Hi everyone and welcome to our first video for module 8.

With the start of chapter 8,

we’re now moving into part 4 of the course, which moves away from a lot of the
focus on individual modifiable behaviours that we’ve been predominantly talking
about throughout the course so far. We'll now shifts our focus to how the individual
interacts with various health care services that are available. In this section of the
course we’re going to learn about that 4th pillar of what Health Psychologists might
focus on that we touched on way back in module 1: The impact of health institutions
and health professionals on people’s behaviour.

Remember that it is an important area of work for Health Psychologists to try to help
improve the health care system so that it functions best for the people that need it.
The first step in this process, like most research, is investigating how people
currently use or misuse health care services and the impact that use of services has
on people. So those will be some of the broad topics that I’ll focus on in this video. I’ll
first touch on illness schemas, to help us understand how people conceptualize
illness symptoms that might prompt them to seek health care services. Then, I’ll talk
a bit about ways that health care services can be misused. I’ll end with some impacts
of hospitalization on people that require that type of health care service.

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So let’s dive in and investigate the use of health services.
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Treatment-Related Behaviours: A Continuum

LO1: How
do we
recognize
and
interpret
symptoms?

Studying the use of health care services is important because we know that there are
some people who feel ill or are ill but they don’t seek out the use of health care
services when they probably should. Then there are other people that seek out the
use of health care services when they don’t actually need that type of service.

For example, when I had those digestive symptoms that continued to get worse for a
couple years, I really should have sought out some type of health service long before
I finally did. It wasn’t until the pain from those symptoms was almost unbearable and
started to scare me that something was really wrong that I finally sought care.

Another example is a friend of mine. He knew that he had high blood pressure, but
he never did anything about it. One day he noticed his heart felt like it was racing and
he felt really hot and dizzy, so he went to the pharmacy to use one of the blood
pressure machines to check his blood pressure. It was 180/120. That is so high that it
is considered a hypertensive emergency and you should basically get yourself to the
hospital immediately, which is thankfully what he did.

Then on flip side, this same friend’s wife will go to the doctor for every little cough or
sniffle and typically get a prescription for antibiotics each time. Recall our discussion
of the overuse of antibiotics from module 2, as they can often be prescribed for
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symptoms that are actually caused by a virus and would go away in about 5 days
anyway. All of these examples are non-ideal uses of health care services.

As your text points out, there is a continuum of behaviours related to using health
care services, from getting regular screenings, which my friend didn’t do for his blood
pressure, to actually seeking care, which I didn’t do for my gut symptoms, to then
following a prescribed course of care, which many people don’t do when they are
prescribed antibiotics and then stop taking them halfway through when they start to
feel better. Health Psychologists can study all these different areas related to the use
of health services to try to make improvements through various types of
interventions.

This chapter mostly focuses on the care-seeking portion of the spectrum. One part of
what motivates people to seek care is how they recognize and interpret the
symptoms they are experiencing.
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 Illness Schemas

LO1: How do • Conceptions of illness

we recognize • Range from sketchy/inaccurate to extensive/technical
and interpret • Influence preventive behaviours, reactions to symptoms, adherence
symptoms? to treatment, expectations for future health…

• 5 Components:
• Identity
• Consequences
• Causes
• Duration
• Cure

Along with recognizing and interpreting symptoms comes essentially fitting those
symptoms into some kind of illness schema. Schemas are mental short-cuts that we
use all the time. Schemas are concepts we’ve stored in our memory about how
certain actions, objects, or ideas relate to each other. As we acquire knowledge, we
create schemas that enable us to know roughly what to expect in a given situation
and to draw on our previous knowledge when we encounter something new, so
they are an example of top-down processing. They help us to mentally organize
events that share core features so that we don’t have to figure out things from
scratch each time we enter a slightly new scenario.

For example, you have a schema of how to behave when you enter a classroom. You
probably find an empty seat, take out your laptop or notebook, and get ready to
listen and take some notes. You don’t have to think about what you should do every
time you go into a new classroom the first day of a new semester. You already have
that mental short-cut stored in your memory. When we had to switch to online
learning pretty suddenly last Winter, then you had to develop a new schema for how
to go about learning online at home. Or if you have a class or two in person now,
you’ve likely started to develop a slightly revised schema of entering a classroom that
now involves disinfecting your work surface before you can take out your computer
and books. So schemas are mental shortcuts we use to organize events and ideas in
our minds. We have all kinds of them for a variety of everyday behaviours and ideas.

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We also have these types of schemas for illness. An illness schema is someone’s
concept of health and illness that influences how they react to various symptoms.
So basically, what is your collection of prior knowledge about the symptoms you're
experiencing that helps you to figure out if they are something minor, and you should
just stay home and get some rest, or if they are something major for which you
should seek care. In our current times, many of us are having to shift our illness
schema around certain symptoms that we likely previously regarded as pretty minor,
like a runny nose, cough, sore throat, or mild fever, because we’ve now had to add
the potential of COVID-19 into our illness schema for those symptoms. We’re having
to alter some of those previous ideas we had stored in our memories about what
those particular symptoms might mean and the appropriate action we should take if
we notice them. Instead of maybe trying to power through our workday despite
these symptoms, and just trying to get some extra rest, now we have to think about
self-isolating, reporting, and getting tested for coronavirus. We’re developing a new
illness schema.

Our new illness schema for these symptoms has been helped by massive information
campaigns telling us what we should do if we experience these symptoms. We don’t
have those same types of massive sustained information campaigns for a lot of other
types of symptoms. For example, not until I started really digging into research on my
own did I ever suspect that stomach pains like I had could be linked to having a
parasite. You don’t hear about that on the news every day for months on end. This
example highlights the idea that some illness schemas we have can be sketchy or
inaccurate. In this case, we may not have a lot of prior information about certain
symptoms or what they might mean, so we don’t really know how to interpret them
or what to do about them, like me and my gut symptoms. But then other illness
schemas we might have could be very technical and extensive, like all the symptoms
and steps to follow that we now associate with coronavirus. How detailed and
extensive our illness schemas are can have a strong influence on how we react to the
symptoms we experience, what we do about them, how well we adhere to treatment
for them, and our expectations about our future health. If you don’t have a solid
illness schema, you might not recognize certain symptoms as important or severe,
and therefore might not seek care. Or, if you have an illness schema about COVID-19
that it’s basically just a mild flu, that schema would impact how you behave when
you experience symptoms and how well you will adhere to the suggested steps to
follow.

As I previously mentioned, the media can be a big influence on our illness schemas. In
addition, our own prior experience, or experiences we’ve seen our family and friends
go through, can also largely influence our illness schemas around certain symptoms.

