Placebos in primary care? a nominal group study explicating UK GP and patient views of six theoretically plausible models of placebo practice

Abstract

ObjectivesTo better understand which theoretically plausible placebogenic techniques might be acceptable in UK primary care.DesignA qualitative study using nominal group technique and thematic analysis. Participants took part in audio-recorded face-to-face nominal groups in which the researcher presented six scenarios describing the application in primary care of theoretically plausible placebogenic techniques: (1) Withholding side effects information, (2) Monitoring, (3) General practitioner (GP) endorsement, (4) Idealised consultation, (5) Deceptive placebo pills and (6) Open-label placebo pills. Participants voted on whether they thought each scenario was acceptable in practice and discussed their reasoning. Votes were tallied and discussions transcribed verbatim.SettingPrimary care in England.Participants21 GPs in four nominal groups and 20 ‘expert patients’ in five nominal groups.ResultsParticipants found it hard to decide which practices were acceptable and spoke about needing to weigh potential symptomatic benefits against the potential harms of lost trust eroding the therapeutic relationship. Primary care patients and doctors felt it was acceptable to harness placebo effects in practice by patient self-monitoring (scenario 2), by the GP expressing a strongly positive belief in a therapy (scenario 3) and by conducting patient-centred, empathic consultations (scenario 4). Deceptive placebogenic practices (scenarios 1 and 5) were unacceptable to most groups. Patient and GP groups expressed a diverse range of opinions about open-label placebo pills.ConclusionsAttempts to harness placebo effects in UK primary care are more likely to be accepted and implemented if they focus on enhancing positive patient-centred communication and empathic relationships. Using placebos deceptively is likely to be unacceptable to both GPs and patients. Open-label placebos also do not have clear support; they might be acceptable to some doctors and patients in very limited circumstances—but further evidence, clear information and guidance would be needed.

How German general practitioners justify their provision of complementary and alternative medicine – a qualitative study

“…Our findings fit with those in the scarce qualitative literature on prescribing placebos which suggests that exploiting the placebo effects of a treatment seems to be fully legitimate only if the provider believes that it also has specific intrinsic effects [31,32]. Parsons identified functional specificity as a core value of the medical profession [32,33]. In her seminal study among Welsh GPs from 1976 [25], Comaroff described how physicians internalize the professional ideal to provide treatment only if needed and only if it has specific effects (over placebo).…”

“…Another interesting empirical finding of our study is the important link between being able to act in an authentic manner, the exploitation of placebo effects and the personal belief in specific effects. Our findings fit with those in the scarce qualitative literature on prescribing placebos which suggests that exploiting the placebo effects of a treatment seems to be fully legitimate only if the provider believes that it also has specific intrinsic effects [31,32]. Parsons identified functional specificity as a core value of the medical profession [32,33].…”

Primary care providers' use of and attitudes towards placebos: An exploratory focus group study with US physicians

“…Although some physicians expressed cautious support for the possibility of prescribing OLPs, many opposed their use as "disrespectful" toward patients. The divergent opinions observed here is consistent with the one other study we are aware of that has investigated open placebo willingness among physicians (Ratnapalan et al, 2020). Reasons for skepticism included lack of clinical guidelines about when to use OLPs, perceptions of cultural or institutional resistance within the medical community, and concerns about the potential harms of OLPs, including patients' perceptions that their complaint would be trivialized.…”

“…First, no previous survey has examined physicians' opinions about OLPs. Second, the present study examines the opinions of US-based physicians on placebo use, which has only been previously explored once using qualitative methodology (Ratnapalan et al, 2020). If OLPs are to find a role within primary care, it is first important to develop a rich and nuanced understanding of how physicians perceive their usefulness in clinical practice.…”

Lay perspectives of the open-label placebo rationale: a qualitative study of participants in an experimental trial

“…This is related to the notion that their openness would ‘depend on the symptoms or disorder’, a finding that is in line with a previous qualitative study, applying a scenario to explain OLP to participants. 71 Patients with chronic primary pain, for example, often describe that different treatment approaches have turned out to be unsatisfactory, leading to a perceived lack of alternatives and a state of demoralisation, 72 which might lead to an openness towards OLPs. Therefore, the idea of informing participants that a positive attitude helps but is not necessary might be problematic: not only do participants use other strategies to reduce scepticism, they are also convinced that positive attitudes are an important mechanism for placebos to work—a sentiment which is supported by current scientific evidence.…”