A patient waits weeks for test results, only to learn they are normal: no lump, no blockage, and no sign of serious illness. Yet the news does little to ease his anxiety. He seeks a second opinion and returns days later with the same concern. Why can a reassuring result fail to reassure?

The explanation for this disconnect between diagnostic evidence and the patient’s perception was explored in a study published in the Annals of Family Medicine, conducted by German scientists. The researchers recruited 349 participants for a controlled experiment, testing the hypothesis that a doctor’s empathy and competence significantly and independently influence patients’ responses to diagnostic test results that fall within the normal range. The study demonstrated that the information in a technical report does not speak for itself: When the doctor in the video shown to participants demonstrated high competence, patients’ estimated probability of a serious illness dropped significantly, with a medium-sized effect (Cohen’s d = 0.439); the doctor’s manner had a significant but smaller effect (d = 0.281). The two factors were found to be independent of one another.

Cognitive immunization is the psychological mechanism behind this result: The individual actively downplays information that contradicts the diagnosis in order to preserve their prior beliefs about illness. When the doctor conveys hesitation, coldness, or uncertainty, the patient’s brain interprets a normal test result not as proof of good health, but as a failure of the test to detect a serious problem. In the German study, this was the largest effect observed (d = 1.058), and it was even more pronounced in the specific question about fear of colorectal cancer — the central scenario of the video shown to participants (d = 0.555).

Nonverbal Communication as a Clinical Tool

“Nonverbal communication is often more relevant to the message than verbal communication. And if we look at more traditional medical schools, there is an excessive focus on the words that will be used, which is a flaw. Physician-patient communication does not take place in a vacuum; it occurs within a relationship and a context of trust,” explained Marco Antonio de Carvalho-Filho, MD, PhD, full professor of health professions education research at the University Medical Center Groningen in Groningen, Netherlands. “When we communicate the results, we need to understand what that information means to the patient. Emotions help us understand others, our context, and the impact of our attitudes. If we convey detachment or insecurity, even the most perfect test result loses its impact.”

In the German study, researchers manipulated the healthcare professional’s behavior in standardized videos. Nonverbal behaviors indicating low competence and a lack of warmth — such as a slumped posture, hesitation when handling medical records, lack of eye contact, and excessive use of verbal fillers — directly increased participants’ uncertainty and fear of serious conditions, such as colorectal cancer.

According to Carolina Felipe Soares Brandão, a faculty member at the Clinical Simulation Laboratory for the medical programs at Universidade Cidade de São Paulo and the Universidade Municipal de São Caetano do Sul inSão Paulo, Brazil, this insecurity demonstrated by the physician often reflects a weakness in the professional’s technical training. “We cannot separate communication skills from technical competence. It is very difficult to convey confidence and properly contextualize a result when the professional does not sufficiently understand that test, its indications, and its limitations,” pointed out Brandão.

“A normal test result needs to be contextualized. Students need to learn to explain what conclusions can be drawn from that result, what its limitations are, and what the follow-up will be, without turning the uncertainty inherent in medicine into an additional source of anxiety. The answer to uncertainty shouldn’t simply be to order more tests; we need to improve the quality of the explanation,” Brandão explained.

This nonverbal aspect, Carvalho-Filho noted, should not be confused with the application of rigid behavioral rules. It’s impossible to prescribe communication or behavior. In medical school, doctor-patient communication is taught as if it were something separate, but it arises from communication between two human beings. For example, there’s a lot of talk about how eye contact is essential, but if we stare at the patient for 5 minutes, they’ll want to disappear. When we share bad news or discuss uncertainties, there are moments when the person becomes introspective, turning inward. In those moments, direct eye contact can be the worst approach; an assertive presence is conveyed through respectful silence. Silence is the absence of words, but not the absence of meaning.

