The document discusses the nocebo phenomenon in patient-doctor communication. Nocebo refers to negative symptoms induced by negative suggestions from clinical staff or a patient's own expectations. Unintentional negative suggestions from doctors and staff can induce new symptoms or worsen existing ones through psychological and neurobiological mechanisms. A study found that surgeons and anesthetists commonly use nocebo words and phrases when communicating with patients, such as emphasizing negatives, focusing on pain, and causing uncertainty. The conclusion is that nocebo phenomenon exists in clinical practice and doctors should be educated to avoid subtle negative messages that can negatively impact patient outcomes.

1. Nocebo Phenomenon
in Patient-Doctor
Communication
Dr Muhammad Saaiq
FCPS(Surgery), FCPS(Plastic Surgery),
Islamabad.
Authors:
Dr Bushra Ashraf, M. Saaiq, Prof Khaleeq Uz Zaman
PIMS, Islamabad.

2. Nocebo Phenomenon
It is the induction of a negative symptom by
negative suggestions from the clinical staff
and/or the patient’s own negative expectations.

3. Nocebo effect often
results from
“Subtle Mis-communication”

4. Unintentional Negative Suggestions
Patient
Induction of new
Symptoms or
Worsening of pre-existing
ones
Doctor/ Staff

5. What are the
underlying mechanisms

6. Psychological mechanisms:
Similar to the placebo effects of learning
by conditioning and reaction to
expectations.
Neurobiological mechanisms:
Placebo and nocebo effects are based
on similar neurobiological events.
Inter-individual variations:
Women were more susceptible to
conditioning and men to generated
expectations

7. Unintended negative
suggestions in Our
everyday clinical practice

8. Ineffective negation and trivialization:
“You don’t need to worry.”
“It’s just going to bleed a bit.”
“You won’t have pain”
“You won’t die”

9. You may feel “sting,” “burn,” “hurt,” “bad,” or
“pain” when explaining the Injection or
procedure.
“Are you feeling nauseous?” (recovery room)
“Signal if you feel pain.” (recovery room)
Focusing attention or Distraction in
a wrong way:

10. Emphasizing the Negatives:
“You are a high-risk patient.”
“That always hurts a lot.”
“You must strictly avoid lifting heavy objects—
you don’t want to end up paralyzed.”
“Your spinal canal is very narrow—the spinal
cord is being compressed.”

11. Causing uncertainty:
“This medication may help.”
“Let’s try this drug.”
“Try to take your medicines regularly.”

12. “We’re wiring you up now.” (connection to the
monitoring device)
“The machine will cut you into lots of thin
slices.” (CT Scan)
“Now we’re hooking you up to the artificial
nose.” (attaching an oxygen mask)
Unnecessary explanations:

13. “We’ll just finish you off.” (preparation for
surgery)
“We’re putting you to sleep now, it’ll soon be
all over.” (induction of anesthesia)
Ambiguity:

14. Ineffective negation
Focusing attention wrongly
Unnecessary Jargons
Emphasizing the negatives
Causing uncertainty
Ambiguity

15. Our Study

16. Responses of the
participants
Questions
Nocebo
communication
N
p-value
(%)
1 Whenever I come across an anxious patient in the
operating room or on the operating room table or in the
procedure room, I try to reduce the anxiety of the patient
by saying
111(72.52%)
42(27.45%)
<0.000*
2 When a patient is undergoing an intervention
under local anesthesia, I address the anxiety by
usually saying
107(69.93%)
46(30.06%)
<0.000*
3 In the recovery room of the operating theatre,
when the patient is recovering from anesthesia, I
allay the anxiety, pain, nausea, vomiting of the
patient by saying
93(60.78%)
60(39.21%)
<0.000*
4 At the time of changing wound dressing of my patient, I
often console my patient and allay his anxiety of pain by
saying
103(67.32%)
50(32.67%)
<0.000*
5 Sometimes my patient needs distraction of
attention and I often say the following sentences/
words to do that
119(77.78%)
34(22.22%)
<0.000*
6 In the process of briefing to patients while taking consent
or doing counseling, I explain the risks of procedure by
using the following effective sentences
95(62.09%)
58(37.90%)
<0.000*
7 Can the choice of my words affect the well being of my
patients during communication Yes 100(100%) N0
-
--
8 Do you know NOCEBO phenomenon in clinical
practice? Yes - No 100(100%)
--

17. Nocebo words and sentences Categorization
Don’t worry, everything will be fine. Counterproductive negation
Don’t be afraid -
There won’t be any problem -
There is no danger, it just a small
operation
-
You won’t have pain -
There is no risk to life -
The injection will hurt a bit Emphasizing the negative
There may be just a small bleeding -
Tell me if you have any pain Focusing attention on the negatives
Are you experiencing any nausea or
vertigo?
-
Is your heart sinking? -

18. Conclusion
Nocebo phenomenon existed in the clinical
practice of the surgeons and anesthetists during
their communication with patients.
There is need to create awareness among these
professionals about the subtle negative
messages conveyed by such mis-communication
and alert them that the nocebo effects have
negative repercussions on the clinical outcomes
of their patients.
The professionals should be formally educated to
avoid nocebo words and phrases.

19. Thank You
Dr Muhammad Saaiq
Department of Medical Education,
SZABMU/ PIMS, Islamabad.
Dr Muhammad SaaiqDr Muhammad Saaiq
Department of Medical Education,Department of Medical Education,
SZABMU/SZABMU/ PIMS, Islamabad.PIMS, Islamabad.