Doctors who unintentionally communicate that they don’t understand or accept patient concerns have a negative effect on patients’ outcomes. Find our how.
It may be unintentional, but doctors who communicate to their patients that they do not believe or understand their concerns could make patients’ symptoms worse, according to new research.
The opposite of the placebo response, the nocebo response occurs when patient outcomes are negatively impacted because providers give patients the impression that they don’t believe or understand their concerns.
University of Exeter and University of Southampton, UK, researchers explored the potential role of negative patient–doctor communication in facilitating nocebo responses, by analyzing medical consultations involving five women with widespread chronic pain at a pain management clinic. The study is published in the February 2015 American Journal of Medicine.
Patients reported during subsequent interviews that they felt the healthcare providers dismissed their concerns and didn’t believe them. Patients described hopelessness and anger after the invalidating consultations. They felt the need to justify their conditions or to avoid particular doctors or treatment altogether.
Consultants or providers, on the other hand, reported conflict and criticism from patients. They felt patients were entrenched in their views or didn’t believe the providers’ diagnoses.
Doctors who unintentionally communicate that they don’t understand or accept patient concerns have a negative effect on patients’ outcomes. Patients perceive this lack of understanding or acceptance from their doctors, responding with anger and distress, which could worsen their illnesses, according to the study.
Earlier work by the researchers involved 90 subjects who took part in math tests. Maddy Greville-Harris, MSc, Ph.D., University of Southampton, and colleagues randomly assigned participants to a facilitator who provided understanding feedback, by using phrases such as “lots of people find these tests hard,” or one who offered non-understanding feedback, such as “I don't understand why you're struggling - it's just numbers." In that study, which is in the process of being published, Dr. Greville-Harris writes the researchers found that during a series of stressor tasks, participants who received invalidating feedback were more physiologically aroused, were less willing to take part in the study again, showed higher levels of negative mood and reported that they felt less safe, compared with those who received validated or no feedback. There were no differences between the validated and no feedback group, however. And the researchers did not study their task performance.
"This study [in the American Journal of Medicine] is really about humanity in healthcare. We have found that patients perceive a lack of empathy and understanding, even when the doctor is trying to be comforting. Comments such as 'there's no physiological reason that you're experiencing pain' seek to reassure, but can be perceived as patronizing or disbelieving. We now need to see more research in this area, and for that to feed into training doctors to be more effective communicators for every patient they see," study author Professor Paul Dieppe, M.D., of the University of Exeter Medical School, says in a press release.
Dermatologists and clinical psychologist Rick Fried, M.D., Ph.D., writes in an email to Dermatology Times that this is an important study.
“Simply stated, empathy, validation of the seriousness and validity of symptoms and provision of an understandable explanation of the etiology of symptoms (one that avoids blame or judgment of the patient) work best,” Dr. Fried writes.
Nocebo effects can include anxiety, fear, confusion, hopelessness, despondency and anger (to name but a few). All these, he writes, can trigger stress pathways leading to psychophysiologic activation. The results: increased vigilance, increased heart rate, increased blood pressure, jitteriness, sleep impairment, GI distress, fatigue, arthralgias, impaired attention and concentration, decreased sexual desire and function and more.
“Nocebo effects can lead to increased release of inflammatory mediators that can objectively worsen common skin conditions such as eczema, psoriasis, rosacea, acne, urticaria, pruritus, pain, and other dysesthetic symptoms and syndromes,” Dr. Fried writes.
One solution? Be empathic, offer hope, offer solutions, offer understanding and humanity, Dr. Fried writes.
Tavel ME. The placebo effect: the good, the bad, and the ugly. Am J Med. 2014;127(6):484-8.