Arizona Center for Integrative Medicine

Transcript

Dr. Victoria Maizes
Hi, Andy.

Dr. Andrew Weil
Hi, Victoria.

Dr. Victoria Maizes
Today we have Dr. Steve Bierman joining us and he is truly an expert on the art of language and how we communicate with our patients.

Dr. Andrew Weil
Favorite subject of mine. And I think we're very lucky to have Steve as a teacher in our programs. He's one of the, I think, most powerful explainers of the power of ideas and how that can either impact the possibility of healing or work against it.

Dr. Victoria Maizes
And there are going to be tips for you about what you can do if you do feel like you might have gotten hexed. How to mitigate that. So let's welcome Steve.

Intro Music

Dr. Victoria Maizes
Dr. Steve Bierman received his M.D. from Northwestern University's School of Medicine and worked for nearly 20 years as an emergency physician at Scripps Memorial Hospital in Encinitas. He became well known for performing painless injections and laceration repairs and even reducing the pain of childbirth. In private practice, Dr. Bierman learned the importance of communication. When addressing autoimmune diseases, depression, and cancer. Dr. Bierman teaches how we can focus the power of ideas to access our healer within.
Welcome, Steve.

Dr. Steve Bierman
Thank you very much. It's great to be here.

Dr. Victoria Maizes
Well, we're delighted to have you and one of the things I'd like to ask is that you have a concern that patients can be inadvertently harmed during typical communications that are embedded in the doctor patient encounter. How did you first become aware of this?

Dr. Steve Bierman
It was a gradual learning, actually, and it connected to my early studies of hypnosis. I have to say this may be surprising. Also, some early readings of works by Dr. Weil and others. In particular, I remember well a chapter on placebo in health and healing that had a profound effect on me. But as I got deeper and deeper into clinical hypnosis, of course, I realized through that the importance of crafting my messages clearly and the impact of ideas on health and healing.
And initially, it wasn't clear to me that the words of a physician outside of trance could have a profound impact. But what happened to me was I was working in the emergency room. And over time, it became busier and busier. And I ultimately did not have time to do formal trance inductions. So, I abandoned that aspect of the technique and kept closely to the careful language that I had learned.

And by happenstance, patient after patient, I realized that trance was just a response I could induce, and that my authority, by virtue of the patient's sense of helplessness and dependency and their attribution of that authority to me gave me a hypnotic influence, as it does all doctors. And so I began hearing, you know, through the curtain things other doctors were saying or in my own mind, things that I might have said and realizing no that's dangerous. It can do harm. And then it's it's a small jump from that to nocebo effects. And realizing that in advertently, I don't think any of this is really intended, of course, but inadvertently doctors often do a lot of harm because they don't realize they hypnotic influence of their words.

Dr. Victoria Maizes
So there's a lot to unpack there. And before we start unpacking it, I want to turn to Andy. Andy. You have also spoken about how formative hypnosis training was for you. And, of course, the art of medicine, the art of using language well, has always been a part of your conception of integrative medicine.

Dr. Andrew Weil
Yes. And I think Steve and I have similar background and interests. I took a course in clinical hypnosis after I got out of my clinical training. One of the best courses I have ever taken. And but I've always been fascinated by the power of words, by the placebo response, and how that is so misunderstood in medicine. And the inverse of that sometimes called the nocebo response. You know, negative effects produced through the mind body connection. And I have just collected in the course of my practice many instances in which doctors actually see if occasionally it is done intentionally. But it's rare. But it happens. But mostly unconsciously hex patients and I wrote about medical hexing in Health and Healing. And I've seen just some spectacular examples of that.

Dr. Victoria Maizes
Andy, would you give one example? Because people may not recognize what medical hexing is.

