Sunday, January 13, 2013

Death by 1000 Needlesticks: The Nocebo effects of Hospitalization

When I read an excellent article by Krumholz in this week's NEJM, a paradigm that has been evolving in my mind and my practice patterns for several years congealed:  hospitals and hospitalizations are, to some extent, bad for you.  In this post, I will extend Krumholz's ideas to conjecture about several modifiable aspects of hospitalization that I think do more harm than good.  Many interventions employed by physicians are thought to be benign or beneficial, but there are at least three ways that they could be subversively harmful:  1.) because they prolong hospitalization which is harmful in the way described by Krumholz as the "post-hospital syndrome"; 2.) because there are unrecognized direct untoward effects of the interventions and the environment in which they are administered; and 3.) because patients have adverse psychological reactions to otherwise benign interventions - that is, nocebo effects of hospitalization.  (See also this recent NYT article on nocebos.)

One of the most notorious bugbears of hospitalized patients is the blood draw.  As my colleagues and I mused in this review of laboratory testing in the ICU, much laboratory testing is unnecessary or wasteful, and may even be harmful. Nonetheless, patients admitted for a whole spectrum of maladies have laboratory studies pre-ordered on admission at distinct intervals:  daily labs in the wee hours of the morning (don't get me started on that one - why on Earth we awaken patients at 4AM to draw blood, and how do we justify it?), interval labs throughout the day to "monitor" things (e.g., hemoglobin in gastrointestinal hemorrhage), labs ordered for that Sisyphean task of electrolyte replacement, and so on.  Beyond the oft discussed topics of wasted resources and the anemia-inducing effects of phlebotomy, what if the act of drawing blood has a nocebo effect on patients?  That is, what if they perceive psychologically or unconsciously that many blood draws implies a greater degree of sickness or a stalled, stuttering, or laggard recovery?  What if the pain of phlebotomy induces neurohumoral responses that impair recovery?  What if being awakened at 4AM every day for a painful nuisance not only disturbs sleep, but impedes response to specific therapy through a nocebo effect?