Placebos in Primary Care? A Nominal Group Study Explicating GP and Patient Views

Problem

Researchers are exploring techniques to help harness placebo effects in clinical settings (“placebogenic” practice). However, we know relatively little about how GPs and patients view different placebogenic practices. Placebogenic practice could offer cost-effective healthcare, which enhances health outcomes whilst minimising patient harm from drug side effects. We undertook this study to better understand the acceptability to patients and GPs of key theoretically plausible placebogenic techniques.

Approach

A qualitative study using nominal group technique. 21 GPs and 20 “expert” patients from across the UK took part in 9 face to face audio-recorded nominal groups (4 GP and 5 patient groups). Participants discussed scenarios illustrating 6 placebogenic practices: (1) Positive therapeutic message but withholding information on side-effects; (2) Regular review and patient self-monitoring (3) GP stating a strong belief that the therapy will work (4) Idealised patient-centered, empathic consultation (5) Placebo pills with deception (6) Open-label placebo pills. Groups voted on the acceptability of each scenario. Votes were collated and audio-recordings transcribed verbatim, then coded thematically.

Findings

Participants found it hard to decide on what practices were acceptable and spoke about needing to balance the positive effects of the placebogenic practice against the harms from erosion of the therapeutic relationship from the loss of trust. Scenarios that were acceptable included: (2) self-monitoring (3) GP expressing belief in a therapy and (4) the idealised consultation. The scenarios which featured elements of deception, (1) withholding information on side effects and (5) placebo pills with deception, were felt by most groups to be unacceptable. Groups worried that patients would come to both physical and psychological harm from the deception. Interestingly, there was a range of opinion on the acceptability of open label placebo.

Consequences

These results improve understanding of which aspects of placebogenic practice patients and practitioners may find acceptable to employ in clinical practice and highlight the difficulties in determining acceptability.