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With Comments from Russell H. Greenfield, MD, Dr. Greenfield is Clinical Assistant Professor, School of Medicine, University of North Carolina, Chapel Hill, NC; and Visiting Assistant Professor, University of Arizona, College of Medicine, Tucson, AZ.
Heaven Scent? Aromatherapy Massage for Cancer Anxiety
Source: Wilkinson SM, et al. Effectiveness of aromatherapy massage in the management of anxiety and depression in patients with cancer: A multicenter randomized controlled trial. J Clin Oncol 2007;25:532-539.
Goal: To determine if aromatherapy massage (AM), when added to usual supportive care (USC) for people with cancer experiencing anxiety and depression, is more effective than USC alone.
Study design: Ten-week pragmatic, two-armed, randomized, controlled trial.
Subjects: Patients with cancer who were referred to complementary therapy services for treatment of anxiety and depression (n = 288, of whom 221 completed at least some of the final assessment) recruited form four U.K. National Health Service cancer centers and one hospice.
Methods: Twelve participating massage therapists agreed upon a treatment protocol that included 20 essential oils, specific massage strokes, timings, and overall style, with individual treatments chosen from these protocols to meet the unique needs of subjects. Participants with DSM-IV criteria for anxiety and depression were randomly allocated to receive either USC + AM, or USC alone. USC consisted of access to psychological support services. Those randomized to massage received one-hour sessions of AM once a week for four weeks in addition to USC. Demographic, clinical, and socioeconomic data were collected at baseline, and interview and questionnaire data were collected at baseline, and six and 12 weeks later. The primary outcome of interest was change in anxiety and/or depression between "full case and borderline and noncase, or between borderline and noncase" at trial's end. Secondary outcomes included change in clinical anxiety and/or depression at six weeks post-randomization, change in self-reported anxiety at six and 10 weeks post-randomization, change in self-reported depression at six and 10 weeks post-randomization, and change in self-reported fatigue, pain, nausea and vomiting, and global quality of life at six and 10 weeks post-randomization. Twelve participants at each center were asked to complete pre- and post-AM session questionnaires to evaluate immediate effects of AM.
Results: At baseline, 38% (109) of subjects were deemed to have borderline anxiety and/or depression, and 62% (179) as having case anxiety and/or depression. Of the 144 people assigned to AM + USC, 86% received 2-4 sessions of AM. At six weeks post-randomization, 55% of subjects had experienced improvement in their clinical anxiety and/or depression, with more in the USC + AM group showing improvement than in the USC alone group. The greatest improvement was noted for symptoms of anxiety and borderline depression. At 10 weeks post-randomization, 63% of subjects had experienced improvement in anxiety and/or depression, but no objective difference was identified between those in the USC + AM group and the USC group. Subjects using psychotropic medications at baseline were less likely to experience symptom improvement. At both six and 10 weeks post-randomization, those who received AM reported a significant improvement in self-reported anxiety; there was, however, no significant difference between groups with respect to self-reported symptoms of depression. In addition, no differences between the two arms were noted for any secondary outcome measures. A total of 57 subjects completed pre- and post-AM session State Anxiety Inventory questionnaires, showing a mean improvement of 13.9.
Conclusion: AM acutely improves clinical anxiety and/or mild depression in cancer patients, with objective benefits from four weekly one-hour sessions persisting for two weeks beyond the last treatment. Subjective benefit endures significantly beyond objective symptom improvement. AM appears to be most effective for amelioration of anxiety.
Study strengths: Degree to which consensus of diagnosis assured; testing for researcher bias; sample size; duration of follow-up; intention-to-treat analysis; range of clinical presentations (subjects with early and advanced cancers entered into study); combination of standardized outcome measures, patient self-report, and structured interviews; autonomy of therapists (approximating real-world application).