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For example, I mentioned before that my grandma had a stroke back when I was 8.
My Mom (that lovely woman pictured on the slide) then took care of my grandma for
many years after that, since my grandma lost a lot of her mobility and independence.
So my Mom was really familiar with the symptoms and consequences of a stroke. A
few years ago, my Mom experienced symptoms where one side of her body suddenly
felt weak and limp, she dropped the shopping bad she was carrying, and her vision
started to blur. She immediately sat down and my Dad went to get her baby aspirin
right away. They knew those symptoms were some of the symptoms of stroke
because of the extensive experience my Mom had dealing with stroke with my
grandma. So they took those symptoms seriously right away and knew what to do
about them. My Mom then went to the hospital immediately to get checked out and
it turned out that she had indeed had a mini stroke. If my parents hadn’t had an
illness schema for those particular symptoms and what to do about them, they may
not have taken them seriously and my Mom could have potentially suffered an even
more severe stroke later because she didn’t do anything about those early warning
symptoms.

I’ve put an example on this slide of a media campaign to help people become aware
of the symptoms of stroke. Media campaigns can help improve people's illness
schemas for symptoms and help them know what to do quickly if they do experience
them, just like my parents did. A media campaign like this is something a Health
Psychologist might help develop.

Illness schemas have five distinct components that include basic information about
an illness. These components are:
1) The identity, or label, for an illness, like Stroke or COVID-19.
2) The consequences of the illness, which include its symptoms and treatments, as
well as the extent to which the person believes the illness has ramifications for
their life, For example, do you believe that COVID-19 can potentially lead to
longterm health complications or do you believe it’s more of a mild flu that will
go away in a week or so with no potential lasting consequences.
3) The causes are the factors that the person believes gave rise to the illness, such
as environmental or behavioural factors. For example, does a person believe that
their diet can contribute to symptoms of a stroke or that attending large social
gatherings could potentially lead to catching coronavirus.
4) The duration refers to the length of time the illness is expected to last.
5) The cure refers to whether the person believes the illness can be cured through
appropriate treatment.

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All of these elements of an illness schema basically guide a person’s decisions about
the types of actions that may need to be taken to help deal with the perceived
illness.

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 Misuse of Health Care Services

LO3: How are

Health • Psychological Issues
Services
Misused? • 2/3 of physician time spent with people with
psychological concerns
• Doctors can misattribute physical symptoms to
psychological causes
• Worried well vs. Somaticizers
• Stigma
• Secondary gains/Malingering/MunchausenSyndrome

Ok, now that we’ve covered some reasons why people might not seek out the use of
health care services when they should, perhaps because they have a sketchy or
inaccurate illness schema for the symptoms they are experiencing, let’s now turn to
other ways that people misuse health care services. This is also an area that a Health
Psychologist may want to focus on to help improve access and efficiency of health
care services for those people that truly need those particular services.

One misuse of health care services is seeking the care of a physician for symptoms
that are primarily brought on by emotional or psychological concerns. Physicians
estimate that as much as two-thirds of their time is spent with patients whose
symptoms are psychological rather than medical. These symptoms are typically
related to anxiety and depression. Now, of course we know through much of what
we’ve learned in this course that physical issues can arise from psychological
disturbance, like those brought on by excess stress, which is closely linked to anxiety
and depression. But this statistic is mostly referring to people that don’t present with
physical symptoms as a result of their psychological symptoms.

Another issue is that sometimes patients present with physical symptoms, for
example chronic fatigue or fibromyalgia pain, but nothing can be found in the body
that seems to be causing the issue, so a physician may then assume the physical
symptom is related to something psychological. I experienced this when I had my gut
symptoms. After all my blood tests came back normal my doctor basically insinuated
that the symptoms must be all in my head or related to something psychological.

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Now this of course was very frustrating because I study stress, I know if I’m stressed
or not, and I knew that was not the cause. However, when the traditional tests didn’t
show anything, assuming a psychological cause seemed to be my provider’s default
response. So sometimes doctors may mistakenly attribute symptoms to psychological
causes when something may actually be legitimately going on with the body, like my
parasite, but the doctor just doesn’t know what it might be. Statistically research
shows doctors are more likely to make this assumption about their female patients
than their male patients. We’ll talk about this idea more in the next video when we
talk about stereotypes in medicine.

There are of course some times when people will present with symptoms that are
psychological or emotional. While these concerns are of course still valid and
important reasons to seek health care services, there are other services that are
more appropriate, such as mental health counsellors, rather than visiting an ER or a
family physician. But, another caveat to keep in mind here is that some of this use of
services may be related to a lack of adequate mental health service availability. If
people are really struggling, they may present to a different type of care service just
to get access to some care. This is again an area that Health Psychologists may study
to see how often this is the reason that people “misuse” health care services to then
make recommendations for additional resources to be put towards care in the areas
where it is needed.

There are also a type of people referred to as the “worried well”. These people are
concerned about physical and mental health, are inclined to perceive minor
symptoms as serious, and believe that they should take care of their own health.
These people’s health beliefs, and their commitment to self-care, actually leads them
to use health services more for minor symptoms that may not necessarily require
those services.

Another type of people that may misuse health services are somaticizers, or people
who express distress and conflict through bodily symptoms (remember
Psychosomatic Medicine from module 1). When somaticizers have experienced a
threat to self-esteem or to their accomplishments, they are especially likely to
somaticize, convince themselves they are physically ill, and seek treatment. In this
case, the condition is generally psychological in nature, but is expressed through
physical symptoms. In this case, again treatment by a different provider, such as a
counsellor, may be more appropriate than a medical provider.

Another reason that people use health services for psychological complaints is that
medical disorders may still sometimes be perceived as more “legitimate” than
psychological ones. For example, a person that is too stressed out to go to work may
think that is not a valid reason for taking a personal day. Instead they may call in sick

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as a physical illness may be perceived as a more legitimate reason for missing work.
Cultural differences can also play a role here. For example, in some Asian societies,
expressing emotional distress as a physical complaint is seen as more culturally
acceptable, as mental health issues can carry considerable stigma.

And lastly, illness can bring some benefits, called secondary gains, like the ability to
rest, to be freed from things you don’t want to do, like go to work, and to be doted
on by others. These benefits might be perceived as rewarding, which may encourage
the person to not look forward to regaining their health because they might lose
some of those benefits of rest and attention or sympathy from others.

Sometimes the inappropriate use of health services can represent true malingering.
This happens when a person fakes some type of illness because they want some of
those secondary gains I just mentioned, like time off work, or attention. For example,
there is a fascinating and disturbing condition called Munchausen Syndrome in
which people deliberately act like they’re sick when they’re not, often times to
garner sympathy or attention from others. A particularly disturbing manifestation of
this condition is Munchausen by Proxy. In this condition, a caregiver either makes
up, or actually causes, an illness in someone under their care, like a dependent child
or an elderly person, again usually to get sympathy or attention or to be viewed as a
great and sacrificing caregiver. I’ve posted a video about one of these cases as one of
your optional videos for this module. These cases are very disturbing because the
caregiver is harming the person under their care, who often thinks they have a
legitimate illness, and thus it is considered a form of abuse.