Dr. Andrew Weil
Well, this is a very glaring example that you've heard me tell before. Some years ago, I had a patient, a middle-aged woman from Helsinki who came to Tucson to spend some time at Canyon Ranch. She had a fairly early diagnosis of multiple sclerosis, she was very depressed. She came in the winter and in the course of staying here, brightened up considerably I think just being in the sunshine in an agreeable climate. But we had several meetings and at one point she said, you wouldn't believe what that doctor did to me in Helsinki. She was at the main University Hospital, and she said when he gave her the diagnosis, she was having some weakness of multiple sclerosis. He said, wait here a minute.

He went out and brought a wheelchair in and asked her to sit in the wheelchair and she said, ‘Why should I sit in the wheelchair?’ He said he wanted to get a wheelchair and sit in it for an hour a day to practice for the time when she would be disabled.

Dr. Victoria Maizes
Wow. Wow. That that's like a horrific example. Steve, one of the things you talk about is there is a way in which we can mitigate the effects of that kind of medical hexing. Can you talk about what Andy could have said to that woman or what you would have said to that woman?

Dr. Steve Bierman
Well, sure, it depends on understanding two simple things, really, the nature of our knowledge, the kind of knowledge we as physicians have, which is fundamentally statistical or anecdotal, but never relates directly to the patient who sits before you. That's one thing. And the other is the sheer fallacy of prophecy, which we should all really be instructed on in medical school, I tell my patients frequently when when you feel a hex coming at you.

Dr. Victoria Maizes
Is there a certain sensation that they get?

Dr. Steve Bierman
You feel like you. You're instinctively aware that potential damage is being done when you feel that recite the mantra I have given you, which is, “You don't know me, you don't know me.” But also understand that the guy or woman who's telling you that can't predict their own future, their own tomorrow. So how possibly could they predict yours? And so understanding the nature of our knowledge and that we really can't predict no matter what, because things will always change in the future.

A cure for what you think is incurable will be found tomorrow. In some cases, once you have that as your mindset, it becomes much more easy to say it right.

Dr. Victoria Maizes
I read something you wrote where every word matters and even something as simple as when you're greeting a patient, when you're saying goodbye to a patient, you can infuse those greetings with suggestions that the patient will do well. And I'd love for you to talk a little bit about that.

Dr. Steve Bierman
I teach that your greeting, for example, is your first opportunity to establish rapport. I mean rapport and a tight sort of method, a logical way that relates to hypnotic. It's an imitative technique, and it empowers your words even greater. But it's also your first opportunity to set fear and anxiety aside. For example, in the emergency room, I might say I see you're bleeding, that must have been really scary, wasn't it? Never assent to that puts it in the past. “Yes it was”. Right. At the same time I'll be doing other things, breathing with them, matching my vocal energy with them and so forth, to tighten the rapport and make a greater oneness between the two of us. In terms of goodbyes.

That's your last opportunity in that session, any way to implant a therapeutic suggestion. So instead of saying to someone as is frequently done well, you just have to go home and tough it out. It'll take a week or two to get better. Call me if you're not better in two weeks. There's a lot. There's a lot of negativity in that you might say something like this.
You know, some people might take up to a week. On the other hand, our patients, perhaps very much like you, who get well in a day or two, why don't you let me know how well you feel?

Dr. Victoria Maizes
Yeah, that's beautiful. And Andy you have a really wonderful closing statement that you sometimes use at the end of your consults.

Dr. Andrew Weil
Well, I often say to patients that I know you can get better. I don't know exactly how you can get better, but I'll give you suggestions of things to try and you let me know how it goes. And I've had so many patients over the years come back to me and say, the most important thing you did is that you're the only doctor I saw who told me I could get better.

And it makes me sad to hear that that so few doctors let patients think that they can get better. But this is what I've seen again and again, is that many patients get better. And by the way, that woman with MS., my response to that was still burst out laughing and tell her that I'd seen so many cases where MS goes into remission and really nobody can predict the course of it.

Dr. Victoria Maizes
It sounds like that was a really great way to burst that hex with laughter.

Dr. Andrew Weil
Right.