Study weaknesses: Frequency of intervention (a single one-hour massage per week); only people referred for complementary therapy services were enrolled in the trial; not all assessments took place in person; incomplete blinding; significant amount of missing data requiring multiple imputation (the authors state that "nonmissing data at the two outcome assessment points were not representative of the patients randomly selected"); suboptimal recruitment; significant attrition, mainly due to poor health; don't know if any subjects received AM outside of protocol.
Of note: AM is commonly offered within cancer centers, and is very popular among people with cancer; patients generally perceive AM in a positive light, feeling that it offers subjective therapeutic benefit; only cancer patients with an expected survival of more than three months were included in the present trial; cancer patients who had been prescribed psychotropic medication or received psychological counseling within three months of baseline assessment were excluded from participating; the majority of participants were female, and > 50% had breast cancer (almost half had advanced cancer, and two-thirds were receiving chemotherapy and/or radiation therapy); subjects randomized to USC only were offered a course of AM at the end of the trial; diagnostic assessments were tape recorded, and consensus meetings held regularly to assure both quality and consistency of diagnostic rating; most assessments took place in face-to-face meetings within clinics, but 50 occurred by phone and 12 at subjects' homes; participants were from a wide variety of socioeconomic backgrounds; participants were recruited over a period of approximately 3.5 years (yielding an average of 82 patients per year).
We knew that: Relieving mild-to-moderate psychological distress for people with cancer is a significant challenge; psychological distress appears to be closely related to symptoms like pain, nausea, and insomnia; prior data have shown that aromatherapy massage may decrease self-reported symptoms of anxiety immediately following treatments; inhaled aromatherapy oils administered without human touch do not appear to have a positive impact on anxiety.
Comments: Significant issues exist that somewhat limit interpretation of the results of this study, but the authors are to be commended for carrying out such a methodologically difficult trial. Troubles like the significant attrition rate, anemic subject recruitment, and missing data are problematic, but challenges like these can only be expected when focusing on such an ill patient population. There are other issues as well. It is unfortunate that recruitment only took place through referral to complementary therapy services, as a significant number of potential subjects may have been missed. Those who were referred for complementary therapy services and who followed through were likely those most open to complementary therapies, and thus may have been more likely to respond favorably to AM. Measured benefit may have been subconsciously inflated because of the face-to-face nature of interviews. In addition, the authors sagely note that improvement in anxiety levels could well have occurred simply due to passage of time beyond that when the dual crises of diagnosis and discussion of necessary treatment first occurred. Beyond all the challenges inherent in such a study, however, results showed that the trajectory of improvement was significantly greater in the AM arm than in the USC group, and that subjective improvements were even more enduring than objective benefits. The results cannot be classified as definitive, but when considered together with prior data, they suggest that appropriate human touch is an underutilized therapeutic tool.
What to do with this article: Keep a copy on your computer.
I'm OK, You're OK—Physician Self-Disclosure
Source: McDaniel SH, et al. Physician self-disclosure in primary care visits. Enough about you, what about me? Arch Intern Med 2007;167:1321-1326.
Goal: To examine the presence and impact of physician self-disclosure (MD-SD) on patients, the nature and sequence of communication, and the process of care.
Study design: Descriptive study (sequence analysis applied to existing database of patients' first visits to a selected group of primary care providers).
Subjects: Primary care providers (n = 100) who agreed to complete surveys and have two unannounced, covertly audio-recorded, standardized patient visits (n = 193, data analyzed on 113).
Methods: Standardized patients were intensively trained to portray specific patient roles in a manner indistinguishable from actual patients. Detailed bio-graphies were developed for two middle-aged, Caucasian patient presentations (gastroesophageal reflux disease and medically unexplained symptoms). Each physician was randomly assigned two standardized patients who presented with one or the other malady, one male patient and one female. Initial contact was made by requesting a new patient appointment for a person with "chest pain for a couple of weeks" that appeared to be non-urgent. Each visit was surreptitiously recorded, later transcribed, and reviewed for verbal content and intonation. Two days after the standardized patient visit, practitioners received a faxed inquiry about the interaction to determine whether the doctor correctly identified the person as a standardized patient, and if their practice style changed in response to their opinion.