Now, like I mentioned with my case, it can be very frustrating when someone thinks
you’re misusing health services when you really aren’t. Another example of this
situation is my brother-in-law (the man on the slide). He works for a professional
moving company. Last year he hurt his elbow on the job and he wasn’t able to go to
work for a few months. He was trying to get documentation from his doctor to apply
for his disability money since he couldn’t work due to an injury sustained on the job.
But because my brother-in-law is in such good shape from being a mover, the doctor
gave him a really hard time and insinuated that he was faking his injury to get off
work and still get paid. He essentially accused him of malingering. Now here I’ll
mention this is in America as my in-laws live in Massachusetts. It took my brother-
inlaw about 4 months to finally get the medical paperwork he needed to get his
disability money. So in this case, he was trying to use health care services
appropriately, but was experiencing issues due to the perception of the physician. I’ll
touch on this topic more in chapter 9 when we learn about patient-provider
relations.

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So we can see there are a variety of ways that health care services might be used or
misused that are related to psychological symptoms. These cases can be very hard to
distinguish. Sometimes symptoms are actually caused by something in the body, but
a provider may mistakenly assume they are caused by something psychological, or
symptoms that are caused primarily by psychological issues may be expressed
physically, or a person may be using services for reasons not related to health, like
attention, which is also a psychological issue, or they may be trying to use health
services legitimately but their provider misattributes their use to something else, like
malingering, which is a psychological perception on the part of the provider. It can be
very complicated to try to figure out what is truly going on in any particular case and
how the best care should be delivered for each particular person’s needs.

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 Misuse of Health Care Services

LO3: How are

Health
Services
Misused?
• Delay Behaviour
• Normalize symptoms
• 1) Appraisal, 2) illness, 3) behavioural, 4) medical
• No regular doctor, fear, type of symptom,
provider delay

Another type of misuse of health care services is delay behaviour. This was again me
with my gut symptoms. Delay behaviour occurs when someone should seek
treatment for a symptom but puts it off, which is a misuse of health services by not
using them when you should. One reason people engage in delay is normalizing their
symptoms, which often stems from having an illness schema that those symptoms
aren’t serious or requiring of health care services. This is exactly what I did for a
couple years when my symptoms were more mild. I figured lots of people have
digestive symptoms these days, so it’s just something that you get used to and it’s
not something for which you seek care.

Delay is basically defined as the time between when a person recognizes a symptom
and when the person obtains treatment. So for me and my gut symptoms, the delay
was literally years.

Delay is composed of 4 broad time periods:

1) Appraisal delay, which is the time it takes an individual to decide that a
symptom is serious. For me, this was years before I finally decided my symptoms
were serious enough to do anything about. And that only happened when I was
laying in bed one night and was in so much pain that I thought I might have a
whole body infection, which of course the internet told me could be fatal.
2) Illness delay, which is the time between the recognition that a symptom implies
an illness and the decision to seek treatment. Here my delay was short. Once I
decided that my symptoms were serious, I pretty much decided right away that I
would finally do something about them and see a doctor.

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3) Behavioural delay, which is the time between deciding to seek treatment and
actually doing it. Here I had a delay of a couple months. First because I made my
decision to do something about my symptoms when I was back in Ontario in the
summertime visiting my family. I figured I would do something about my
symptoms when I got back to Alberta, which was a couple weeks away. I also
didn’t have a family doctor in Alberta, so I had to go about finding one that was
taking patients, getting approval to be a patient there, then booking an
appointment.
4) Medical delay, which is the time that elapses between making an appointment
and receiving appropriate medical care. Again this was awhile for me because
first it took a couple weeks after I finally found a doctor to actually get in to see
her. Then once I did, she didn’t know what was wrong with me, so she was
unable to provide appropriate medical care. Ultimately I ended up providing the
care to myself.

Medical delay is more likely when a patient deviates from the profile of the average
person with a given disease. For example, I have a friend from high school that was
diagnosed with Hodgkin’s lymphoma, which is a type of cancer. When she first went
to get checked out for her symptoms, which were general fatigue and just not quite
feeling right, she was basically dismissed as her symptoms being related to stress.
She didn’t fit the profile of someone that typically gets Hodgkin’s because she was
young and female. She experienced medical delay because it took months for her to
get the appropriate treatment after making an appointment because they didn’t
recognize what was wrong with her at first. It was only after lumps started appearing
on her neck that she was properly diagnosed.

Your text highlights that delay is common among people who don’t have a regular
physician, like me, and my delay was caused by exactly what your textbook
describes. In addition to actually seeking treatment, I first had the extra burden of
finding someone to get treatment from. Your textbook highlights that in Canada,
about 3.5 million adults do not have a regular family physician, and they are
therefore less likely to visit a doctor. And with what is currently going on with
Alberta’s health care system and the government, who knows what will happen to
those numbers in the future…

Another reason for delay, which I’ll admit factored into my delay behaviour too, is
fear. I’ve never really liked going to the doctor and I have a pretty legit phobia of
needles. I get lightheaded at just the sight of them. I knew I’d have to get blood
drawn to figure out what was wrong with me, so that contributed to my delay
behaviour. Even after I finally saw my doctor and she gave me the requisition for the

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blood tests, I then further delayed actually going to get my blood drawn by another
couple weeks.

Another factor that predicts delay is the nature of the symptoms. When a symptom
is similar to one that previously turned out to be minor, the person will seek
treatment less quickly than if the symptom is new. This again relates to that idea of
illness schemas. If you have a symptom that was a minor thing before, you store that
information in your memory and form a schema about what that symptom means –
that it’s not that serious. Symptoms that don’t cause pain, that don’t change quickly,
and that aren’t incapacitating are less likely to prompt someone to seek medical
treatment.

Further, similar to what I just mentioned related to my fear of needles, delay doesn’t
end with the first treatment visit. Up to 25 percent of patients delay taking
recommended treatments, put off getting tests, or postpone acting on referrals. In
some cases, patients have had their curiosity satisfied by the first visit and no longer
feel any urgency about their condition. In other cases, the opposite happens and
patients become truly alarmed by the symptoms and, to avoid thinking about them,
take no further action.

Here I want to point out one more factor that can contribute to delay: being busy.
That was another reason I delayed for so long. It seemed like it would take so much
valuable time out of my day to actually take care of my health when I had so many
other work-related things going on. I’m sure many of you have probably experienced
this phenomenon too. You put off getting something looked at until you have ‘more
time’, but ‘more time’ never seems to materialize. This is another example of that
Dalai Lama quote I started our course with. We sacrifice our health to make money,
then have to sacrifice our money to try to regain our health. I’m just as guilty of this
as anyone being a part of our go go go productivity culture. Trust me, it’s something
I’m thinking about more seriously these days and trying to work on: establishing
more balance in my life for the sake of my overall health.

