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Henriquetateixeira.com.brQuestionnaire survey on use of placebo
Uriel Nitzan, Pesach Lichtenberg
We approached three groups of physicians and nurses, Objectives To gauge the frequency and circumstances
who might be expected to differ in their attitudes of use of placebo in clinical practice and the attitudes towards the use of a placebo and its legitimacy as a towards its use among those who administer it.
therapeutic tool. Of around 110 physicians and nurses Design Retrospective questionnaire.
approached, 89 agreed to participate in the survey, all of Setting Two large hospitals and various community
whom received and returned completed questionnaires.
Senior physicians working in hospital inpatient and out- Participants 31 physicians working in hospital
patient departments in medical and surgical specialties and inpatient and outpatient departments, 31 head nurses subspecialties—The bulk of the work of these respond- working in hospital inpatient departments, and 27 ents was with inpatients, with one or two half days a family physicians working in community clinics.
week spent in the associated hospital based outpatient Main outcome measures Self report of frequency and
clinic. So as not to collect duplicate data for the same circumstances of, and attitudes towards, use of placebo.
inpatient department, we included only one physician Results Among the 89 respondents, 53 (60%) used
from each department. We covered all 31 inpatient placebos (95% confidence interval 49% to 70%).
departments at two major hospitals in Jerusalem and Among users, 33 (62%) prescribed a placebo as often therefore included 31 respondents in this category. Ten as once a month or more; 36 (68%) told patients they physicians declined to receive the questionnaire.
were receiving actual medication; 15 (28%) considered Head nurses working in the same hospital inpatient that placebos were a diagnostic tool; and 48/51 (94%) departments as senior physicians—Here too we had 31 reported that they found placebos generally or respondents, one per department. As the nurses are responsible for dispensing medications on inpatient Conclusion Most practitioners questioned in this
wards, we included them to get a picture of what actu- study continue to use placebos. Used wisely, placebos ally takes place in the hospital services. All nurses might have a legitimate place in therapeutics. Wider approached agreed to participate in the survey.
recognition of the practice and debate about its Family physicians working in community clinics—These respondents were recruited from a weekly gathering ofabout 40 family physicians working in Jerusalem. Of Introduction
these, 27 agreed to receive the questionnaire and allcompleted it. As we expected physicians working in the How common is the use of placebos in clinical same clinic to display independent prescribing habits, practice? From the dearth of discussion in the medical we allowed more than one physician from a single literature—almost all references to placebo from a Medline search refer to a research context—one mightsurmise that the clinical use of placebos is exceedingly Statistical methods
rare. The deception involved in administering a To assess the precision of the estimated proportion of placebo certainly raises ethical questions, and some placebo use in clinical practice, we calculated 95% con- institutions have banned its use. Yet informal fidence intervals. We used Pearson 2 test and Fisher’s discussions with colleagues, as well as first hand obser- exact test to test the significance of the association vation of clinical activity in various medical depart- between two qualitative parameters. P ≤ 5 was consid- ments, suggest the practice still occurs. The only other report that we could locate of placebo use in a clinicalcontext goes back a quarter of a century.1 The authorsfound that the placebo was rarely (about once a year per physician) and inappropriately used.
Table 1 shows the composition of the group. We have We reappraised how frequently and in what summarised the data from the questionnaire under six circumstances physicians and hospital nurses use placebos in a clinical setting, how they understand the Frequency—When we planned the study we assumed mechanisms of actions, their views on ethics, and that the use of placebo was not widespread and would not exceed 10%. Among our 89 respondents, however,53 (60%) admitted using a placebo (95% confidence interval 49% to 70%). The age and sex of respondent didnot affect results. In total, 53% of doctors and 71% of Questionnaire
nurses reported using a placebo. Among users, 33 (62%; We developed a questionnaire on attitudes and experi- 37% of the total sample) used a placebo as often as once ence with placebos. We sought information on basicdemographics, the frequency of placebo use, thecircumstances of its administration, accompanying An English translation of the questionnaire can be found on beliefs about mechanisms of action, and ethical positions. The questionnaire was administered in This article was posted on bmj.com on 17 September 2004: Hebrew (see bmj.com for an English translation).
http://bmj.com/cgi/doi/10.1136/bmj.38236.646678.55 BMJ VOLUME 329 23 OCTOBER 2004
action for placebos. Of 83 responses, most (62, or 75%) Table 1 Demographic and professional data for respondents to
mechanisms. An additional nine (11%) respondents suggested a combination of psychological and Discussion
We attempted to gauge the extent of placebo use in Mean (SD) professional experience (years) clinical work. Despite general disapproval in the medi- cal literature,2 3 such use continues among 60% of our respondents. The circumstances varied but included a wide variety of clinical situations. Indeed, as only one in 20 would prohibit the placebo in all circumstances thepotential for placebo prescriptions is even greater than a month or more. Differences between physicians and the actual extent of use. We also found that most prac- nurses in reported use and frequency of use of placebo titioners who use placebos claim effectiveness for the treatment in some or most cases. In light of this Perceived therapeutic value—Of those who used a pla- finding, it seems likely that the many such practitioners cebo, most (48 of 51 who answered the question, or will continue to prescribe placebos.
