Throughout history, doctor-patient relationships have been acknowledged as having an important therapeutic effect, irrespective of any prescribed drug or treatment.

In an era of brief doctor visits and high-tech medicine, it may be the development of warmth and empathy between doctors and their patients that makes the difference in care.

The study found that doctors who showed empathy and acknowledged their patients' fears and anxieties were more effective than doctors who kept patients at an emotional arm's length.

Researchers grouped 25 medical, psychological and sociological studies of care delivery by the doctor's style of interaction with patients. In "cognitive" care, the doctor tried to influence or convince a patient about an illness or treatment, while in "emotional" care, the consultation was deemed warm and empathic and the doctor tried to relieve patients' anxiety and fears.

Although none of the studies looked exclusively at emotional care, four evaluated both cognitive and emotional care. Three of these studies showed that support and reassurance enhanced health outcomes as measured by blood pressure readings and patient reports of pain.

In a healthcare consultation, doctors can offer social support to patients, give them a safe space to open up and discuss their problems and reassure them with a diagnosis or a treatment, thereby relaxing them and lowering their anxiety. l of these ingredients have been linked with immune function.

The study should be a wake-up call to doctors.

The effects of the relationship on the course of illness indicates that the context of care influences patients' well-being.

As long ago as 400 BC, Hippocrates wrote of how "the patient, though conscious that his condition is perilous, may recover his health simply through his contentment with the goodness of the physician".

Author (Lancet 1955; 1: 683-88) later added that what mattered was "not only the medicine . . . or the pills . . . but the way the doctor gave them to the patient -- in fact the whole atmosphere in which the drug was given.

A review (JAMA 1994; 271: 1609-14) on pain and the placebo effect concluded that

"The quality of the interaction between physician and patient can be extremely influential in patient outcomes,

and . . . patient and provider expectations may be more important than specific treatment".

Effects originating from health-care interactions include factors common to all medical, alternative, and psychological therapies -- eg, attention, bedside manner, empathy, positive regard, compassion, hope, and enthusiasm.

When threatened by signs and symptoms of illness, individuals respond with cognitive and emotional reactions. For example, sudden pain may cause an individual to feel anxious and to try to make sense of the situation by thinking about what it might be, what caused it, whether it is curable, what the consequences could be, and how long these symptoms might last.

The researchers found that practitioners who attempted to form a warm and friendly relationship with their patients, and reassured them that they would soon be better, were found to be more effective than practitioners who kept their consultations impersonal, formal, or uncertain.

Giving different diagnoses to patients presenting with similar symptoms had little or no effect, perhaps because the diagnoses given were for relatively mild conditions. For more serious illnesses, effects are possibly stronger, but ethical and practical reasons would obviously prevent researchers from doing such studies.

Vast amounts of energy and resources have been spent to advance diagnostic tools, and pharmacological and surgical treatment. The lack of attention to the more humane aspects of care, alongside increased specialization and shortened consultation time affects the patient-practitioner relationship.

Bedside manners, the warmth of the doctor-patient relationship, and other features of good doctoring contribute to the outcome of medical care, yet they have been treated contemptuously by the biomedical community as factors that produce placebo (or context, or non-specific) effects that should not work even if they do. The most impressive examples of the potential clinical relevance of context of care have been found in relation to the survival of cancer.

The Lancet March 10, 2001;357:757-762