Dr. Victoria Maizes
So I think we have this all over medicine. Like, one of the things I've thought about is the phrase that we used to use for when someone had a very indolent prostate cancer. We used to say watchful waiting. And that sounds okay. But it really what it implied to the patient, I think, was that we were waiting for it to get worse. Whereas active surveillance to me is a so much more positive term that we're actively as their health care providers, we're keeping a watch on who they are and how they're doing. But maybe there's a better term yet. That implies that they will continue to have an indolent course of prostate cancer. We know that many men die with prostate cancer, not of prostate cancer. And that we could suggest to them that that will be the case.

Dr. Steve Bierman
We have terms like that scattered throughout medicine. The worst or the most prevalent, in my view, is the term chronic. Chronic illness to anyone implies that there isn't and never will be cure. And there's that fallacy of prophecy. How can how can you know? There never will be. And that one individual patient can you know that their intrinsic healing capacities won't suddenly arise and extinguish it like like this patient.

Dr. Steve Bierman
Andy’s talking about with MS you can't possibly know that. So even that word to me is an implicit curse. And we really do need to inspect closely the language that we use. It won't happen until we realize that ideas have an impact on health and healing, and we have a scientific underpinning to clinical medicine now that ignores utterly the impact of ideas on everything.

Dr. Andrew Weil
Isn't it astonishing that there is no teaching on the power of words in medical training? I mean, it seems to me that should be a required subject.

Dr. Steve Bierman
we may not realize it, but our labels inhibit us from recognizing that we call one thing placebo and we call another the nocebo. And yet another thing, hypnosis and another thing, distraction technique. And and without realizing that what's happening here, this is a communication continuum. Mm hmm. And that the under lying drivers of ideas producing effects are the same.

And that it's the ideas and how we vary them that make for different effects and our labels kind of shutter us off from recognizing that and allow us to go ahead with our material science willy nilly, just as it as if the petri dish is the person.

Dr. Victoria Maizes
Yeah. I think this also very much points out the power of the mind body relationship. And you know what people hear and I've certainly heard stories about people hearing things when they were unconscious because they were having surgery. You know, you hear some terrible things that someone in the operating theater might say like this person will never heal.

And then that person hears that. So I do think that the mind body connection is completely undervalued in medicine, and that's one of the things we're trying to try to change in our integrative medicine training.

Dr. Steve Bierman
Right well, think of the flip of that. If what you're saying is true and it is, think on the flip, you know, one of the things I teach is that when the patient is helpless and dependent and you're the one least uncertain, you're the authority, you have hypnotic influence. Now where in medicine going to your example, Victoria, where in medicine is that just absolutely perfect? It's in that moment, just prior to surgery, just prior to administering the pre-op sedative, the anesthesiologist turns to the patient and says, I'm going to give you this drug and take over all your bodily functions.

That's maximum authority. And imagine this. Imagine if instead of quick pushing the set and dropping them into their unconsciousness, it push it slowly and said, and isn't it nice to know you'll keep your own blood every drop with delightfully surprising comfort so that even when you hear the word pain, how's your pain? You want a pain medicine on a scale from 1 to 10, how much pain? The word pain will be a trigger to feel even more comfort and really rapid wound healing. And then he pushes the last dose, and they drop off.

Dr. Victoria Maizes
Years ago, I had a friend who asked me to accompany her to surgery and she had a statement that she wanted me to read as she was coming out of anesthesia. So suggestable. And it was I will only eat when I'm hungry and I will stop easily when my body is satisfied. So I thought that was a very clever use of that very suggestible moment to induce a healing response of another kind.

Dr. Andrew Weil
Victoria I was quite pleased, I think I told you this, that one of our recent fellowship graduates, who's an anesthesiologist, is interested in working on an Oxford University press volume on integrative anesthesiology. And we have another graduate who's into this field also, I never even thought about integrative anesthesiology, but how great that would be.

Dr. Victoria Maizes
I completely agree people are always asking you about the potential for psychedelics to induce healing, but it seems from what Steve is saying, that maybe this is this other moment where messages that could trigger a healing response are appropriate.