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 Impact of
Hospitalization

LO4: How
doe
hospitaliza
tion

impact the
patient? • Nosocomial Infection
• Infection from disease exposure in
a hospital
• 250,000 people/year infected.
8,000-12,000 die
• ~1 Billion year cost for treatment
• Inadequate hand washing
The last topic I’m going to touch on in this video is the impact of hospitalization on the patient.
This topic seems particularly relevant during these pandemic days when we are all concerned
about the capacity and safety of people in our hospitals. Your text describes that more than 2.9
million Canadians are admitted yearly to more than 800 hospitals, with childbirth, respiratory
disease, and heart attack as the top three reasons. That’s a lot of people admitted to the
hospital before we even consider COVID numbers.

One of the big impacts of hospitalization, that everyone is even more concerned about in these
pandemic days, is nosocomial infections. These are infections that result from exposure to
disease in the hospital setting. If someone catches COVID-19 due to exposure when they were
at a hospital, that would be considered a nosocomial infection. Fear of this type of exposure is
one of the things keeping people away from hospitals these days, even when they actually
should seek care for certain symptoms, like those of a mild heart attack or stroke.

Your textbook cites a study suggesting that every year about 250,000 Canadians, or one in every
nine who are admitted to the hospital, pick up an infection unrelated to their original health
complaint. The cost of treating those people who are infected is estimated to be about $1
billion a year. Just from treating infections that resulted from exposure at a hospital.
Nosocomial infections account for more deaths per year in Canada than breast cancer, AIDS,
and car accidents combined. And again these numbers are pre-COVID.

Sadly, many of these infections result from simply not following the strict guidelines for
handwashing, sterilization, and waste control in hospital settings. Perhaps one silver lining of
this pandemic is that these types of sanitation protocols are being followed much more strictly
now; hopefully this level of diligence will help to cut down on the number of nosocomial
infections. Another disturbing statistic is that, of all hospital workers, physicians are the most
likely to not strictly follow sanitation protocols. Physicians are also the ones least likely to be
corrected by other hospital staff, like nurses. If staff members felt better able to point out
sanitation protocol violations to others in a constructive way, better infection control, and a
reduction in nosocomial infections, might result. A Health Psychologist could be involved in
developing policies or providing training for communication to help staff be more assertive in
communicating with doctors when they notice violations of the sanitation protocols.

I’ve included some diagrams on the slide that highlight the most common types of nosocomial
infections that people pick up from hospital exposure. One of the more serious types of
nosocomial infections, aside from COVID, is infection with one of the ‘superbugs’ that we talked
about back in module 2 when discussing antibiotic resistance. An example is infection with
MRSA. These infections are particularly serious precisely because the infectious bacteria are
resistant to antibiotics, so if someone catches one of these infections, there is not much that can
be done for them.

This was the situation with my cousin, who you see on this slide. About 10 years ago, he was in a
serious head on car crash with someone in a van who wasn’t paying attention and hit him. They
had to use the jaws of life to get him out of the car. He broke many bones in his body and was in
the hospital for over a month. During one part of his hospital stay, he contracted a blood
infection from exposure to bacteria at the hospital. He ended up with full body sepsis, which is a
full body infection. The hospital staff called my aunt and uncle to come stay the night with him
because they honestly weren’t sure if he was going to survive the night. Thankfully his immune
system was ultimately able to fight the infection and he recovered, but it was really scary. So the
closest he came to losing his life was not actually because of the dramatic injuries from his car
crash, but because of an infection he picked up from being in the hospital. Thankfully he made a
full recovery and now runs a small organic farm in Ontario.

This story also relates back to my illness schema of symptoms of whole body pain and thinking
that maybe I had a full body infection when I had my gut issues. That was about 6 years after my
cousin’s accident and hospital, stay so my familiarity with his case of a full body infection being

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potentially fatal was one of the things that finally convinced me that maybe my symptoms were
serious enough to seek care.

This brings us to the end of our discussion about the use of health care services, some reasons
why people do or don’t use services, ways services can be misused, and a dramatic effect of the
impact of hospitalization on patients in the form of nosocomial infections. I hope throughout
the course of this video that you’re starting to see some ways that Health Psychologists might
intervene to help improve the use of health care services from both an efficiency perspective, so
people are better able to access the care they need, and from a patient care perspective, so that
when patients do access care they receive appropriate, timely, and high quality care. Some ways
Health Psychologists can intervene include creating media campaigns to improve people’s illness
schemas, assessing the use of health care services to help develop policies and rationale for
adequate resources for services, and studying behaviours that may contribute to or mitigate
things like nosocomial infections to help improve patient care. The field of Health Psychology is
definitely broad in terms of its scope and impact.

I’ll see you back here for our second video about module 8, where we’ll talk all about patient-
provider communication, another factor that can impact the use of health services. I hope
you’re all staying safe and healthy and I will see you in our next video. Bye for now.

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Hi everyone and welcome to our second video for module 8. In this video, I’ll cover a
couple of the topics from chapter 9 of your textbook. Chapter 9 is all about
patientprovider relations. The relationship between a medical provider and a patient
can play a large role in how satisfied a patient feels with their medical care and can
also influence things like whether the patient will seek care in the future. I wonder
how many of you have had interactions with a medical provider that left you feeling
dissatisfied with the care that you were provided. I have a specific example of my
own that springs to mind.

There was one instance where I was in grad school and I was walking home from the
bar one night, after I’ll admit a good number of drinks. I was eating a slice of pizza
while I was walking. Suddenly I stepped awkwardly off the curb and rolled my ankle
a bit and started to fall. In classic drunk person fashion, I decided in that moment
that it was more important to save my piece of pizza than my body, so I did not
throw my pizza on the ground and use my hand to catch me and instead landed on
the pavement on my elbow. Since that incident, when I lean on my elbow at a
certain angle, a sharp pain shoots through my arm. I suspect maybe I chipped a bone
and a fragment is in there. Eventually, after a couple years of classic delay, I decided

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to get my elbow checked out, so I went to the health centre on the UofA campus. I
waiting in the waiting room for over an hour before I finally got in to see one of the
doctors. The doctor asked me why I was there, I explained the situation, and he
basically told me ‘Well, don’t lean on your elbow that way’. And that was it! The
entire exchange lasted less than 5 minutes. He didn’t offer to send me for x-rays or
anything. He essentially totally dismissed me and then left the room. I was so
stunned I didn’t even think to advocate for myself and ask to have an x-ray, I just left.
But I left with the feeling that I was dumb to have bothered the doctor with this
minor symptom, which was one of the reasons I delayed going to get it checked out
in the first place. That experience still makes me consider whether a symptom is
‘worthy’ enough to get checked out or bring up to a medical provider. So that one
negative interaction with a health care provider has influenced my decisions around
seeking care for years afterwards. I’m sure that doctor forgot all about me 5 minutes
later, but that interaction has stuck with me for years.

