Doctors Recognize the Power of Negative Thinking, and They Want to Change

Long ago, before tort lawyers ruled the land, the family doctor knew how important it was to reassure and support patients.  Physicians wouldn't dream of giving a treatment in a negative context because the power of suggestion (what we now call the placebo response) was respected as a healing factor. Fast forward to the modern era when doctors afraid of malpractice suits routinely give patients long lists of what might go wrong and often tend to err on the side of worst case scenarios.

Nurse Ratched: the poster child for caregiver negativity.Now along comes a wake-up call from the Department of Bioethics at the NIH basically telling doctors to stop being so negative. Deeply researched and thoughtful, the communication published in the vaunted Journal of the American Medical Association describes the potent effects of nocebos (negative suggestions) and calls for a new direction in the medical community that ethically takes into consideration the power of negativity. The communication sites some pretty astonishing research to back-up the authors' eye-popping assertion that "just one occasion of negative information can induce long-lasting negative effects."

Informing men about the potential sexual dysfunction induced by a drug--by saying, “It may cause erectile dysfunction, decreased libido, problems of ejaculation but these are uncommon”--was associated with 43.6% of men actually experiencing sexual adverse effects. In comparison, 15.3% of the men who were not told of the potential side effect experienced similar adversity.

Negative commentary from a health care provider--including doctors, nurses and front office staff (anyone who comes in contact with patients in the healthcare environment)--can effect a wide-range of physical responses from pain to impotence.  In a paper published in the journal Pain, researchers found that clinical-trial participants have reported a wide variety of nocebo-fueled medical complaints, including burning sensations outside the stomach, sleepiness, fatigue, vomiting, weakness and even taste disturbances, tinnitus and upper-respiratory-tract infection.

Enough to scare any medical professional into communicating better is a study conducted on sexual dysfunction. In a study of men recieving the drug finasteride for benign prostatic hyperplasia, informing the men about the potential sexual dysfunction induced by finasteride--by saying, “It may cause erectile dysfunction, decreased libido, problems of ejaculation but these are uncommon”--produced 43.6% of sexual adverse effects vs 15.3% when the same adverse effects were concealed. It turns out the simple word "may," which no doubt sounded harmless enough to the providor, sounded quite threatening to the patient--enough to make some of them lose their mojo. 

No one is suggesting people not be informed of potential side-effects, but there are ways to do it that will cause less harm. Rather than merely delivering general lists of specific adverse effects the JAMA authors suggest, "clinicians should incorporate in their communication positive framing and percentage formats as opposed to negative framing and frequency format." In other words, the exact stastic--ie saying this happens to 2% of people --is more reassuring than hearing it's "a possiblity." Think specific information as opposed to doomsday scenarios.

The biological mechanisms to explain the nocebo--or even for that matter the placebo--are not well understood.  Since the late 1970s advances in neuroscience research have been able to show that the brain produces its own pharmacy, it's able to secrete substances similar to morphine and heroin to a name a couple. And research has established that some individuals' "brain pharmacies" are more susceptible to suggestion than others.

But this doesn't explain clearly why ailing patients who are mistakenly informed that they have only a few months to live have died within their given time frame, even though postmortem investigations show that there was no physiological explanation for early death. Possibly nocebos pull the rug out from under the body's attempts to self-heal. 

In any case, framing a concept more positively is an easy way to help a person heal. Wouldn't it be wonderful if everyone in your doctors' office--from the person who makes your appointment to the person who takes your payment (and yes the doctor him or herself)--actually believed in you and your ability to heal. What a pleasure it would be to visit that office.