Dr. Steve Bierman
We know that psychedelics offer a lot. But one thing they do and and clinical setting, the way they're being used and experimented with is they recreate the situation I just described whereby the patient, especially on their first trip, feels really maximally helpless and dependent.
And the trip master, the physician, or guide, whoever it is, is the one least uncertain how to get you through it. And so they again have this tremendous hypnotic influence and their words and their ideas matter. And so to me, it's just another example of the sort of everyday circumstance a physician finds himself with when his face to face with a patient.

Dr. Victoria Maizes
Yeah. Now, I interrupted you earlier. You were going to teach a much better way of offering informed consent. And I think you do that so beautifully. And I do want to say for our listeners who are on audio, you're going to miss some interesting hand positions. But if you have a chance, maybe turn on the video, at least for this piece.

Dr. Steve Bierman
A little hand jive. Okay. Well, for your listeners, let me remind them that if they're not hearing informed consent coming at them the way I'm about to describe it, it's very useful to say to yourself, because this is true of the doctor who's giving informed consent or whoever it is, “you don't know me. You don't know me, you don't know me.”

That mantra will protect you if they accidentally misspeak. But the way to give the information is to realize they don't. You really don't know the individual. You know some people who are in the sample or some people who you've experienced anecdotally and some patients. And so you put the some off all backup here, off away from the patient.

I indicate that with my right-hand arm up away from the patient. And I'll say, for example, ‘well, let's consider the risks and benefits.’ Let's say it's an antibiotic and I'm going to abbreviate this. Some people taking this medicine might have a reaction to the light. Others I'm not saying you here others could have nausea or vomiting, yet others might have diarrhea.

Some good others might have diarrhea. And I can give that information and give those statistics off if necessary. But that's all put off to the side, directed away from the patient with that important referential index linguist call “some people”, “others” “them”, basically. And then when it comes to benefits, I'll turn with my palm up, indicating toward them my eyes directly at them, my voice perhaps a little stronger, I'll say. On the other hand, I have patients perhaps very much like you. Now, I want to say perhaps because this whole thing has to be done with honesty, but this is more honest than doing it the traditional way. You, you, you, you, you. Some people perhaps like you who benefit quickly from this without any side effects and in fact become well within a few days.

So I need to advise you to continue the antibiotic for its full course. I usually send people off, whether it's for this or something else with my final send off is, “And you're not opposed to surprising yourself or pleasantly surprising yourself, are you?” So I've implanted that delightful surprise suggestion as my goodbye, but the informed consent is risks over there, some people, others, some patients. And perhaps you here with the benefits, you know, uneventful, good outcome and so forth. “Don't be opposed to surprising yourself. Let me know how well you are tomorrow or the next day.”

Dr. Victoria Maizes
It's such a beautiful way of offering informed consent. I will tell you, I was at a conference recently it was for internal medicine docs and I described offering informed consent for chemotherapy in this way. And one person in the end during the Q&A raised your hand and said, “But is it ethical to give informed consent this way?”

And I said to her, “You know, you have to find your own integrity with your language. And isn't it interesting that we have been acculturated in medicine to think that we have to put forward the most negative.” It wasn't like I wasn't giving the example of the risks and the benefit, but I was suggesting that the patient would have a good outcome.

And this physician was uncomfortable because of her training and I just think that medical acculturation, which is perhaps to emphasize the negative Andy, what do you think about that?

Dr. Andrew Weil
Well, I've written about that and my sense is that the training of physicians exposes them to more negative outcomes and positive. If you look at the total spectrum of illness in the majority of conditions get better on their own. I mean, by far. But but in a hospital training particularly residents, interns are exposed to very extreme cases of illness where positive outcomes are much less likely.
So I think that's one one reason why they are predisposed to predict negative outcomes. Another is that I think it increases a sense of control. You know, if you predict a negative outcome and it happens, then you have predicted that you're right. But if there's a positive outcome, you can be pleasant surprised isn't least surprised.

