Use of Placebos and Nonspecific and Complementary Treatments by German Physicians - Rationale and Development of a Questionnaire for a Nationwide Survey

Abstract

Background: We are performing a nationwide survey in a random sample of German general practitioners (GPs), orthopedists, and internists on the use of placebos and nonspecific as well as complementary treatments and their association with basic professional attitudes. In this article we explain the theoretical considerations behind the study approach and the development of the questionnaire. Methods: Based on a systematic review of published surveys, own surveys on the topic, and on theoretical considerations we developed a preliminary version of a 4-page questionnaire that was tested for feasibility in a convenience sample of 80 participants of a general medical education event. We also performed cognitive interviews with 8 physicians to investigate whether the questions were understood adequately. Results: The questions on typical placebos and complementary treatments were well understood and easy to answer for participants. Discussions about the phrasing of questions on nonspecific treatments during interview reflected the vagueness of this concept; but this did not seem to create major problems when answering the related questions. The original questions regarding basic professional attitudes partly were not understood in the manner intended. The relevant questions were modified but the interviews suggest that these issues are difficult to grasp in a quantitative survey. Conclusion: Our testing procedures suggest that our questionnaire is well-suited to investigate our questions with some limitations regarding the issue of basic professional attitudes.

From substance to process: A meta-ethnographic review of how healthcare professionals and patients understand placebos and their effects in primary care

“…First, as other researchers have noted, it is conceptually misleading to define any substance as inert, as all substances can be treated in physico-chemical terms if one chooses to do so (Grünbaum, 1986; Howick, 2017); for example, even the classic sugar pill is not inert to a diabetic. In this sense, the distinction between ‘pure’ and ‘impure’ placebos is not just, as our findings suggest, confusing (Linde et al, 2013) but untenable.…”

“…Healthcare professionals and patients predominantly defined placebos as material substances (Babel, 2013; Bishop et al, 2014b; Fässler et al, 2009, 2011; Fent et al, 2011; Ferentzi et al, 2010; Hróbjartsson and Norup, 2003; Hull et al, 2013; Kermen et al, 2010; Kisaalita and Robinson, 2012; Linde et al, 2013; Nitzan and Lichtenberg, 2004; Tandjung et al, 2014). Healthcare professionals indicatively defined a placebo as a ‘pharmacological intervention, for example vitamin tablets, thus reflecting the narrow meaning of the term’ (Hróbjartsson and Norup, 2003: 162) or as ‘an inert substance that when taken by a person can have an effect on that person–either good or bad’ (Bishop et al, 2014b: 359).…”

“…Healthcare professionals indicatively defined a placebo as a ‘pharmacological intervention, for example vitamin tablets, thus reflecting the narrow meaning of the term’ (Hróbjartsson and Norup, 2003: 162) or as ‘an inert substance that when taken by a person can have an effect on that person–either good or bad’ (Bishop et al, 2014b: 359). Moreover, although in many surveys, the definitions were fixed by the researchers, when given an opportunity to define placebos themselves, healthcare professionals often focussed explicitly on placebos as inert substances: in one study ‘the majority of PCPs [primary care providers] stated that a placebo is a dummy drug without substance’ (Fent et al, 2011: 3), and another stated that ‘physicians intuitively equate placebo or typical placebo with pure placebo [inert substance]… [and] the cognitive interviews clearly confirmed that the concept of impure placebos [substances known to be effective for other conditions] is unfamiliar and confusing to physicians’ (Linde et al, 2013: 364).…”

Placebos Without Deception: Outcomes, Mechanisms, and Ethics

“…A number of studies reported that placebos are indeed used by clinicians across different countries (Fassler, Meissner, Schneider, & Linde, 2010; Kermen, Hickner, Brody, & Hasham, 2010; Louhiala, 2012; Meissner, Hofner, Fassler, & Linde, 2012; Nizan, Barash, Valinsky, Lichter, & Manulis, 1997; Tilburt, Emanuel, Kaptchuk, Curlin, & Miller, 2008) including United States (Kermen et al, 2010; Sherman & Hickner, 2008; Tilburt et al, 2008), Canada (Harris & Raz, 2012; Raz et al, 2011), Germany (Linde et al., 2013; Meissner, 2005), Switzerland (Fassler, Gnadinger, Rosemann, & Biller-Andorno, 2009), Denmark (Hrobjartsson & Norup, 2003), United Kingdom (Howick et al, 2013), Israel (Nitzan & Lichtenberg, 2004), India (Shah, Panchal, Vyas, & Patel, 2009), Saudi Arabia (Hassan, Fauzi, & Hasan, 2011), and New Zealand (Holt & Gilbey, 2009). A systematic review of 22 studies from 12 different countries reported that between 17% and 80% of interviewed clinicians administered sugar pills or saline injections during their careers (Fassler et al., 2010).…”

Relieving pain using dose-extending placebos: a scoping review

“…Intentional use of placebos has been recently documented in survey studies spanning different countries including USA [76; 80; 51], Canada [69; 44], Germany [59; 57], Switzerland [30], Denmark [48], UK [47], Israel [63], India [75], Saudi Arabia [45], and New Zealand [46] (see also Table 1). A systematic review of 22 studies from 12 different countries reported that between 17 and 80% of clinicians interviewed have administered such placebo treatments as sugar pills or saline injections during their careers [32].…”