Communication is so powerful, it can make you sick

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I just had to share a podcast I listened to recently, produced by ABC Radio National.

Placebo Power is part of ABC Radio National's All in the Mind series, exploring exactly what its title suggests. The podcast is a cracker and I loved hearing about the power of the placebo and how it all works. Unexpectedly, it really got me thinking about the power of communication.

Perhaps we take our ability to communicate a little for granted. We communicate, and are communicated to, every day all day. It is intrinsic to everything we do - in fact it is essential to our survival. This is true not just for humans, but for all animals and for plants too. Yes plants - they are quite the talkers.

In 2014, The Scientist published Plant Talk an article confirming 'far from being unresponsive and uncommunicative organisms, plants engage in regular conversation'. Author Dan Cossins covers a number of examples to support this, including one where a group of researchers bagged the leaves and stems of some broad bean plants after they popped some nasty aphids on them. They already knew aphid-infested bean plants release an odour into the air to warn their neighbours of an attack, and these neighbouring plants respond with gusto by releasing an odorous chemical of a different kind to attract aphid-hunting wasps. But what they were trying to find out was if the plants communicate under the soil. And they do.

'...plants can “talk” in several different ways: via airborne chemicals, soluble compounds exchanged by roots and networks of threadlike fungi, and perhaps even ultrasonic sounds. Plants, it seems, have a social life that scientists are just beginning to understand.' 

Animals also communicate for survival through a variety of ways: visual displays, noise and sound, through scent, touch and other signals. They communicate to attract mates, scare off predators, warn others of a threat and create group cohesion. As humans are part of the animal kingdom, we too communicate in these ways to achieve all these things.

Humans will go to extreme lengths, and overcome enormous barriers, to communicate. Living with locked-in syndrome Jean-Dominique Bauby communicated with what only those suffering from this condition have available - movement of their eyes. Using this method he wrote a best selling memoir.

The brilliance of Stephen Hawking and what he had to say to the world was made possible through Hawking moving his cheek. Using a computer powered by his wheelchair and an open source program designed by Intel called ACAT, Hawking was able to talk by stopping a cursor running across a keyboard to select a letter by moving his cheek, the movement detected by an infrared switch mounted to his spectacles.

'This switch is my only interface with the computer. ACAT includes a word prediction algorithm provided by SwiftKey, trained on my books and lectures, so I usually only have to type the first couple of characters before I can select the whole word. When I have built up a sentence, I can send it to my speech synthesizer.' Stephen Hawking

I don't know about you, but I find both these stories extraordinary. Hawking was first diagnosed with amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's Disease) when he was 21. He was not expected to survive beyond his 25th birthday, and yet he did. He lived to see his 76th birthday in fact. There are many reasons why: he could have had the very rare slow progressing form of the disease, and this combined with the fact that his disease presented when he was young (when it usually hits after the age of 50) could also have contributed to his ability to live with the disease 11 times longer than expected. I can't help wondering though, if his ability to communicate, to contribute to the world and have purpose, also played a part in his longevity.

But let's get back to where this all started - the podcast. Placebo Power got me from the very beginning with a story from Associate Professor Damien Finniss about something that changed the course of his career some 17 years ago, when he was working as a sports physiotherapist treating professional athletes. Prior to a game or training, he would administer ultrasound therapy. One day after treating multiple athletes who all got up after therapy as normal, thanking him, saying they felt better and running off onto the field to play, Finniss realised that for the entire session his ultrasound machine was off. The light was broken, so he hadn't noticed it wasn't plugged in. At the time he was astonished that he 'wasn't actually doing anything' and yet it had the same effect as normal treatment. Now a medical doctor and Associate Professor at the University of Sydney's Pain Management and Research Institute, he understands more than most that on that particular day he was actually doing something, something very important. He was communicating the whole time that he was providing treatment, going through the ritual of treatment and setting an expectation of treatment - tricking the brain and spinal chord into believing the body has had treatment for pain so it releases endorphin-like chemicals and other natural chemicals produced by the body, such as cannabinoids, to counter the pain. This event prompted him to research the power of placebos, the body's reaction and the importance of the context of the situation, particularly the influence of words, gestures and interactions between health care professionals and their patients on the placebo effect.