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In this video, I’m going to cover some aspects of patient-provider communication that
can lead to some dissatisfying interactions, like the one I had. We’ll see how both
behaviours of the provider and also behaviours of the patient can contribute to these
dissatisfying interactions. So let’s dive in…

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 Provider Behaviours
that Affect Communication

LO2: Why is • Not Listening

patient- • Interrupting, directing, assertive
provider
communication
important?
• Use of Jargon
• Explanations are too complex
• Baby Talk/Elderspeak
• Too simplistic explanations
• Overly familiar
• Stereotypes
• Gender, SES, race, etc.

We’re going to start by talking about some of the provider behaviours that can
negatively affect communication and interactions with patients. Before we delve
more into this topic though, I want to highlight that of course there are many MANY
doctors and health care professionals that have great interactions with their
patients. I hope we have all experienced those types of interactions as well, where
you leave the interaction feeling heard and that you received high quality care. But
of course, like most things, there is always room for improvement. This is one of the
areas that a Health Psychologist could assist with. They can identify specific
behaviours, on both the part of the medical provider and the patient, that can
contribute to dissatisfying interactions. A Health Psychologist can then make
recommendations or create training or educational materials to help people learn
ways to mitigate these behaviours to improve interactions all around.

We’ll focus on 4 specific provider behaviours that negatively impact communication

with a patient:
1) Not listening: This behaviour involves interrupting, directing the conversation, or being
overly assertive with the patient. Your text describes some disturbing statistics that the
average doctor visit lasts only 12 to 15 minutes. In that visit,

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 when you are trying to explain your symptoms to the physician, they will, on
average, interrupt you before you get 23 seconds into your explanation. 23
seconds! We wouldn’t appreciate that kind of behaviour from anyone we’re
trying to have a conversation with. Now there are of course some systemic
reasons for the short visits and the abruptness of doctors. These can relate to the
volume of patients that they tend to see in a day and running on a very tight
schedule, as there are typically many people waiting in the waiting room to get in
for an appointment with the same doctor.

Your text further describes that, in a study of 74 office visits, in only 23% of cases did
patients have the opportunity to finish their explanation of their concerns and
symptoms before the provider began making a diagnosis. This can lead to some of
those issues we talked about in the previous video. For example, dismissing certain
symptoms that might seem minor, but could indicate a serious issue. As we learned,
this scenario is more likely to happen if the patient doesn’t fit the typical profile of
someone that would be likely to have that issue, like my young female friend that
ended up having cancer that started with fairly minor symptoms. Doctors can also
tend to be assertive to project an air of being the authority or the expert on the
subject, which can be intimidating to the patients and lead to them not speaking up
to advocate for themselves. This was my situation where I didn’t even ask to have an
x-ray taken. Not listening, in this variety of forms, often leads to not getting
adequate information from the patient, so that information doesn’t end up in their
medical record, where it may prove to be important down the line.

When I was first hired at MacEwan, we talked about this idea of projecting an
assertive demeanor to be viewed as an ‘expert’ in terms of being the professor in a
classroom. Surveys have shown that more male professors, particularly when they
are newer to teaching and trying to establish themselves, think they need to use
authority to maintain control of the classroom. They dress in suits and project an
authoritative demeanor. Survey results of students show that kind of demeanor
actually turns students off and isn’t great for learning. Doctor is actually Latin for
TEACHER, so really the first job of doctors was to educate people about what was
going on with their bodies. It’s hard to do that adequately if you don’t listen to
people. Expressing more empathy than assertiveness, and actually demonstrating
that they are listening to patients by allowing them to finish speaking before
interrupting or diagnosing, may be one way to improve communication and enhance
patients’ perceptions of quality of care. Listening and showing empathy are also
good qualities in a University professor.

2) The next provider behaviour is using jargon. Studies reveal that patients
understand relatively few of the complex terms that providers often use. This is

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 also similar to the idea of professors or teachers. If you’re teaching using words
that your students don’t understand, how can you expect them to understand
the main take home points if they have no idea what you’re talking about?
Explaining medical information in complex terms that patients don’t understand
is not going to help them feel like they had a quality experience, or that they
have any control over their health, because they may not understand what the
actual outcome of the visit was.
So then the question is, why do professors and doctors tend to use a lot of jargon?
Commonly, it’s basically a lasting effect of their training. They have to spend so
much time learning the new language of their field, and they become so familiar with
it, that they can easily forget that not everyone shares their same level of knowledge
about the terms they are using.

3) On the flip side of the jargon coin is the next behaviour that can negatively affect
communication between a patient and a provider: baby talk or elderspeak. This
is when a medical professional dumbs things down so much that they are
essentially treating the patient like they are a helpless child. This can take the
form of explanations that are overly simplified, like you might give to a child, or,
in the case of elderspeak, using terms that are too familiar, like ‘dear’ or ‘sweetie’
with the patient. This kind of communication can send the patient the message
that they are incompetent, or at least that the medical provider views them that
way. Elderspeak also reinforces negative age-related stereotypes; for example,
that older people doesn’t have sophisticated cognitive abilities.

4) The last really problematic provider behaviour we’ll cover is stereotypes. There
are a variety of stereotypes that medical providers may hold that have been
documented in the research. Of course this doesn’t mean that these stereotypes
are held by every provider; however, they tend to be the ones that show up most
often. Some stereotypes are based on gender, like I briefly touched on in the first
module 8 video. Doctors are more likely to attribute symptoms to a psychological
issue for female patients than for male patients. Your text also describes a few
studies that showed that when chest pain and stress were reported by either a
male or female patient, medical intervention was perceived to be less important
for the female patient. This may be because the symptoms weren’t taken as
seriously because they may be attributed to more psychological causes than
physical causes.

Another issue with sexism in medicine is in medical research. For decades, most
medical research was conducted with just male participants and then those results
were generalized to female bodies. This was done to essentially avoid the
‘problematic hormonal fluctuations’ that women have monthly that could often

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impact the results of medical research. But if you think about it, if those hormonal
fluctuations impact the results of medical research, that should be a good sign that
they are an important consideration when conducting medical research. That idea
was not appreciated for much of the history of medical science. This practice results
in less being known in general about female bodies and how they may respond to
certain types of medical interventions, like medications.

Another area of bias is related to socio-economic status. In chapter 8, your textbook

briefly touches on how people from lower SES backgrounds can find it more difficult
to even get in to see a medical provider in the first place.

The last big one we will touch on is race. There is a lot of documented evidence
showing medical bias towards people of colour. This bias shows up in a variety of
disturbing ways, which are predominantly related to not believing people of colour
when they report symptoms, especially pain. There have been studies reporting
that some medical professionals actually believe that black people have thicker skin
than white people, and therefore black people don’t feel pain as acutely as white
people. There is also a lot of evidence that black mothers have statistically higher
rates of death during childbirth than white mothers. Some people used to try to
explain this phenomenon by saying that black mothers were in poorer health to
begin with due to typically being lower in socio-economic status. However, research
has shown this trend is similar across SES for black women. Also, black babies have
higher infant mortality rates than white babies, across the spectrum of SES, as you
can see from the graph on this slide, which shows infant mortality rates across the
scope of educational backgrounds, which are typically tied to SES.

