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      In response to Braillon,
      • Braillon A.
      The good, the bad and the empathic.
      we agree that conditioning and expectancy are mechanisms that explain part of both the nocebo and placebo effects, but nocebo and placebo are opposing in their actions; negative expectation can result in a worsening of symptoms, whereas positive expectation can improve symptoms. We would argue that “one [nocebo] can indeed be more powerful than the other [placebo],” as indicated in the review by Baumeister et al.
      • Baumeister R.F.
      • Bratslavsky E.
      • Finkenauer C.
      • Vohs K.D.
      Bad is stronger than good.
      Undoubtedly, the “doctor's duty is not to please but to help,”
      • Braillon A.
      The good, the bad and the empathic.
      but we are certainly not defining placebo effects as a method of “pleasing patients” or merely as the action of a dummy pill. By “placebo effect,” we are describing nonspecific, context effects that arise from a variety of factors, including the whole sociocultural context of the use of the drug; the expectations; the health beliefs and prior experiences that the patients bring with them; the environment in which the prescriptions are given; the size, shape, and color of the pills used; and the nature of the interactions between patient and provider.
      • Kaptchuk T.J.
      • Kelley J.M.
      • Conboy L.A.
      • et al.
      Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome.
      • Howick J.
      Escaping from placebo prison.
      • Doherty M.
      • Dieppe P.
      The “placebo” response in osteoarthritis and its implications for clinical practice.
      These are not “disease-mongering” and can have long-lasting effects.
      Thus, one component of treatment that can affect patient outcome is the communication between the patient and the provider. Braillon states that poor professional relationships are “malpractice,”
      • Braillon A.
      The good, the bad and the empathic.
      but we argue that sometimes negative communication between doctor and patient can be unintentional; attempts to reassure the patient can leave the patient feeling misunderstood.
      • Linton S.J.
      • McCracken L.M.
      • Vlaeyen J.W.S.
      Reassurance: help or hinder in the treatment of pain.
      We do not argue that placebo should replace taking time, being open, and listening to the patient. Rather, these are likely to enhance the placebo effect that we describe.
      Furthermore, we do not confuse compassion and empathy, but believe that attempts to be compassionate or to empathize do not necessarily help the patient, if such attempts are not perceived as such by the patient. We stress the importance of the intention of the words being successfully transmitted to the recipient and argue that sometimes (even unintentionally) we can be left feeling misunderstood. In essence, feeling misunderstood does matter.
      • Greville-Harris M.
      • Dieppe P.
      Bad is more powerful than good: the nocebo response in medical consultations.

      References

        • Braillon A.
        The good, the bad and the empathic.
        Am J Med. 2015; 128: e27
        • Baumeister R.F.
        • Bratslavsky E.
        • Finkenauer C.
        • Vohs K.D.
        Bad is stronger than good.
        Rev Gen Psychol. 2001; 5: 323
        • Kaptchuk T.J.
        • Kelley J.M.
        • Conboy L.A.
        • et al.
        Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome.
        BMJ. 2008; 336: 999-1003
        • Howick J.
        Escaping from placebo prison.
        BMJ. 2009; 338: b1898
        • Doherty M.
        • Dieppe P.
        The “placebo” response in osteoarthritis and its implications for clinical practice.
        Osteoarthritis Cartilage. 2009; 17: 1255-1262
        • Linton S.J.
        • McCracken L.M.
        • Vlaeyen J.W.S.
        Reassurance: help or hinder in the treatment of pain.
        Pain. 2008; 134: 5-8
        • Greville-Harris M.
        • Dieppe P.
        Bad is more powerful than good: the nocebo response in medical consultations.
        Am J Med. 2015; 128: 126-129

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