The Cost of Rework and the Conflict Between Cronos and Kairos

“If a patient receives a normal test result but leaves the appointment unconvinced, the consultation may be over from the doctor’s perspective, but not from the patient’s,” explained Paulo Borem, MD, a physician and senior director in the Latin American region of the US-based Institute for Healthcare Improvement in Minneapolis. That patient may seek another physician’s opinion, undergo repeat testing, or return to the emergency department. These repeat visits and tests amount to rework — and the cost of poor-quality care — using resources without adding value. In public health systems, they strain limited capacity and lengthen wait times; in private systems, they increase service use and costs. When a patient does not understand or trust a technically accurate test result, the healthcare system’s work is not finished.

Faced with time pressures in overburdened outpatient clinics and emergency rooms, Carvalho-Filho debunks the idea that listening and reassuring patients require long appointments. “The ancient Greeks had two words for time: Cronos, which is the physical, linear time of the clock, and Kairos, which is the time of opportunity. If we don’t seize the opportunity during our encounter with the patient, we’re wasting time. When we’re truly present — in body, mind, and heart — the connection happens very quickly, and time ceases to be the limiting factor,” he explained.

The doctor highlights his experience leading the emergency department at the University of Campinas in Campinas, Brazil. “I remember a patient in the ER [emergency room] who had been experiencing stomach complaints for years and had undergone countless endoscopies with normal results. We sat down to talk, and I asked her directly what she was afraid of. She cried and revealed her terror of having stomach cancer, like her father. By putting her history into context and showing that her normal test results over the past 4 years proved she didn’t have cancer, she left feeling relieved and never returned to the department. If the consultation ends without the patient’s concerns being addressed, we’ve wasted time.”

“Welcoming the patient and instilling a sense of security don’t require long consultations. Looking at the patient, calling them by name, explaining clearly, and checking if any questions remain takes only a matter of seconds,” noted José Roberto Generoso Jr, MD, PhD, president of the Brazilian Society for Simulation in Healthcare. “Our simulation training shows that a brief, confident explanation reassures the patient more than a long but hesitant conversation. Perceived competence conveys calm, organization, and clarity — attitudes that don’t take time and often save the system’s resources.”

Borem added that proactive, patient-centered care can help prevent cascades of unnecessary testing and serve as an important safety strategy. “Compassionate communication should be considered a best practice in patient safety. Every unnecessary test creates another opportunity for harm, as it may yield an incidental finding that leads to further investigations and invasive procedures. But simply telling doctors to order fewer tests isn’t enough. The doctor needs to be able to say to the patient, “I believe what you’re feeling is real, but based on what we know today, another test won’t help. Let me explain what we’ll do next.” Reassurance and clarity don’t mean doing nothing; they are active components of care.”

When Digital Anxiety Strikes Before the Appointment

The proliferation of generative AI tools and online symptom checkers has transformed the profile of patients arriving at the doctor’s office. According to a survey by Gallup in partnership with the West Health-Gallup Center on Healthcare in the US, 59% of American adults who consult AI for health information do so specifically before a doctor’s appointment to explore differential diagnoses and prepare questions. The same survey identified another concerning trend: Approximately 14 million adults reported having decided not to seek out a healthcare professional after consulting an AI tool, and only 4% of users of these tools said they strongly trusted the accuracy of the information provided.

This preliminary research often increases health-related anxiety and fuels cyberchondria, a phenomenon characterized by hypochondria exacerbated by compulsive internet use. A systematic review conducted by Wallace and colleagues of Imperial College London in London, England, published in 2022 in npj Digital Medicine, analyzed 10 studies on online symptom checkers and found that the primary diagnostic accuracy of these systems remained low and highly variable, correctly identifying the primary diagnosis between 19% and 38% of the time. Triage accuracy — that is, guidance on whether or not to seek care — was higher but also inconsistent, ranging from 49% to 90%.

Another study, published in Communications Medicine, evaluated the triage accuracy of 22 ChatGPT models and found that AI algorithms have a strong tendency to overestimate the severity of conditions. Because they are programmed to avoid overlooking emergencies, the models frequently classify benign presentations as urgent conditions and rarely recommend simple self-care. The result is that patients no longer arrive at their appointments asking, “What’s wrong with me?” but are instead influenced by a list of alarming hypotheses generated by AI.

