Article Text

Download PDFPDF
Open notes: Unintended consequences and teachable moments
  1. George Patrick Joseph Hutchins1,2,
  2. Valerie E Stone1,3,
  3. Kathryn T Hall1,3,4
  1. 1 Harvard Medical School, Boston, Massachusetts, USA
  2. 2 Department of Sociology, Harvard University, Cambridge, Massachusetts, USA
  3. 3 Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  4. 4 Boston Public Health Commission, Boston, Massachusetts, USA
  1. Correspondence to Dr Kathryn T Hall, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; khall0{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

While positive information in the context of clinical care can lead to placebo effects, negatively framed information can have negative or nocebo effects. Extant literature documents how doctor–patient encounters are fertile ground for suboptimal interactions leading to negative experiences for ethnoracial minority patients. In their JME paper, Blease presents a critical perspective on the potential for patients’ access to their doctors’ clinical notes, ‘open notes’, to engender nocebo effects.1 In this commentary, we affirm the central claim that nocebo effects could emerge ‘via negative wording or framing of health information expressed by clinicians in documentation’. The advent of electronic health records (EHR) allowed patients the unprecedented opportunity to access personal clinical documentation, giving them a window into decision making around their health. This shift is undoubtedly complex, and thus warrants a more fulsome rendering of the unique challenges faced by ethnoracial minority patients. Herein, we highlight three critical areas for consideration of potential nocebogenic impacts of open notes on these patients. First, we examine doctor–patient power dynamics through the frame of historic and contemporary medical racism. Second, we discuss the application of a more critical health equity lens through a consideration of disparities in not only information technology access, but also utilisation. Finally, we discuss ethical considerations of medical providers’ roles as ‘gatekeepers’ of medical information and the changing nature of this role in the 21st century. Given the nuanced implications for unequal distribution of nocebo effects burdening racial minorities, we argue that the conversation surrounding effects of open notes must not only centre questions of access, but also questions of agency.

The history of …

View Full Text


  • 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.

Linked Articles

Other content recommended for you