Results: Thirty-eight visits (34%) to 32 physicians contained at least one MD-SD, with an average of one MD-SD per self-disclosing physician, and a total of 73 MD-SDs identified. No association was found between the number of MD-SDs and gender, role, or duration of patient visit. Most MD-SDs occurred prior to the physical examination, during history and information gathering, and typically were preceded by patient statements. MD-SDs were related to the patient statement in the majority of instances, but were seldom a response to a direct patient inquiry; rather, it appeared that the physician assumed patient interest in her or his experience. None of the identified MD-SDs were patient-focused. There were but three identifiable instances where the MD-SD was deemed potentially helpful to the patient; in each case the physician mentioned that she or he had the same medical condition as the standardized patient. There were eight MD-SDs that seemed disruptive, in some way detracting from the physician-patient relationship. There was a suggestion that longer MD-SDs tend to be disruptive or at least not helpful.
Conclusion: MD-SDs are common in primary care, are usually not helpful to patients, and may serve to impede development of a healthy patient-practitioner relationship.
Study strengths: Avoidance of potential confounding factors; method of review.
Study weaknesses: A significant number of patient visits (40%) were excluded from analysis because practitioners suspected the standardized patient was not a real patient; assumptions of authors relating to value of specific interactions between patient and practitioner.
Of note: MD-SD, when the practitioner shares personal information and/or experiences, is a controversial topic with a paucity of data despite it being widely perceived as a way to deepen the patient-practitioner relationship; the current analysis is part of a larger study using covert audio recordings of office visits to study patient-centered communication and health outcomes; prior qualitative evaluation of these data focused on physician responses to ambiguous symptoms, but researchers remarked on the frequency of MD-SDs, which led to the current study; existing studies suggest MD-SDs to be beneficial in a surgeon's office, where they were associated with enhanced patient satisfaction and reports of friendliness and reassurance, while MD-SDs in primary care practices are not helpful, and were associated with low scores on similar scales; researchers were blinded to gender when evaluating transcripts; participating physicians were reimbursed $400 for their time.
We knew that: Effective communication between patient and health care provider appears to improve health outcomes; doctors may work harder to create connection with a new patient, and may use SD to promote a healing, trusting relationship.
Comments: This article was widely discussed in the lay press, with headlines and video introductions suggesting that doctors should stop talking about themselves. The implication is that health care practitioners are often self-centered, and in the office more concerned with their own daily concerns than with those of their patients.
Aside from the large number of patient-practitioner interactions not evaluated, this is a well-done study. A question for our readers: Have you ever perused a well-done study and disagreed with its conclusions?
The authors rightly state that MD-SDs may take away from important patient concerns, especially in an age where time for supporting the healing relationship between patient and provider is in high demand but often in short supply. The authors note they saw no evidence that MD-SDs help build rapport, and cite examples of discussions that offered no therapeutic benefit. However, many patients prefer to work with a health care provider who creates an equal plane of interaction, and who prudently shares something about themselves if appropriate. Of course a practitioner should not be presumptuous, but provision of excellent health care does not necessarily mean patients cannot know anything about the personal nature of their health care providers. As with all of health care, such decisions need be made on an individualized basis. The authors state that physicians should be empathetic, and fulfill their need to share by speaking with friends, or joining support groups. This reviewer believes physicians are a privileged lot to have people share their stories with us. Those stories often help us on our own paths; in return, we offer expertise in the hope that our patients will be well. We have shared vulnerabilities, often shared dreams. Doctors need not be dissuaded from appropriately, cautiously, and respectfully sharing of themselves, provided that doing so does not interfere with patients' expectations and care.
What to do with this article: Keep a copy of the abstract on your computer.