I think that predicting negative outcomes gives physicians a sense of greater control. And I want to ask Steve a question. Another aspect of this is that our society projects onto physicians the kind of belief and power that is projected onto priests and shamans and traditional cultures. I think most doctors are completely unaware of that and unprepared to use that projected power in the service of healing.

And I think that's very crucial to make people aware of that. And I know, Steve, this is something you've written about how the authority, a projected belief on to a doctor really interacts with the suggestibility of patients so that for many patients, even just walking into a doctor's office is is the beginning of a trance experience and leaves them very vulnerable to suggestion.

Dr. Steve Bierman
Right. This is the whole notion of authority. And I actually use your phrase, I think this was from your book, Spontaneous Healing. I tell people when you put on a white coat and stethoscope, you have done the romance of medical technology, that's your phrase. Yeah, but it's true. And with that comes as I'm saying, this hypnotic influence where every word, every gesture, perhaps every thought even matters, because you have these micro-expressions that convey those thoughts.
And so we're not taught that. In fact, we're taught exact opposite, which is material science, ideas don't matter. Ideas are epi-phenomena at best. And they don't count in medicine. The argument to that is and I think this is one of the greatest deficiencies in medical education, the argument to that is that the single most established fact in medicine proven in every single randomized controlled, placebo-controlled study is that ideas do matter.
The placebo is not the sham surgery or the sugar pill. It's the idea that if you do this, then you will get these various effects. And if instead of reading the primary secondary outcomes of the study, you read those same studies asking this one question, “Do ideas matter? Does the implicit placebo suggestion have force?” Every single study since 1949 to today
Well, affirm and reaffirm and yet again reaffirm that yes, ideas matter. And to me and I owe you them in part for this, because it really health and healing and put me on this road. But to me, this is the cardinal fact of medicine, and it should be the first lecture everyone gets in medical school. And the question then is and again, it's a question I think we all should ponder and delight in, is how the hell does this work. If you take this pill, if you undergo this procedure, if you X, then the following things will happen. And given theprecondition of their helplessness and dependency and your certainty about how to get them to the promised land, things will happen within their body. Their intrinsic healing capacities will kick in and do things that are miraculous, wondrous, just the marvels of individual healing. And we never teach that.

Dr. Victoria Maizes
You know, it's one of the things I often hear from patients is that they did so well and their doctor remarked about how well they were doing, but had no curiosity about what led to that really great outcome.

Dr. Steve Bierman
Well, a lot of people get stuck in their own box.

Dr. Andrew Weil
You know, I teach that the placebo response is the greatest ally you have as a physician. And the goal of medicine should be to produce the maximum healing response with the minimum intervention as called for by the circumstances of illness.

Dr. Steve Bierman
Right. If we didn't call it placebo and we didn't push it from nocebo, but we just said like elicit the intrinsic healing.

Dr. Andrew Weil
Healing, Yes. right?

Dr. Steve Bierman
We will get a lot farther. It's these labels are opaque, and they really don't allow us to see through to what's going on.

Dr. Victoria Maizes
Your statement of that, you expect that someone can do well, recover heal is a statement of expecting that their intrinsic healing system will turn on and be effective.

Dr. Andrew Weil
And it's not giving people false hope because my experience, both in my own body and in my, you know, observations of people, is that most conditions get better. You know, there's a famous adage in medicine that the business of the physician is to distract the patient while time heals the problem.

Dr. Victoria Maizes
Right. Right. Steve, you have a wonderful question that you'd like to pose to all of your patients that gets to their sense of why they have become ill or injured themselves or something else. Can you share that question?

Dr. Steve Bierman
I'm happy to do that. Can I give it a little ramp?

Dr. Victoria Maizes
Absolutely.

