses) which sometimes may be as powerful as those generated by real medical treatments. In this regard, the present book wants to put the placebo effect into a broader context compared to my previous book