Another example showing that these effects are not tied to SES is the story of the
birth of Serena Williams' first child. Serena is a famous tennis player, so obviously
she has lots of money and is in pretty darn good health. Serena gave birth to her
daughter in September 2017. She delivered via emergency C-section after the baby's
heart rate dropped dramatically during contractions. The next day, Serena was
having trouble breathing. She immediately suspected she had a pulmonary
embolism, which is a blood clot in the lungs. She thought this because she knows she
is prone to those types of clots and one almost killed her back in 2011. This example
relates to an illness schema that Serena had from her prior experience, so she took
the symptoms of shortness of breath seriously. However, when she voiced her
concerns to her medical team, and asked for a CT scan and blood thinners, her nurse
suggested that the pain medication she received after her C-section had probably left
her confused. So even a powerful and famous woman like Serena Williams was not
listened to seriously when receiving medical care. She eventually did finally get a CT
scan, after asking a number of times, and the scan revealed several small blood clots

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in her lungs, just like she suspected. This example highlights how medical
professionals can easily dismiss the concerns of patients, and how this dismissal
happens more frequently for certain patients, like patients of colour.

One other aspect of medical racism that is important to bring up is around the
prescription of opioid pain medication to people of colour. Because doctors don’t
tend to take reports of pain from black people as seriously, they don’t prescribe as
many opioids to help them manage their pain. This lack of opioid prescriptions has
been suspected to have led to less opioid addiction in black people; however, much
of the reason for the lack of prescriptions is rooted in racism. For example, in
addition to being less sensitive to black people’s reports of pain, research reveals
that some doctors report not prescribing opioids for fear that their black patients
will become addicted to them or try to sell them. So here we see the racial
stereotype of an addict because these same doctors are fine prescribing tons of
opioids to white middle-class folks, who have just as high a likelihood of developing
an addiction to them.

All of the reasons I have touched on related to provider stereotypes may help explain
the findings that patients are often most comfortable interacting with physicians
who are similar to themselves, particularly in terms of factors like gender and
ethnicity.

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 Patient Behaviours that
Affect Communication

LO2: Why is
patientprov • Characteristics
ider
communica
• Neuroticism, anxiety
tio
important? • Knowledge
• Unable to understand/language
barriers
• Attitudes about Symptoms
• Emphasize pain/interfering with life
• Embarrassment
Congruency between patient/provider styles seems to work best
Now that we’ve covered some examples of provider behaviours that negatively impact
communication and care of patients, it’s also important to recognize that patients also
exhibit some behaviours and characteristics that negatively impact communication with
providers.

We’ll focus on 4 different patient behaviours/characteristics in this section:

1) The first is general personality characteristics of the patient. Patients scoring high in
neuroticism can sometimes exaggerate their symptoms, which then makes it hard for the
medical provider to accurately gauge the severity of the symptoms. In previous modules, we
talked a bit about how a tendency towards negativity can cause a person to notice
symptoms more and to think about them more.
Another personality characteristic that can complicate communication with a medical provider is
anxiety. We all know that it can be a lot harder to sit down and focus when we are stressed out
and our thoughts feel like they are jumping all over the place. Health anxiety can be big source
of anxiety for some people, so they may get more anxious just being in a medical setting or
talking about medical topics. This anxiety can then make it more difficult for the patient to
focus, to clearly communicate their symptoms, and then to focus on processing and
remembering the information given to them by their medical provider.

2) The next patient behaviour, which isn’t really a behaviour but again more of a characteristic
of the patient, is knowledge. Some patients might not be able to understand even simple
information about their case. This might relate to the amount of background knowledge
they have about medical topics and how the body works, or many times can be related to
language barriers. My Dad’s side of the family is Polish (that’s the origin of my last name,
Moscicki). My grandma on my Dad’s side has been in Canada for over 60 years, yet she still
has trouble with a lot of English words. Now that she is older (she’s in her mid-80s), she has
to go to a lot more medical appointments. She always brings my aunt with her, who speaks
both English and Polish fluently, so that she can translate not only the vocabulary for my
grandma but also the information into a form that my grandma can understand. If my
grandma didn’t have my aunt to accompany her to these appointments, she would have an
incredibly hard time trying to communicate with her doctors.

3) Our next patient behaviour/characteristic is attitude towards symptoms. Patients often

place considerable emphasis on pain and on symptoms that interfere with their activities.
This was me with my gut issues. I emphasized the pain and how it would sometimes prevent
me from being able to eat. If patients are predominantly just reporting symptoms related to
pain, they may be missing some symptoms that are out of the ordinary for them but don’t
cause pain, so they don’t think they are important to report. For example, a change in bowel
habits that don’t cause pain, but is unusual, is important to report when dealing with
gastrointestinal issues.

4) The last patient behaviour/characteristic we’ll talk about is embarrassment. Embarrassment

can lead to giving misleading information about past health history or current or past health
habits. For example, a patient might be embarrassed about having previously had an STI that
was treated, so they might not disclose that to their medical provider because they might
not think it is important or relevant, but it could be. Or a patient might not reveal that they
are a smoker, or that they use drugs recreationally, particularly if those drugs aren’t legal. Or
patients may under-report their drinking habits to their doctor due to embarrassment. All of
these pieces of medical information could be important for the doctor to know.

With the issues we’ve brought up surrounding both provider and patient behaviours, we can see
many areas in which Health Psychologists might be able to intervene to improve
communication. But, some interesting research suggests that not all people prefer the same
kind of communication from their providers. For example, someone may like a more
authoritative provider, whereas someone else might like being more involved in making
decisions about their own care. An example of these different styles are the different care
providers that people might choose for birth.
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For example, I have one friend that wanted to give birth at a hospital with a medical doctor
because she found that sense of authority and the care team telling her exactly what she
needed to do comforting. I have another friend that opted to go with a midwife because she
wanted to be the one ultimately making decisions about her care and birth circumstances, while
receiving information about the pros and cons of the various choices from her midwife. So it’s
hard to say there are blanket suggestions that might improve communication across the board.
There are some obvious candidates though, like listening on the part of the provider and
providing truthful information on the part of the patient. Ultimately, it seems that the best
communication happens when there is congruency, or similarity, between the communication
styles of the patient and provider, so that they work well together as a team.

This brings us to the end of our content for module 8 video 2. Everything we’ve talked about in
this video can impact not only a patient’s perception of the quality of care they received from
their provider due to how the interaction went, but can also influence their future use of health
services. We see this with my example of my symptom of elbow pain being dismissed, which still
leads me to sometimes think symptoms might be too minor to do anything about. So, studying
and improving patient-provider communication is an important area that Health Psychologists
may focus on to help improve the effective use of health services and quality of care.

