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Using open notes to advance nocebo research: challenges and opportunities
  1. Marco Annoni
  1. Interdepartmental Center for Research Ethics and Integrity, National Research Council of Italy, Rome, Italy
  1. Correspondence to Dr Marco Annoni, Interdepartmental Center for Research Ethics and Integrity, National Research Council of Italy, Rome, Italy; marco.annoni{at}

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In this article, Charlotte Blease argues that patient access to online shared clinical notes (also called ‘open notes’) may cause or exacerbate nocebo effects in two ways.1

First, open notes may enhance patient understanding about the adverse effects of medications and treatments. However, reading information about adverse effects may lead patients to form negative expectations that, in turn, may cause or worsen symptoms via nocebo mechanisms.

Second, open notes may paradoxically lower the quality of the therapeutic relationship by allowing patients to detect signs of discrimination and stigma in clinical notes. By accessing their shared notes, patients may identify (or think that they are identifying) signs of stigmatisation and discrimination in clinicians’ words. This may diminish their trust while increasing their anxieties and fears, all factors that have been associated with enhanced nocebo effects.

The article then suggests different strategies to mitigate nocebo effects while using open notes, highlighting the need for more empirical research. This call for more empirical research is crucial, as most of Blaise’s conclusions rest on limited or indirect empirical evidence. Rather than being a shortcoming of the argument per se, however, this is …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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