“The approach should not be to clash with the patient’s prior research,” warned Brandão. Both students and physicians need to learn to listen, understand where that concern came from, technically evaluate the information, and, from there, help the patient put it into context. Technical competence is essential for recognizing what is relevant, what is out of context, and what requires further investigation. AI should enhance care, but it does not replace the ability to establish a quality human relationship.

When a doctor reacts with impatience, sarcasm, or a simplistic dismissal to a hypothesis generated by AI and presented by the patient, they validate the individual’s preexisting insecurity. This defensive response from the healthcare professional acts as the perfect trigger for cognitive immunization: The patient concludes that the physician downplayed the symptom, dismissing the technical explanation and maintaining the conviction that they need to seek a second opinion or request additional tests.

Methodology and Medical Training

The German study has methodological limitations that call for caution when applying its findings to clinical practice: it is an analog experimental study based on vignettes and videos, with a predominantly young online convenience sample (n = 349; mean age, 29.9 years; 79% female), recruited in Germany. The authors themselves acknowledge, in the article’s discussion, that the findings cannot be directly extrapolated to clinical practice without studies in contexts with greater external validity.

Caution is essential when analyzing the applicability of these findings in Brazil, noted Generoso Jr. The study has clear limitations. It was conducted online with young, German-speaking participants who imagined a clinical scenario; we cannot assume the results would be the same in Brazil. Still, it’s worth testing these dynamics here. In the simulation, we have the flexibility to work with actors of different ages, regions, and diverse socioeconomic and cultural backgrounds, thereby validating how Brazilian patients react to these nonverbal behaviors.

Nevertheless, the findings add to a well-established body of evidence in the medical education literature demonstrating that interpersonal skills are not “innate gifts,” but rather measurable competencies that can be taught. An example of this is a study conducted at the Faculty of Medical Sciences of the State University of Campinas, published in Academic Medicine and co-authored by Carvalho-Filho: It followed 124 fourth-year and 123 sixth-year medical students in 2011 and 2012. Simulations with standardized patients, followed by in-depth, guided debriefing, significantly increased students’ empathy scores on the Jefferson Scale of Empathy.

This reasoning underpins the Medical Education Empowered by Theater program, created by Carvalho-Filho and detailed in an article also published in Academic Medicine. The program applies theatrical techniques and Paulo Freire’s critical pedagogy to develop in students a state of presence, improvisation, and stage intelligence, that is, the ability to evaluate their own performance while acting.

“To teach relational skills and prevent cognitive immunization, it’s not enough to simply introduce ‘communication’ as theoretical content,” argued Brandão. It’s necessary to create opportunities for students to practice, be observed in simulations, and receive structured feedback. Furthermore, to teach simulation, communication, and debriefing, it’s not enough to be an expert in the clinical content; one needs to study education.

According to Generoso Jr, the fundamental role of simulation is to make students aware of automatic behaviors they are not consciously aware of. “No one corrects a gesture they don’t know they’re making. In the simulation, the student interacts with a trained actor, and in the debriefing, we revisit the case together and discuss the group’s perceptions. Often, they are surprised to see that they spent a good part of the conversation looking at the computer or observing how many times they hesitated. The main focus should be on investing in a qualified and trained faculty in the use of simulation strategies in healthcare and not in pharaonic structures with equipment costing millions of reais that sometimes tend to be superlative and do not meet measurable learning objectives.”

The reasoning concluded with a reflection on the need to humanize the relationship between teachers and students in the academic environment, according to Carvalho-Filho. There is a power imbalance between teacher and student very similar to the dynamic that occurs between doctor and patient. If the teacher uses power in an authoritarian way, the student learns that it is acceptable to be authoritarian and reproduces this with the patient. We need student-centered education so that we can have person-centered care. The human presence, openness, curiosity, and vulnerability of the doctor are already therapeutic in themselves.

This story was translated from Medscape’s Portuguese edition.