At this point, less than a minute into the podcast, I was hooked and couldn't stop listening.

The host, Lynne Malcolm, goes on to interview a number of researchers and practitioners. Dr Claire Ashton-James, ‎Senior Lecturer at the Pain Management Research Institute at Sydney Medical School, talks directly about the influence of communication on our perception of pain. She talks about how changing the way we communicate can improve patient care by making procedures less distressing. Among a number of examples, she gives a simple but gorgeous one about telling her daughter that the stinging from a disinfectant applied to her cut or abrasion means the medicine is doing its job, and this helps her daughter feel less fearful of the stinging.

'Mummy, mummy the Dettol is stinging! It's cleaning! It's working!'

Dr Kate Fausee from the University of NSW, is interviewed about the media's influence and role in changing patient outcomes. She shares a story from New Zealand about a drug to treat under-active thyroid conditions. This drug had its binding agent changed but the active ingredients all remained the same. Regardless, people using this drug on a regular basis became concerned because the colour of the pill was different. The media across New Zealand broadcast reports about the drug changing, all running the same interview with a patient who talked about symptoms which came back because the drug had changed. Suddenly, many regular users of this drug complained of symptoms even though the binding agent had nothing to do with the effect of the drug and the drug company couldn't replicate any of these symptoms in thorough testing. This suggested to Fausse that these negative side effects were being caused by negative expectations driven by the media coverage. She mapped the reporting of symptoms correlating a link to the airing of these media interviews.

Intrigued by the power of suggestion on patient outcomes, Fausse took her research further in an experimental study. University students were told they were getting a fast acting beta blocker to reduce their anxiety by lowering their blood pressure and slowing down their heart rate. Subjects were given a sugar pill placebo and then asked to wait in a waiting room with another participant to make sure there were no adverse reactions to the beta blocker and to see if the drug would work. What the university students participating in the study didn't know was that the person they were arranged to sit with in the waiting room wasn't another student participating in the research but was actually an actor hired by the researchers.

When the researchers came in and asked the actor if they had any symptoms sometimes the actor said yes and explained them, sometimes the actor said no. The researchers also asked the actor if they felt the drug working. Sometimes the actor said yes, sometimes no. The findings from this experimental research showed people were influenced by what they heard. They too had symptoms if the actor did. They too thought the drug was not working, if the actor said they didn't feel the drug working. In fact, the students who reported feeling the drug was working (after hearing the actor confirm they too felt the drug was working) actually showed physical signs of the placebo effect - with lower blood pressure and lower heart rates. Yet all they took was a sugar pill.

So in short, not only does communication change how we feel about treatment, it also impacts the effectiveness of treatment.

 Another important take out from this podcast is the fact that we build trust through communication, and that this trust can be eroded in a microsecond. This is important because the health outcomes of a patient is linked to their trust and belief in their doctor,  and in their perception of their doctor's levels of empathy and care. A doctor can communicate in a microsecond, through facial cues, their disbelief or disgust in something and undermine trust previously built up. As humans we are hard wired to pick up the things others don't even know they are communicating. 

Although I have shared a lot of what is in the podcast, there is a fair chunk I haven't covered, so I would highly recommend you take some time out to listen to it. It confirmed for me how much of an important role communication plays in whether or not people feel better or sick, experience pain or no pain, or are fearful of pain or not.

It also reminded me of a time when I worked at BreastScreen Victoria, and research which showed that women were more likely to report feeling pain during their mammogram if the radiographer was perceived to be rude, and uncaring. 

I think we can all agree: communication is powerful and has a direct impact on our wellbeing and whether or not we feel sick or experience pain. So please, be careful what you say.