The benefits of good communication between doctors and patients are well-recognized and include better adherence with medical treatment, better outcomes, fewer hospitalizations, and greater utilization of preventive care. But no less important—and absolutely fascinating—is how this communication can affect a patient’s well-being, for better or for worse, through the placebo and nocebo effects.
Both words are Latin and are used to describe inactive substances given to patients by doctors or other healers that are described as possessing either helpful or harmful properties. Placebo means “I will please,” and nocebo “I will harm.” After partaking of the placebo or nocebo, the patient responds as she would have been expected to had she actually consumed an active medication (or poison), despite it lacking any intrinsic power.
How placebos work remains unclear. Possible explanations include response conditioning, anxiety reduction, and increases in hormone levels such as oxytocin and vasopressin. That placebos do actually work, however, is not in doubt. Robust placebo effects been demonstrated in multiple studies over the last 60 years. These include the relief of acute pain after an injection of sterile salt water, and the reduction of anticipatory pain, such as, for example, when someone is told that taking or doing x will reduce the discomfort associated with surgery or with childbirth. This is why most trials of new medications are done with placebo controls—and without participants or researchers knowing who is receiving what—so that this effect can be eliminated.
Although it is hard to imagine that nocebos would be purposely used in the practice of Western biomedicine, it is very likely that the nocebo effect is much more prevalent than either patients or physicians recognize.
Medical placebos have also been successfully used to treat ailments such as irritable bowel syndrome, lower-back pain, asthma, depression, and erectile dysfunction. Surgical placebos—also known as sham surgery—in which a patient undergoes a lesser surgical procedure than the one he believes he is undergoing, can also possess therapeutic value in some cases. A great example was published in the New England Journal of Medicine in 2013. In this study, 146 adults with chronic knee pain caused by a torn meniscus underwent arthroscopy of the affected knee followed either by removal of portions of the damaged meniscus or by simulated surgery in which no tissue was actually removed. None of the patients knew whether or not they’d actually undergone surgery, and all received similar post-operative care and follow up. Remarkably, the patients in both groups reported significant improvement in their symptoms irrespective of whether or not any meniscal tissue had been removed.
Nocebos, on the other hand, make pain and discomfort worse because of the negative association that accompanies the administration of an otherwise inactive substance. For example: Nocebos can induce itch or pain in research subjects who believe that these will be the expected results. Interestingly, placebos and nocebos yield opposite effects upon levels of dopamine and opioid neurotransmitters in specific areas of the brain.
In societies where a person of authority is believed to possess supernatural powers that can either heal or harm, the nocebo can take the form of black magic that can be lethal, as described by W.B. Cannon in American Anthropologist in1942. Although difficult at times to comprehend through Western cultural constructs, belief in the injurious powers of supernatural hexes is widespread throughout the world. One example of this is Koro, otherwise known as “shrinking genital syndrome,” in which men come to believe that their genitals are shrinking into their bodies as the result of sorcery, witchcraft, poisoning, or intervention of evil spirits. Although there are no physical findings to confirm the delusion, those afflicted by Koro become very anxious, fearing for their fertility and even for their lives. Koro has resulted in panic and murderous witch hunts—in vain attempts to undo the spell—in many places in Africa and Asia.
Although it is hard to imagine that nocebos would be purposely used in the practice of Western biomedicine, it is very likely that the nocebo effect is much more prevalent than either patients or physicians recognize. For example, when doctors highlight the potential side effects of new medications, such as GI distress or sexual dysfunction, patients complain of these much more frequently than when they are minimized. The same is true with pain caused by medical procedures: Women in labor who are given an epidural anesthetic are much more likely to report discomfort if the procedure is described beforehand as being more, rather than less, painful.
So what can we learn from this? It is vitally important that physicians understand how potent the effect of what they tell their patients can be upon their well-being. This means, for example, that when prescribing a new medication, doctors need to review the most commonly encountered side effects in a matter-of-fact way that doesn’t induce panic instead, for example, of rattling through the entire list of possible-yet-rare complications found on the package insert. At the same time, the physician needs to make sure that the patient understands what he needs to do should side effects indeed materialize.
Being able to harness the placebo effect, including that which can augment the effect of actual medications that do indeed possess therapeutic powers, and to avoid the nocebo effect are important parts of the doctor’s healing role. Bound up as they are with the ability to communicate well with patients, it is very troubling that physicians find themselves under growing pressure to see more patients in less time. This time now also needs to be allotted to data-entry and other administrative tasks intended to improve the quality of care, but which may actually achieve the opposite by undermining doctors’ relationships with their patients and the communication which arises from within them. Unless our medical system recognizes the true value of good communication between doctors and patients, and genuinely prioritizes this by providing the conditions necessary for it to thrive, the quality of our care will suffer even as its costs continue to rise.