{
  "abstract": "Patient Comfort and Communication.Introduction Modern healthcare systems, particularly under financial and organizational pressure, tend to focus on efficiency and standardization. Protocols, care pathways, and checklists improve safety and consistency, but can inadvertently reduce patient encounters to technical transactions. This shift often overlooks a fundamental truth: the context in which care is delivered has a powerful impact on clinical outcomes. 1 2 Pain is not merely a sensory experience; it is a subjective, multifactorial phenomenon shaped by individual expectations, emotional states, prior experiences, and environmental cues. Contextual factors (CFs) and clinician communication modulate pain perception—sometimes amplifying it through nocebo effects, sometimes reducing it via placebo mechanisms or hypnotic techniques. Understanding and applying these principles enables clinicians to enhance patient comfort, reduce medication reliance, and improve outcomes, often without additional time or cost.Contextual Factors Pain is best understood as a biopsychosocial phenomenon. Beyond nociception, it is influenced by a complex interplay of physical, emotional, cognitive, and social dimensions. The environment and interpersonal cues surrounding an intervention—the contextual factors—can significantly influence a patient’s experience of pain and healing. 3 4 CFs include:Physical environment: design, noise, lighting, smellClinician behavior: tone of voice, body language, facial expressionCommunication: verbal and non-verbal suggestions, explanations, and framingSymbols of care: white coats, monitors, infusion bags, equipmentPatient factors: prior experiences, anxiety levels, expectationsCFs are omnipresent and unavoidable in every healthcare interaction. They can induce beneficial placebo effects or harmful nocebo responses, depending on how they are perceived by the patient.The Therapeutic Power of Placebo EffectsPlacebos—interventions with no pharmacological activity—can nevertheless produce real, measurable improvements in pain, function, and well-being. These effects are not limited to ‘sugar pills’ but are elicited primarily through meaning, expectation, and interpersonal connection.Key components of a strong placebo response include:A clear and reassuring explanation from a trusted clinicianThe patient feeling seen, heard, and cared forThe patient actively participating in their careThe placebo effect is, at its core, a contextual and communicative phenomenon.5 For example, a study by Thomas (1987) found that 64% of patients with unexplained symptoms improved when the general practitioner gave a positive, confident diagnosis and reassurance. In contrast, only 39% improved when the GP expressed diagnostic uncertainty.6 Placebo responses also occur at the physiological level. Neuroimaging studies reveal that verbal suggestions of pain relief can activate the prefrontal cortex, periaqueductal gray, and endogenous opioid systems, leading to reduced pain perception and enhanced well-being.Placebo mechanisms thus represent active ingredients of the clinician-patient interaction, whether or not a medical intervention is performed.The Nocebo Effect: When Words HarmIn contrast, nocebo effects occur when negative expectations or communication worsen symptoms or outcomes. Like placebo effects, they are contextually and neurobiologically mediated.Examples of nocebo effects include:Worsened pain after being warned about possible side effectsIncreased anxiety during informed consent proceduresIncreased nausea or dizziness after hearing others talk about themHeightened pain due to repeated verbal focus on ‘pain scores’A study showed that patients who were warned that a drug might cause erectile dysfunction were more likely to report it (32%) than those who were not (13%).7 Similarly, during epidural needle insertion, patients who were told ‘this might hurt a bit’ reported significantly more discomfort than those receiving neutral or positive suggestions.8 Nocebo responses are not imagined—they are accompanied by real biological changes, including, activation of cholecystokinin (CCK), a neuropeptide that mediates the nocebo hyperalgesic response and is an anxiogenic stimulus.9 Unfortunately, many nocebo triggers are embedded in routine clinical communication. The language used by clinicians, the expression on their face, or the tone of a warning can prime patients for pain and anxiety. This is particularly problematic in high-stress or ambiguous settings like emergency departments or surgery.Expectations Expectations, not the drug alone, drives therapeutic efficacy. A compelling line of research has examined the difference between open (announced) versus hidden (concealed) treatment administration. 10–12 These studies reveal the critical role of expectations:Morphine, when administered openly with verbal reassurance, produced robust pain relief.The same dose, when administered without the patient’s knowledge, produced significantly less analgesia.In contrast, saline placebo, when given with confident verbal suggestion, often outperformed hidden morphine.The Role of Language in Pain PerceptionLanguage is a powerful modulator of pain. Even well-intentioned statements can have unintended negative consequences. Examples include:Abstract FT28 Table 1 Traditional Phrase Alternative ‘This may hurt a bit.’ ‘Some people feel a sensation—let me know how you experience it.’ ‘We’re going to inject the anesthetic now.’ ‘You may notice a cooling or warming feeling.’ ‘Don’t worry.’ ‘You’re doing great, and I’ll guide you through this.’ Words direct attention Saying ‘we’re going to monitor your pain closely’ reinforces the presence of pain. In contrast, asking ‘What helps you feel more comfortable?’ shifts focus toward comfort and control. Repeatedly asking patients to rate pain (e.g., ‘What’s your pain on a scale from 1–10?’) reinforces vigilance and may lead to a cycle of expectation and amplification. 13 Stress and Suggestibility When under severe stress patients often enter an altered state of awareness marked by increased suggestibility and focused attention. This state resembles natural hypnosis and opens the door to both helpful and harmful suggestions. 