There’s a refrain you might have heard or used as a kid in response to insults hurled your way. “Sticks and stones can break my bones, but words can never hurt me.” Did you really believe that words could never hurt you?

As a fourth year medical student I had a deeply disturbing experience that permanently changed the way I speak to my patients.

During my two-month rotation in the pulmonary department, I learned about all sorts of conditions related to the respiratory tract. My job was to take a complete history and perform an abbreviated physical exam on each patient, after the nurse had checked the vital signs. When the attending physician came into the room, I presented the history and physical findings and then stood back to observe the doctor/patient interaction.

One of the patients I saw—I will call him Jim—had a lingering cough. I remember Jim as tall, slim, and looking like a basically healthy fifty-year-old man with a hacking cough.

During the history taking, I discovered Jim never smoked and had no prior history of respiratory problems. He had recently started a new job making bread at a popular bakery in town. In hindsight, I can see the pulmonologist overlooked an important clue to the cause of the cough. No one asked him if the onset of the cough coincided with the time he started working at the bakery where flour dust was undoubtedly inhaled by all the bakers. Flour dust is a lung irritant.

Jim said the only reason he came for an appointment was because his wife was concerned that his cough had lasted for six weeks. There was no fever, no chills or any other symptoms. When I listened to his lungs, they sounded perfectly clear. The attending physician listened to my presentation, then asked the patient a few questions and checked his lungs. He said Jim’s lungs were clear, but he was going to order a chest x-ray anyway since the cough had lasted so long. “We need to rule out anything serious like cancer.”

The patient was taken to the ground floor to get the x-ray series and then escorted back to the exam room to wait for the doctor. I chatted with the patient, reassuring him that the x-ray results would probably be totally normal. I sensed his agitation after the physician said he wanted to “rule out cancer.”

The attending physician walked into the room with a grave look on his face. He was clearly uncomfortable and made little eye contact with the patient. He cleared his throat a couple of times, then said, “I have some bad news. Your x-ray shows a large mass in your upper right lung. We’ll have to schedule you for surgery to have the mass biopsied and sent to pathology.” In those days, CT and MRI scans were not commonly used.

“Doctor, do you think I have cancer?”

The doctor said he couldn’t say for certain, but that it looked like a strong possibility. He asked the patient to make a follow up appointment in one week for further testing.

As the physician said those words, I watched the color leave Jim’s face. In almost a whisper, he asked, “How long do I have to live, Doctor?” The pulmonologist said he didn’t know if the mass was infectious or cancerous. He explained that he wouldn’t know until a biopsy was done and the pathology report was back.

Jim pressed the pulmonologist. “If the pathology report shows I have cancer, how long do I have to live?”

The pulmonologist said it could be three to six months, given the size of the mass, but he couldn’t say for sure.

The patient looked like he had been hit in the stomach with a baseball bat. The life force seemed to have drained out of him. He got off the examining table and walked like a ghost out the door.

Several months after I left the pulmonary rotation, I ran into a classmate who told me what happened to Jim. He never came back to the hospital for follow-up and died after about three months.

His wife was upset and wanted answers. She insisted an autopsy be performed on her husband because, as she said, he had been perfectly healthy with just a simple cough.

The autopsy was done and no tumor was found in the lungs. The radiologists and pulmonologists did an investigation. The x-rays were re-examined at which time it was discovered that the dead man’s chest x-ray was mislabeled and was actually someone else’s x-ray. Jim’s x-rays were perfectly normal.

The news left me stunned. The patient essentially died from the impact of the words that were spoken to him. At that moment, I made a silent pact with myself to be mindful of the words I spoke. Primum non nocere.

We all know about the placebo effect—the healing power of our thoughts, perceptions and emotions when given a supposedly inert substance. But not much is spoken about the nocebo effect.

The English translation of the Latin word, nocebo, is “I shall harm”—the opposite of placebo. Just as our expectations can have the potential to heal, they can also have the potential to harm us.

Perhaps the children’s refrain should be: Sticks and stones can break my bones, but words can really harm me— if I believe them.

When I lived with the Navajo People as an elementary school teacher in the early 1970s, witchcraft was still practiced. My students reassured me that white people were safe from the effects of Navajo witchcraft. When I asked why white people weren’t affected, one of my students, a ten-year-old boy, said, “because white people don’t believe in witchcraft.”

Such wisdom from a young child.