Dr. Steve Bierman
No one has to believe what we're talking about. All they have to do is ask this question of people who get sick. There's a particular way you have to ask it and I'll show you that. But if you asked this question of people who come in with illnesses or even of yourself and allow for a moment of brutal honesty, you'll realize over time that ideas matter and that, in fact, errant ideas can contribute, if not caused themselves bad things to happen within the body.

So, I was an emergency room physician at the time I hatched this idea. I couldn't wait to go in and ask it, and I was shocked. And I continue to be shocked daily at the answer. Here's the question somebody is ill was something could have happened a day ago or two days ago. Could it happen in a week from now or two weeks.

Why today? Why now? And I don't want them to think about it because I'm not asking for their thoughts there. I want them to guess… just guess just as an important word  it means and nothing else. Don't think, don't reason, just guess. Why today just gas. And what you're doing with that question is you're evoking, you know, a whisper from the unconscious.
What are the unconscious causes or cause? So the first guy I did this to had epididymitis just above the testicle, a little organ had become inflamed. I didn't know why I treated him appropriately, gave him a referral. But I had thought of this question the night before, and as I was leaving, just casually, I turned around and I said to him this may not be important, but I'm just curious, trying to disarm his consciousness.
Just kind of curious. You know, you could have had this a week or two ago you're not going to know and I'm not going to know. Let's not pretend. But if you had to guess, why did they why did it just guess and they all say the same thing. At first they said, “well, I don't know you're the doctor you tell me”… and I said, Well, you're right, I'm the doctor. But like I said, I don't know. I'm not going to pretend to know. And I know you don't know… just guess and that's when the moment comes. You have to zip you lips and wait. The silence as it percolated up and is buckling his you know belt and getting thing and at the very end it frequently the answer comes often as a question he turns around and says, “Yeah, I don't know, doc, but do you think this is going to interfere with the vasectomy my wife…
And you cannot doubt the contributory effect of ideas and in particular what I call baleful wishes the wish to get out of something.

Dr. Victoria Maizes
Yeah. We ask a similar, different question in integrative medicine practice, which is do you have any intuition about what you might need to do to get well?


Dr. Steve Bierman
Right.

Dr. Victoria Maizes
And again, you're asking them to guess, not to have like the doctors expertise or to think it, but to guess, “oh, I, you know, do you think I need to quit my job?” You know, whatever it is, it's very interesting what shows up for people.

Dr. Steve Bierman
And that's beautiful.

What we're talking about is something that we deal with on a daily basis. We have our constant confirming experiences. And I and I suspect many in your audience just being aware of themselves in their environment do too.
But we live in this world of almost religious belief in science or scientism, and I wonder you guys are well connected to institutions and you have multiple resources, I wonder if it isn't time to really go after and develop evidentiary base so that this becomes incontrovertible and arrives at its rightful place as the centerpiece of medicine.

Dr. Andrew Weil
Steve I think the big problem is that what we're up against, it is a religious belief in scientific materialism and that paradigm says that all that is real is that which is physical, can be touched, measured, and that if you observe a change in a physical system, the cause has to be physical, nonphysical or causation of physical events is not allowed for in that paradigm.

Dr. Andrew Weil
And that's very upsetting to the priests of scientific materialism. You know, that's the challenge. And I think there is evidence accumulating. You know, the development of functional MRI has made the reality of placebo responses, clear to some people our ability now to show that meditation produces physical changes in the brain. I mean, there is an accumulating body of evidence, but it still is not enough to change that reigning paradigm.

Dr. Andrew Weil
We are definitely trying to do that in our Center and we have provoked some very sharp criticism from, you know, some of the scientific materialists for what we're doing. But that has to happen. Things have to go in that direction. And I'm confident that time is on our side.

Dr. Victoria Maizes
And one of the ways, of course, that we are also changing the system is by training fellows and medical students and residents. And we so appreciate you coming. Yeah. And sharing this body of knowledge and helping to educate them in the art of language and the importance of every word. Every word matters. So thank you so much, Steve, for your body of work and thank you for being on Body of Wonder.

Dr. Steve Bierman
Thanks. Right back to you