14 15 In these moments it is important to realize that non-verbal communication becomes just as influential as spoken words.Hypnotic Communication Hypnotic communication is a clinical skill set that uses language and attention techniques to reduce distress, anxiety, and pain. One well-studied method is Comfort Talk®, developed by interventional radiologist Dr. Elvira Lang. It consists of rapid rapport building, reframing language to avoid negative suggestions and guided self-hypnosis or relaxation scripts. In randomized trials of over 700 patients undergoing interventional radiology procedures, pain and anxiety were significantly lower in the intervention group, but also procedure times were shorter. 16–18 Examples of hypnotic phrasing include:‘You might notice your breathing becoming calmer as we continue.’‘Some people find it helpful to focus on a pleasant place or activity.’‘You may choose how deeply you want to relax right now.’Such suggestions are indirect, permissive, and patient-centered, increasing the sense of control while reducing resistance. Pain is easier to tolerate when patients feel in control and safe. Even simple interventions can have profound effects:Offer patients a signal to pause the procedure if neededLet them choose a coping strategy (e.g., listening to music, holding a stress ball)Ask, ‘What has helped you during similar procedures before?’These measures provide predictability, reduce helplessness, and enhance the patient’s belief that they can manage discomfort. The result: less pain, less anxiety, and more cooperation.Clinical Recommendations Integrating this knowledge into daily practice does not require major system changes—just awareness, language adjustment, and intention. 19 Implementation consists of:Train clinicians in communication techniques that avoid nocebo language and enhance placebo potentialDesign clinical environments to convey calm, cleanliness, and trust (lighting, noise control, art, scent)Adjust intake questions to explore comfort and coping (e.g., ‘What’s important to you right now?’)Encourage patient participation in decisions, choices, and coping strategiesIncorporate hypnotic communication skills into standard care, especially in procedures, emergency settings, and pain managementThese strategies can reduce medication needs, shorten recovery times, and increase patient satisfaction—all while supporting the clinician-patient relationship.Conclusion Pain and healing are not determined solely by anatomy, pharmacology, or protocols—they are deeply influenced by meaning, expectation, and context. Every interaction between a patient and healthcare provider offers a biopsychosocial intervention with real physiological effects.By recognizing the power of contextual factors, avoiding inadvertent nocebo effects, and incorporating elements of hypnotic communication, clinicians can significantly enhance the quality and humanity of care. These methods are grounded in neuroscience, supported by evidence, and available to every practitioner—regardless of specialty.Ultimately, words are medicine. Let us use them wisely.References Rosenthal DI, Verghese A. Meaning and the nature of physicians’ work. New Eng J Med. 2016;375(19):1813–15.Verghese A. Culture shock – patient as icon, icon as patient. New Eng J Med. 2008;359(26):2748–51.Balint M. The doctor, his patient, and the illness. Lancet 1955;268(6866):683–88.Miller FG, Kaptchuk TJ. The power of context: reconceptualizing the placebo effect. J Royal Soc Med. 2008;101(5):222–25.Brody H. Meaning and an overview of the placebo effect. Perspect Biol Med. 2018;61(3):353–60.Thomas KB. General practice consultations: is there any point in being positive? Br Med J (Clinical research ed). 1987;294(6581):1200–2.Planes S, Villier C, Mallaret M. The nocebo effect of drugs. Pharmacol Res Perspect. 2016;4(2):e00208.Varelmann D, Pancaro C, Cappiello EC, Camann WR. Nocebo-induced hyperalgesia during local anesthetic injection. Anesth Analg. 2010;110(3):868–70.Frisaldi E, Shaibani A, Benedetti F. Understanding the mechanism of placebo and nocebo effects. Swiss Med Wkly. 2020;150:w20340Levine JD, Gordon NC. Influence of the method of drug administration on analgesic response. Nature 1984;312(5996):755–56.Benedetti F, Carlino E, Pollo A. Hidden administration of drugs. Clin Pharm Ther. 2011;90(5):651–61.Bingel U, Wanigasekera V, Wiech K, Ni Mhuircheartaigh R, Lee MC, Ploner M, Tracey I. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Trans Med. 2011;3(70):70ra14.Chooi CS, White AM, Tan SG, Dowling K, Cyna AM. Pain vs comfort scores after Caesarean section: a randomized trial. Br J Anaesth. 2013;110(5):780–87.Cheek DB. Importance of recognizing that surgical patients behave as though hypnotized. Am J Clin Hypn. 1962;4:227.Hansen E, Zech N. Nocebo effects and negative suggestions in daily clinical practice – forms, impact and approaches to avoid them. Front. Pharmacol. 2019;10:77. Doi: 10.3389/pharm.2019.00077.Lang EV, Berbaum KS, Faintuch S, Hatsiopoulou O, Halsey N, Li X, Berbaum ML, Laser E, Baum J. Adjunctive self-hypnotic relaxation for outpatient medical procedures: a prospective randomized trial with women undergoing large core breast biopsy. Pain 2006;126(1–3):155–64.Lang EV, Benotsch EG, Fick LJ, Lutgendorf S, Berbaum ML, Berbaum KS, Logan H, Spiegel D. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000;355(9214):1486–90.Lang EV, Berbaum KS, Pauker SG, Faintuch S, Salazar GM, Lutgendorf S, Laser E, Logan H, Spiegel D. Beneficial effects of hypnosis and adverse effects of empathic attention during percutaneous tumor treatment: when being nice does not suffice. J Vasc Interv Radiol. 2008;19(6):897–905.Aarts LAM, van Geffen GJ, Smedema EAL, Smits RM. Therapeutic communication improves patient comfort during venipuncture in children: a single-blinded intervention study. Eur J Pediatr. 2023;182(9);3871–3881.",
  "authors": [
    {
      "affiliations": [
        "Anesthesiology, Radbouduniversity Medical Centre, Nijmegen, The Netherlands"
      ],
      "name": "Geert-Jan Van Geffen"
    }
  ],
  "title": "FT28 Words like medicine",
  "uid": "69f0342d-651b-52e9-9ffa-04a678560532"
}