In our last video for module 8, I’ll talk about placebo effects and how those effects can be
influenced by aspects of the patient-provider relationship, like communication. I’ll see you there.
Bye for now.

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 Hi everyone and welcome to our final video for module 8. In this video, I’m going to
cover some interesting findings related to placebo effects and how characteristics of
the patient, the medical provider, and the medical setting can contribute to placebo
effects.

The Placebo Effect

LO5: What is
the Placebo
effect?
• Improvement resulting from the mere expectation of
improvement
• Can be from any type of procedure (e.g., drugs, surgery,
therapy)
• Can be very effective for reducing pain
• Endorphin release (shown with
Naloxone)
• Parkinson’s treatment

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Placebo effects are effects that result from the mere expectation that effects will
happen. The term placebo effect comes from the Latin for “I will please”. There are
many examples of placebo effects from research but also many examples that we
probably come across in everyday life or see in popular media. For example, one
study looking at this idea found that people that have an allergy to certain types of
flowers would sneeze when they were presented with the flower, even if it was a
fake flower. This experiment showed that their expectation that they were going to
sneeze led to the effect of sneezing, because there was nothing about the fake flower
that should have triggered their allergy. An example from popular media comes from
Stephen King’s story IT, with the creepy clown. Spoiler alert: skip ahead to the next
page if you don’t want to hear it. In that story there is a boy, Eddie, who used an
inhaler for his asthma. He thought he had really severe asthma and that he needed
the inhaler to survive if he had an asthma attack. There were multiple instances in
the book when he would start to have an attack, use the inhaler, and then be able to
breathe fine again. Later in the book you find out that the inhaler was just water with
methol flavour added so it would taste like medicine, but it had no medicinal
ingredients in it. Just the fact that Eddie believed that the substance in the inhaler
had an effect led to positive effects on his breathing.

This idea isn’t just a far-fetched fiction book idea. This popular media example relates to
one of the examples described in your text showing that inhaling a useless drug
improved lung function in children with asthma by 33%.

Placebo effects highlight the mind-body connection we have been coming back to
throughout this course. They show that expectations really can create reality. For
example, many placebo effects are related to pain perception. Often, just the
expectation that you have taken a pain pill can cause endorphins to be released in
your body and then you actually do feel better. Expectations created the reality of
physiological pain reduction.

Any procedure, ranging from drugs to surgery to psychotherapy, can have a

placebo effect. In therapy, just having someone supportive to talk to and listen to
you can have positive effects even if they are not using any specific type of
empirically supported therapeutic intervention.

Placebo effects are often talked about as not the effect that was wanted in an
experiment, but that doesn’t mean they're necessarily bad effects. If you’re in pain
and then your pain is lessened, in a way, who cares if it was because of a drug or a
placebo – the main goal was to reduce your pain and that goal was accomplished.
We’ll see in module 9 how some pain reduction strategies actually try to harness the

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placebo effect to help with pain reduction. So, placebo effects can be valuable; but,
they can get in the way of establishing whether an effect from something else, like a
drug, is a real effect of that drug unless the placebo effect is carefully controlled for.
This is why drugs have to be tested against placebo controls, to see if giving an actual
drug is more effective than just the placebo effect. The drug could have some side
effects and be hard for the liver to metabolize, so we don’t want to give it to
someone if it’s only as effective as a sugar pill. If that’s the case, then just give
someone the sugar pill…

Because placebo effects highlight the mind-body connection, they are typically
stronger for things that have a subjective component, or a component where the
mind must interpret some information, like sensations of pain, rather than things
with a more objective biological component, like cancer or heart disease. Placebos
also often enhance hope, which can trigger the release of dopamine from the reward
centers of the brain and help to improve mood and outlook, which we’ve explored
before can be beneficial for the body, recognition and interpretation of symptoms,
and recovery processes.

I’ll give you a few examples showing the powerful effect of placebos for pain
reduction. One study showed that if a morphine drip is administered and the patient
is not aware they are receiving pain-killing meds, they subjectively experience more
pain than if they know there is morphine in the IV line. Morphine can lose as much as
25% of its effectiveness in reducing pain when patients don't know they have been
injected with a painkiller and are therefore not expecting to experience the drug’s
effects. This example already highlights simple things that medical providers can do to
help reduce patient pain, things as simple as explaining that they are now receiving
pain medication and they should expect their pain to subside shortly.

In another study, participants who were given an actual migraine medication but
labeled as a placebo reported less reduction in pain than participants who took a
placebo medication labeled as the real migraine medication, again highlighting this
idea of expectations leading to actual pain reduction. Further evidence for the
placebo effect being a real effect for reducing pain comes from research that
examines brain activity using functional magnetic resonance imaging (fMRI). This
research shows that when patients report reduced pain after taking a placebo, they
also show decreased activity in pain-sensitive regions of the brain.

Previously I mentioned that placebo effects related to pain reduction can happen
physiologically because just the expectation that pain will be reduced can cause a
release of endorphins in the body, which will actually lead to a reduction in pain. This

2
effect was discovered by using a drug that we talked about back in module 5 when
we discussed opioid addiction. That drug is Naloxone. This is the drug that can help
reverse an opioid overdose because it binds to opioid receptors in the body.
Endorphins also bind to opioid receptors in the body. So experiments using Naloxone
showed that placebo effects that normally worked to reduce pain, like giving a sugar
pill and saying it is a pain-reliever, were no longer effective if the person was first
given Naloxone. Naloxone blocks opioid receptors, so even if endorphins were
released, they couldn’t bind to the appropriate receptors to have their pain-reducing
effects.

Another startling example of the placebo effect that is not related to pain is shown in
the images on the slide. These are images of the brains of people with Parkinson’s
disease. The profound physical effects of Parkinson’s, like tremors, are primarily
caused by low levels of dopamine in certain areas of the brain. In one study of 35
patients with mild to moderate Parkinson’s, brain scans showed that dopamine levels
could be returned to levels close to normal when patients were given the drug Ldopa.
But, the most surprising result was that almost identical levels of dopamine were seen
in the brain when patients were given a placebo. It's only one study, but the results do
seem to show a real physical effect from taking a pill with no active ingredients.

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 Factors that Affect the Placebo Effect

LO5: What is
• Provider attitudes
the Placebo • Warmth, confidence, competence, expectations (e.g.,
effect? chlorpromazine)
• Provider Communication
• Clarity about the treatment
• Patient characteristics
• E.g., spirituality, optimism, anxiety
• Setting characteristics
• Medical formality, pill characteristics

• NOCEBO Effect

Now that we’ve covered a bit about the placebo effect, and how strong those effects
can be for certain outcomes, let’s talk about some factors that can affect the placebo
effect, either enhancing or reducing its effectiveness.

