It’s a warm summer morning in 400 BC Greece, Hippocrates sits and writes commandments of medical ethics.
Cut to modern times; modifications of Hippocrates’ work are now accepted by the ‘World Medical Association’. known to most as the ‘Hippocratic oath.
In this small detail; that concerns our subject today is the phrase ‘primum non nocere’ (first do no harm), which is one of the many codes of ethics, under which the healthcare community functions.
Where does nocebo come into all this?
The term “nocebo” derives from the verb nocere (“I shall harm”), in stark contrast to ‘primum non nocere’.
Initially, the word ‘nocebo’ was used to describe the negative equivalent of the ‘placebo’ phenomenon in research. It was the inactive substance or ineffective procedure that was designed to arouse negative expectations.
Later, as the non-specific effects of interventions in the research were acknowledged further, it was seen that nonspecific positive and negative effects are seen even with active/effective intervention as well, these were called the ‘placebo’ effects when they were beneficial and ‘nocebo’ effects when they were harmful.
Currently!
Where the positive effects are well known and have been extensively researched, nocebo effects have only recently come into focus and their efficacy is being established for subjective symptoms such as pain. Thus placebo and nocebo effects are now seen as psychobiological phenomena that arise from the therapeutic context in its entirety.
Meaning that every aspect of treatment can have both positive and negative effects on the outcome(or symptoms), especially communication. So, it’s not only the intervention or exercise or medicine that is going to treat the patient, it depends on everything that is experienced by the patient as well.
Why stress so much communication?
Clinician-patient communication and patient expectations can have negative impacts on the outcome of the treatment if not used skillfully.
Let’s take an example-
People all over the world lift things off of the ground every day, most of these things are small and quite a few are somewhat heavy, some of these people who lift something heavier; get back pain.
Most healthcare professionals declare the ‘faulty bending posture’, ‘wrong lifting posture’, and ‘wrong lifting behavior’ as the cause of their pain experience, instilling a sense of faulty risk perception in the patient’s mind.
The apprehension that quite understandably sets in after these statements by a health professional limits the extent of possible recovery and reinforces movement avoidance and fear that the patient experiences after getting injured.
This is shown by the fact that in a study on people with LBP(Low Back Pain), 2 groups were asked to perform flexion tests, and both groups were instructed about the tests differently, group one was informed that the test can lead to an increase in the pain, and the second group was informed that there will be no effect on back pain. The group with negative information reported stronger pain and had more performance anxiety in comparison to the group with neutral instructions.
Underestimating nocebo?
Nocebo is quite powerful, in the sense that it can exist in all natures of clinical interactions, especially communication as it is seen that negative verbal information can convert a non-nociceptive stimulus to a pain experience, and that’s quite wild to comprehend; how your words can literally cause pain to someone.
What if there is no choice?
There are many instances in clinician-patient communication where the clinician has to transparently disclose some negative information.
But, the manner in which the clinician chooses to do so is entirely up to their personal preference, and this is where many clinicians choose to be direct and blunt with negative information; not realizing the ‘nocebo’ component of the approach.
The way adverse information is presented shapes the nature of risk perception and even the clinical outcome for a patient.
In a study on pregnant women at the term of gestation requesting labor epidural analgesia, a small difference in framing the information provided along with
labor anesthetic injection was used,
—“We are going to give you a local anesthetic that will numb the area and you will be comfortable during the procedure” vs “You are going to feel a big bee sting; this is the worst part of the procedure”.
Both sentences produced different pain outcomes. Positive framing for the description (first sentence) of the procedure induced significantly lower pain compared to the information deprived of positive words and encouragement.
Then what’s our responsibility?
A patient is someone who is having a very unpleasant experience, that is almost never just because of their pain and pathology, it may be their experiences living with pain, social participation with pain, personal life with pain, loss of autonomy, past experiences with other medical professionals, dealing with constant advice that everyone suddenly has about their pain.
Dealing with all this can be just an inconvenience for some or an ordeal for others, but by no means is it ever a happy ride.
There is not much difference between someone who is unaware and someone who thinks it’s not their ‘job’ to care about these things. compassion should never be something that must be a part of the ‘job description’ to imply.
Providing motivation, support, education, and accountability is our job and we must always try to get better at it.
Remember ! “Words are the most powerful tool a doctor possesses, but words, like a two-edged sword, can maim as well as heal.” -Bernard Lown
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