In her paper, ‘Sharing online clinical notes with patients: implications for nocebo effects and health equity’, Blease bridges findings from two research fields to describe possible unintended consequences of providing patients access to clinical notes. 1 She explains how nocebo effects, genuine psychological and physiological reactions following negative expectations, may arise after patients read such notes. Blease emphasises that the likelihood of nocebo may be greater for those patient groups who experience stigmatisation in healthcare. We argue that this is the (...) case for patients with so-called medically unexplained symptoms (MUSs) and that clinicians who work with them should consider nocebo but not for the reasons they may think. MUS is a term used to refer to persistent physical symptoms which cannot be fully or reliably attributed to a structural pathology. They include common symptoms such as chronic or recurrent pain in joints and muscles, fatigue, paresthesia or digestive... (shrink)

While positive information in the context of clinical care can lead to placebo effects, negatively framed information can have negative or nocebo effects. Extant literature documents how doctor–patient encounters are fertile ground for suboptimal interactions leading to negative experiences for ethnoracial minority patients. In their _JME_ paper, Blease presents a critical perspective on the potential for patients’ access to their doctors’ clinical notes, ‘open notes’, to engender nocebo effects. 1 In this commentary, we affirm the central claim that nocebo effects (...) could emerge ‘via negative wording or framing of health information expressed by clinicians in documentation’. The advent of electronic health records (EHR) allowed patients the unprecedented opportunity to access personal clinical documentation, giving them a window into decision making around their health. This shift is undoubtedly complex, and thus warrants a more fulsome rendering of the unique challenges faced by ethnoracial minority patients. Herein, we highlight three... (shrink)

With more countries implementing Open Notes, the practice of providing patients with unhindered access to their clinical visit notes, research on this practice is finally increasing. Many studies report positive findings, especially around self-reported outcomes, such as feeling more in control of one’s care, increased medication adherence and a strengthened patient–doctor relationship. 1 However, comparatively less research has been done on the potential ramifications that may also arise from Open Notes. Blease’s recent article underscores this and demonstrates why Open Notes (...) must also be considered in terms of nocebo effects, negative side effects that arise from negative expectations. 2 The article presents a compelling and well-thought-out argument for how nocebo effects may vary across different populations by linking patient–clinician communication inequalities with and by presenting preliminary evidence of nocebo effects. Blease’s argument does not detract from Open Notes, but rather takes a balanced approach by imploring us... (shrink)

In this article, Charlotte Blease argues that patient access to online shared clinical notes (also called ‘open notes’) may cause or exacerbate nocebo effects in two ways. 1 First, open notes may enhance patient understanding about the adverse effects of medications and treatments. However, reading information about adverse effects may lead patients to form negative expectations that, in turn, may cause or worsen symptoms via nocebo mechanisms. Second, open notes may paradoxically lower the quality of the therapeutic relationship by allowing (...) patients to detect signs of discrimination and stigma in clinical notes. By accessing their shared notes, patients may identify (or think that they are identifying) signs of stigmatisation and discrimination in clinicians’ words. This may diminish their trust while increasing their anxieties and fears, all factors that have been associated with enhanced nocebo effects. The article then suggests different strategies to mitigate nocebo effects while using open... (shrink)