11/29/2011 12:03 pm ET | Updated Jan 29, 2012

Should Health Care Providers Be Afraid of the 'Nocebo' Effect?

We may soon see "How's my doctoring?" stickers in emergency rooms, operating suites and on the bumpers of ambulances. That's because, as of October 2012, the Affordable Care Act (aka Obamacare) requires patient satisfaction scores to be factored into how much Medicare will pay health care providers.

According to a recent report in the New York Times (Nov. 7, 2011), the hospital industry views reimbursement based on a patient satisfaction reports as a losing proposition. In fact, the power of this purse string may keep many a health care administrator awake at night. Why? Because patients usually don't expect the best from medical care; rather, they often expect the worst! And when discouraged -- despite the best intentions of the doctors, nurses and other hospital staff -- patients can have a negative experience of their care and outcome. This is called the nocebo effect.

We all know about the "placebo" effect: Expecting a positive a response, even to an inactive treatment (like a sugar pill), can bring about a positive outcome for reasons independent of the treatment itself. But when a person enters treatment with negative expectations the result can by the opposite -- they may feel worse after the treatment. This phenomenon is the "nocebo" effect. (In Latin, placebo means "I will please," while nocebo means "I will harm.")

Poor outcomes from poor expectations led Walter Kennedy, in 1961, to coin the term "the nocebo reaction." The power of negative expectations upon clinical outcomes has been well studied since then (see references below). If we think something bad will happen, our gloomy prophecy is apt to be fulfilled. So, how can providers prevent negative treatment responses and the bad scores that will decrease their pay? Answer: avoid the "nocebo" effect.

For better or worse, our minds are as much a part of treatment as the pills and therapies we receive. A good doctor, nurse or therapist will embrace the placebo effect and build positive beliefs and expectations. The nocebo effect, however, is much thornier. The patient's surgery may have been a success, but the surgeon's poor bedside manner, the 24/7 fluorescent overhead lighting and the limited visiting hours may leave the patient feeling more dispirited than they need to be. While some negative outcomes have nothing to do with patient expectations (adverse events are known risks with all treatments), the nocebo effect is especially pernicious because it can contaminate good care and is preventable.

But managing negative expectations is a daunting task. Consumers already believe that the health care industry can do a much better job. In fact, so do health care providers.

There are ways to reduce negative forecasts -- and thus enhance patient satisfaction. As past and future patients ourselves, we suggest that hospitals and doctors try taking the following steps to limit the nocebo effect:

1. Enhance patient (and family) experiences of care. Puncture pessimism with candid, comprehensible and humanely delivered information and support. Design care so it is centered on the patients and their families, not around the routines and conveniences of providers. This is called "patient-centered care" and when done authentically, not as a slogan, it works. Make sure to ask patients if they have understood what has been said. Ask them if they still have questions. Inquire about their concerns, and that of their families. Hope counts immensely and informs positive outcomes, so be sure to provide it.

2. Make patients (and families) true partners in their care. Patients need a durable and genuine partnership with their caregivers. Start by understanding what the patient wants from treatment: Some people want life style interventions, some medications, some surgery, some a combination. Patient preferences should inform clinical decisions -- and this will positively influence how to best proceed. If the patient is not a partner in their treatment plan, then forget about a good outcome, no matter how good the intervention. Continually attending to what the patient needs and wants and building trust will serve as powerful antidotes to the nocebo effect.

3. "Making dreams come true." Walt Disney made dreams a reality and instilled in his organization a culture of friendliness and positive expectations. Disney translated this winning formula into an academy that trains MBAs, corporations and individuals. While a hospital is not Disney World and health care is a serious business, there is much to learn from Walt. Communicating warmth and respect, responding to the customer and delivering the highest quality services are no different. Hospital staff can be trained to be welcoming, positive and responsive.

Better-than-expected services, positive experiences, patient-centered care and human kindness are not a luxury in health care. Importantly, they are opportunities for providers to improve a person's satisfaction with care, achieve better clinical outcomes and even get paid more.


1. Kennedy WP. (1961). The Nocebo Reaction. Medical World, 95, 203-205.

2. Barsky AJ, Saintfort R, Rogers MP, Borus JF. (2002). Nonspecific Medication Side Effects and the Nocebo Phenomenon. Journal of the American Medical Association, 287 (5), 622-627.

3. Amanzio M, Corazzini LL, Vase L, Benedetti F. (2009). A systematic review of adverse events in placebo groups of anti-migraine clinical trials. Pain, 146 (3), 261-269.

4. Colloca L, Miller FG. (2011). The nocebo effect and its relevance for clinical practice. Psychosomatic Medicine, 73 (7), 598-603.

The opinions expressed here are solely those of Drs. Erlich and Sederer, as physicians and public health advocates. Neither receives support from any pharmaceutical or medical device company.

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