1) The first factor is the attitude of the medical provider. The effectiveness of a
placebo can vary depending on how a provider interacts with the patient and how
much the provider seems to believe in the treatment being offered. Providers who
interact with the client in a warm way, convey confidence and competence, and
signal that they believe the treatment being offered will lead to beneficial results for
the patient, get stronger placebo effects in their patients. Basically, the provider
needs to convey belief in the treatment so that the patient believes in the treatment.
When the patient believes in the treatment, they can develop expectations that they
will improve, as the patient's expectations drive the placebo effect.

For example, I’ve included on this slide a graph from a study looking at characteristics
of doctors' personalities, expectations of the patient, and the size of a rash due to an
allergic reaction on the skin. In this study, a rash was induced on the skin of patients
that had a particular allergy. A cream was then administered for the rash by doctors
with different personality types. The important thing here is that the cream was a
placebo – it didn’t have any active ingredients. Researchers divided doctors into ones
that were high in warmth, ones that were high in competence, ones that were low in
both of those qualities, and ones that were high in both of those qualities. They also

6
asked the patients subjectively about their expectations that the cream would work
to reduce their rash. The Y-axis shows the size of the rash after using the placebo
cream. You can see from the graph that the patients that received the cream from a
doctor high in warmth and that exuded competence, and that also had positive
expectations that the cream would work to reduce their rash, had a significantly
smaller rash size than any other patients. This study highlights how both the
behaviour of the medical provider and the expectations of the patient are important
for placebo effects. And the behaviour of the provider can really affect the
expectations of the patient.

Now, provider attitudes can work both ways, either enhancing or decreasing the
effectiveness of treatments through altering patient expectations. An example from
your text that highlights how provider attitude can negatively impact patient
expectations, and thus the effectiveness of treatment, is shown in a study with
chlorpromazine, a tranquilizer drug commonly used with psychiatric patients. In this
study, the drug was either given by a provider who expressed great confidence in its
effectiveness or who voiced doubt about its effectiveness. The study revealed that
when the provider expressed doubts about the effectiveness of the drug, the drug’s
actual effectiveness dropped from 77% to 10%, which is a huge drop.

2) The next factor we’ll look at is provider communication. We touched on this

topic quite a bit in the previous video. We know that it’s important for providers to
clearly communicate with their patients. One thing that can be affected by
communication is the placebo effect. Since it is based all around expectations, the
patient has to have a clear understanding of what the treatment is supposed to do,
and what they need to do, in order to develop those expectations that the treatment
will lead to improvement. Effective communication between the patient and provider
can increase the strength of placebo effects, which is another important reason to
ensure this communication is as effective as possible.

3) The third factor that can affect placebo effects is characteristics of the
patient. These characteristics can relate to both the personality traits of the patient
and also some of their typical beliefs. These characteristics then interact with other
situational variables, like the attitude of the provider, and the effectiveness of
provider-patient communication, to help either enhance or detract from the
effectiveness of placebo effects. People that rate themselves as higher on spirituality
tend to show stronger placebo effects, perhaps because spirituality may be related
to their strength of belief. We also know that optimism contributes to positive health
outcomes in many ways. This characteristic is likely also related to strength of

6
expectations, since one of the hallmarks of optimism is expecting more good rather
than bad things to happen to you.

An interesting patient characteristic affecting placebo effects is anxiety. People that

are higher in anxiety actually tend to show stronger placebo effects. This may be due
to the strength of the mind-body connection in people high in anxiety. Because the
anxiety typically produces a lot of negative physical symptoms, if the highly anxious
person believes that a treatment will work for them, that can help to reduce their
anxiety, which can then reduce some of those negative physical symptoms that were
caused by the anxiety. This effect wouldn’t be as strong in someone that didn’t have
the stronger physical effects from anxiety in the first place.

4) The last factor we’ll touch on is the characteristics of the setting. A setting
that has a lot of features of a medical practice, so that things feel very official, like
medical looking machines, people in medical gowns and white coats, and medical
supplies around, will induce stronger placebo effects. This result might be related to
increasing the expectations that the treatment will work. If you feel like the setting is
professional and this is what these people do, so what they recommend must be
legitimate, that perception can increase your expectations that the treatment will
work. It’s similar to that idea of authority being attributed to people in a white coat.
We’ve been conditioned through experience and media to believe that medical
providers in white coats know what they’re doing and have a sense of medical
authority. That belief can help strengthen expectations that what the person in the
white coat in the formal medical setting tells us is true (i.e., that the treatment will be
effective).

The setting can also apply to things like the characteristics of the medicine. Studies
have shown that pills that seem more like ‘medicine’ induce stronger placebo effects.
Imagine taking a chalky white pill vs. a colourful gummy pill. You probably associate
the chalky white pill more with what a medicine is supposed to be like, so that type
of pill will have a stronger placebo effect. There is also interesting information about
the specific colour of pills. Your text describes how green and blue pills are
associated with having a sedative placebo effect, while yellow and red pills are
associated with having a stimulant placebo effect. This effect might be related to the
types of feelings we initially associate with those colours. Green and blue tend to be
more calming colours in general, while yellow and red tend to be more fiery and
energeticseeming colours. White pills are often perceived to be better at painkilling,
which may be related to our prior experience taking white pills that are meant to
reduce pain.

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Before we finish our discussion of placebo effects, I wanted to touch back on a topic
that I briefly covered with one of the examples. Recall the example about a medical
provider expressing doubt in a treatment leading to less effectiveness of that
treatment, specifically the tranquilizer drug chlorpromazine for psyciatric patients.

This effect is called a nocebo effect. While placebo is Latin for ‘I will please’, nocebo is
Latin for “I will harm”. It’s important to know that these effects can go both ways.
They can really increase the effectiveness of some treatments, but they can also
really reduce the effectiveness of treatment. One startling example of a nocebo
effect was seen in a study examining the effectiveness of chemotherapy. In this
study, a group of people received chemo and another group received saline but were
told it was chemo. In the group that received saline, 30% of the people still lost their
hair, even though they didn’t receive any chemo drugs! They lost their hair just due
to the expectation that they would lose their hair. Since this is a negative effect, it’s
called a nocebo effect. We can see from this example that expectations can have
strong effects for both the positive and the negative. It becomes very important to
consider what kind of expectations a provider may be consciously or unconsciously
contributing to in a patient with their particular communication.

And that brings us to the end of our video content for module 8. I hope that
throughout this module you’ve appreciated the impact that care settings can have on
people and their health, as well as the powerful impact that relationships and
communication with care providers can have. We’ve again seen many areas of health
that a Health Psychologist may be able to play an important role in, from studying
adherence to procedures within hospital settings, to helping both patients and
providers communicate in the most effective way possible. Now we can add to that
list studying placebo effects to try to maximize the positive benefits of placebo
effects for patient treatment.

Enjoy exploring the rest of the content from module 8! I’ll see you back here for
module 9, where we’ll revisit the topic of pain that we touched on a bit in this video
with placebo effects. I’ll see you then!