Opinion

VIEWPOINT
The Iatrogenic Potential of the Physician’s Words
Arthur J. Barsky, MD Some of the information that physicians convey to their knowledge of adverse effects influences the reported in-
Department of patientscaninadvertentlyamplifypatients’symptomsand cidence of these symptoms. Thus, the frequency and
Psychiatry, Brigham & become a source of heightened somatic distress, an effect profile of adverse effects manifested by patients ran-
Women's Hospital,
that must be understood by physicians to ensure optimal domized to receive placebo in controlled, double-blind
Boston, Massachusetts.
clinical trials are similar to those they have been told may
management of patient care. This effect illustrates the iat-
rogenic potential of information, as opposed to the iatro- occur with the active comparator drug.
genic potential of drugs and procedures. Providing test results of dubious clinical signifi-
Supplemental Somatic symptoms and underlying disease do not cance also can lead to increased symptoms. For ex-
content have a fixed, invariable, one-to-one equivalence. Symp- ample, in a randomized study of acute low back pain, one
toms can occur in the absence of demonstrable dis- group (n = 210) underwent spine imaging, whereas the
ease, “silent” disease occurs without symptoms, and other group (n = 211) did not. A treatment plan of con-
servative medical management was implemented in both
there is substantial interindividual variability in the symp-
toms resulting from the same pathology or pathophysi- groups. At 3-month follow-up, the former group had sig-
ology. One mediator of this variability between symp- nificantly more pain, greater functional impairment, and
toms and disease is the patient’s thoughts, beliefs, and more physician visits.4 The problems involved in con-
ideas. These cognitions can amplify symptoms and veying equivocal test results or anatomical abnormali-
bodily distress. Although cognitions may not cause ties of unknown clinical significance (“incidentalomas”)
symptoms, they can amplify, perpetuate, and exacer- are likely to increase in importance as the volume and
bate them, making symptoms more salient, noxious, in- resolution of diagnostic testing accelerate.
trusive, and bothersome. Pain is particularly sensitive to the beliefs, thoughts,
Several common clinical scenarios exemplify the iat- and expectations of patients. The specific language used
rogenic potential of the physician’s words—for ex- in describing and preparing patients for painful proce-
ample, instituting a new medication regimen, review- dures can affect the pain experience. For example, in a
ing an informed consent document, presenting randomized study of women receiving epidural anes-
thesia or spinal anesthesia (n = 140) for
childbirth, those told that the intrader-
Information is an important mediator mal injection of a local anesthetic would
“feel like a bee sting: this is the worst part
of the variability in the relationship of the procedure” reported significantly
between disease and symptoms. more pain than did those told “the local
anesthetic…will numb the area and you
ambiguous laboratory test information, and preparing will be comfortable during the procedure.”5 The impor-
patients for painful procedures. tance of cognitions in the experience of pain is particu-
Knowledge of the nonspecific, diffuse, ambiguous larly timely, given the current crisis in opiate treatment
adverse effects of a drug (such as fatigue, difficulty for chronic, nonmalignant pain.
concentrating, nausea, dizziness, headache) increases
the frequency with which they are experienced and The Mechanism of Viscerosomatic Amplification
reported.1 Whether the information is imparted through Viscerosomatic amplification has been proposed as an
discussion with the physician or when obtaining in- explanatory mechanism whereby information can
formed consent, patients who learn about the com- affect the perception of symptoms.6 The information
mon, nonspecific adverse effects of β-blockers, statins, conveyed by the physician does not cause somatic
estrogen-containing oral contraceptives, and agents for symptoms but rather amplifies symptoms—symptoms
obstructive urinary symptoms report more of these pu- that may be due to the underlying medical condition or
tative adverse effects than comparable patients not in- to normal physiology (eg, ectopy, orthostatic hypoten-
formed of them. For example, in a study of 76 patients sion), common benign dysfunctions (hoarseness,
who received β-blocker treatment for hypertension, bloating, cramps), transient and self-limited ailments
erectile dysfunction occurred in 32% of the 38 patients (rashes, upper respiratory tract infections), stressful life
Corresponding explicitly informed of this adverse effect and in 13% of events, lack of exercise, insufficient sleep, or dietary
Author: Arthur J. the 38 patients not specifically warned about it.2 Like- indiscretion.
Barsky, MD,
Department of
wise, in a double-blind trial of statins, the incidence of New medical information can initiate a self-
Psychiatry, Brigham muscle-related adverse effects increased from 1.00% perpetuating and self-validating cycle of symptom
and Women’s Hospital, per year to 1.26% per year when patients (n = 9899) amplification (eFigure in the Supplement). Learning
60 Fenwood Rd,
were subsequently unblinded and given the active drug.3 that a symptom may be more noteworthy or medically
Boston, MA 02115
(abarsky@bwh The nocebo phenomenon (the development of ad- significant amplifies it. Reattributing the symptom to
.harvard.edu). verse effects to placebo) strongly supports that patient a new and more serious and more concerning source

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 Opinion Viewpoint

then causes the patient to monitor and scrutinize the symptom
more closely, and this heightened attentional focus amplifies the
symptom, making it more intense and intrusive, more disturbing
and distressing.6,7 The misattribution also launches a selective
search for additional symptoms to corroborate the suspicion that
something is wrong, resulting in a heightened awareness of other
diffuse, transient, or ambiguous symptoms that were previously
ignored, minimized, or dismissed as insignificant. The seeming
emergence of these “new” symptoms (along with dismissal of
observations that do not confirm the suspected cause) is taken as
further evidence of seriousness. The cycle of amplification is also
fueled by mounting anxiety: Increasing worry and concern about
the symptom’s medical significance, and its apparent worsening,
make it more threatening and ominous.
Modulating Symptom Amplification
and Minimizing Undue Distress
Careful attention to what and how information is conveyed can
minimize the inadvertent fostering of excessive, disproportionate,
and unduly bothersome symptoms. The initial therapeutic step is
an exploration of the patient’s ideas about the symptoms: What is
the suspected cause of the symptoms and their putative signifi-
cance, what is the future course expected to be, what is most wor-
risome and troubling about them? The answers to these questions
can lead to more realistic and reassuring discussion of the patients’
specific concerns.
Explaining the process of viscerosomatic amplification can be
beneficial. Understanding that the interpretation of medical infor-
mation can exacerbate and perpetuate symptoms, and learning
about the processes of misattribution, selective attention, in-
creased bodily scrutiny, and secondary anxiety, can have a pallia-
tive effect by providing patients with a more benign and reassuring
explanation for their discomfort. The reassurance that the symp-
toms, however bothersome, are not medically harmful makes them
less intrusive and more tolerable. The nocebo phenomenon pro-
vides a vivid, helpful, and nonpejorative illustration of the power of
beliefs to amplify symptoms. This discussion also helps by empha-
sizing and encouraging adaptive coping to increase the tolerance of
discomfort. It may be useful to prospectively identify patients at in-
creased risk of disproportionate or undue nonspecific medication
adverse effects, so that the amplification process can be explained
to them in advance. This can be done with the Perceived Sensitiv-
ity to Medicines scale,8 a 5-item self-report questionnaire with dem-
onstrated validity and reliability.
In addition to exploring the patient’s ideas and explaining the
process of amplification, physicians need to use care in their choice
of words. For example, in discussing potentially painful proce-
dures, physicians can emphasize what will be done to alleviate the
pain (such as simple relaxation techniques), use neutral language to
describe the experience, and give the patient as much choice and
control over the analgesic regimen as is medically feasible. Like-
wise, language is important in discussing nonspecific drug adverse
effects, for example, focusing on the proportion of patients who do
not have the adverse effects being enumerated, rather than on the
proportion who do, and closely coupling information about ben-
efits with information about adverse effects.
When obtaining informed consent, physicians must abso-
lutely provide complete and truthful information and must avoid fos-
tering a “paternalistic” patient-physician relationship. But balanc-
ing the requirement for full and complete disclosure with the
iatrogenic potential of some information is problematic. “Contex-
tualized informed consent” has been proposed as an ethical way of
balancing these competing imperatives.9 When prescribing a medi-
cation, all serious and medically significant adverse effects are of
course described, and the patient is instructed to report all adverse
effects; however, if the patient agrees, benign, nonspecific symp-
toms are not enumerated in advance because it is explained that do-
ing so makes them more likely.
Unusually distressing symptoms may point to difficulties in the
patient-physician relationship, because symptoms can be a non-
confrontational and less explicit way of expressing doubts or con-
cerns that patients feel and are unable or too embarrassed to voice
openly. Symptoms can then become a covert, nonverbal commu-
nication of anxiety about pain, misgivings about medications, con-
cerns about the meaning of a diagnostic test result, or concerns about
the physician’s care or expertise.1
Conclusions
Information is an important mediator of the variability in the rela-
tionship between disease and symptoms. Some nonspecific drug ad-
verse effects, undue pain from procedures, and symptoms exacer-
bated by learning about test results of unclear medical significance
can be understood to share similar pathogenic mechanisms and re-
spond to similar strategies of medical management.

ARTICLE INFORMATION
Published Online: October 31, 2017.
doi:10.1001/jama.2017.16216
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
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