94%) found that it was either generally (17, or 33%) or Many physicians relate to the placebo as a diagnostic occasionally (31, or 61%) effective.
tool. This indicates a persistence of long discredited Information given to patients—Of those using the pla- notions of a separation between mind and body. A cebo, 36 (68%) tell the patient that he or she is receiv- placebo can assuage pain. Even in a meta-analysis that ing a real medicine, and nine (17%) say nothing at all.
raised questions about the actual existence of a placebo The rest either identify the placebo as such (two, or 4%) effect the authors concurred that placebos can have or tell the patient that he or she is receiving a analgesic potency.4 The physician who nevertheless uses non-specific medicine (six, or 11%).
a placebo diagnostically is at risk of reaching unfounded Circumstances of use—We found a wide range of conclusions, to the detriment of his or her patients.
applications for placebo (table 2). Placebos were givenin the form of saline infusions or intramuscular Strengths and weaknesses of study
injections; paracetamol or vitamin C tablets instead of Because we investigated all medical and surgical inpa- the ordinarily prescribed medication; sugar or artificial tient departments at two hospitals and chose only one sweetener pills; or prepared placebo tablets. The medi- senior physician and nurse from each, our findings are cal conditions for which the placebos were used quite comprehensive. A weakness of our paper, included anxiety, pain (including abdominal), agitation, however, is that we rely on self reports made retrospec- vertigo, sleep problems, asthma, contractions in labour, tively. This can be a problem when respondents are withdrawal from recreational drugs, and angina asked to look back and estimate the frequency of a par- pectoris (when the blood pressure was too low to allow ticular behaviour. The fact that a particular respondent for vasodilators). The stated value as a diagnostic tool, uses a placebo in a clinical context is not likely to be referred to in table 2, was to distinguish organic from misremembered, however, even if the frequency is mis- psychogenic or simulated arthralgia, seizure disorder, judged. Moreover, in light of the suspect moral validity of such treatment, we would anticipate that placebo use Ethical stance—Of 79 responses on ethics, only four would be understated in the responses to the question- (5%) thought that the use of placebos should be naire. If so, our finding that placebo prescribing is a categorically prohibited. Most of the others considered widespread practice cannot be doubted.
placebo use conditional on certain circumstances, suchas prior experience (26, or 33%), notifying patients of Previous study
receipt of a placebo (23, or 29%), or evidence from In a previous study, the extent of placebo use was research that the placebo was effective (19, or 24%).
found to be considerably less, about one prescription a Perceived mechanism of action—Respondents were year per physician.1 In our study over a third of the permitted to propose more than one mechanism of respondents reported using a placebo once a month or Table 2 Circumstances in which placebo was administered. Figures are number (percentage of those who reported use) of respondents*
Hospital based physicians
After “unjustified” demand for medication To buy time before next regular dosage of medication *53 respondents reported that they use placebo (19 hospital based physicians, 22 nurses, and 12 family physicians). Each respondent was permitted to cite morethan one circumstance in which he or she used placebo.
BMJ VOLUME 329 23 OCTOBER 2004
more, and nearly 60% at least once a year. Though the What is already known on this topic
differing methods of the data collection rendercomparisons across these studies difficult, our findings No study has recently attempted to assess the use suggest that the use of the placebo is increasing. The former study recorded actual prescriptions and waslimited to actual placebo pills or saline, while we stud- Placebos may be effective in some areas, but their ied the self reports of healthcare providers, and, in cer- tain circumstances, paracetamol and vitamin pills were What this study adds
Three in five clinicians continue to use placebos Some have advocated banning the clinical use of Clinicians believe that some patients benefit from placebos because of the deception involved in administration and the possible harm to the doctor-patient relationship.2 3 Others have suggested guide- The role of placebo treatment, its mechanisms, lines for the proper use of placebos without violating and its ethics need to be the subject of wider the patient’s trust and autonomy.5–7 Our study shows that administration of placebos for clinical purposescontinues. Clearly, wider recognition of the practice,and debate about its implications, are needed. Further Goodwin JS, Goodwin JM, Vogel AV. Knowledge and use of placebos by investigations into the extent and nature of use should house officers and nurses. Ann Intern Med 1979;91:106-10.
be conducted, particularly in a clinical context where De Deyn PP, d’Hooge R. Placebos in clinical practice and research. J MedEthics 1996;22:140-6.
the placebo’s effect may differ from that found in ran- Hill J. Placebos in clinical care: for whose pleasure? Lancet 2003;362:254.
domised controlled trials.8 9 Moreover, though Israeli Hrobjartsson A, Gotzsche PC. Is the placebo powerless? An analysis ofclinical trials comparing placebo with no treatment. N Engl J Med medicine is taught and practised as elsewhere in the Western world, similar surveys in other geographical Brown WA. Placebo as a treatment for depression. Neuropsychopharmacol-ogy 1994;10:265-9.
areas may reveal cross cultural differences.
Lione A. Ethics of placebo use in clinical care. Lancet 2003;362:999.
Lichtenberg P, Heresco-Levy U, Nitzan U. The ethics of the placebo in Contributors: UN had the original idea for the study and com- clinical practice. J Med Ethics (in press).
piled the data. Both authors jointly developed the questionnaire.
Vase L, Riley JL, Price DD. A comparison of placebo effects in clinical PL wrote most of the article and is guarantor.
analgesic trials versus studies of placebo analgesia. Pain 2002; 99:443-52.
Hyland ME. Using the placebo response in clinical practice. Clin Med Are written responses to some referrals to a general
haematology clinic acceptable?
Allison Tso, Lucy Harris, Tim Littlewood
Each year about 1000 patients are referred to the department of haematology in Oxford. Excluded from Questionnaire
this number are referrals for problems related to coagulation, which are seen at the Oxford Haemo- Was a written reply offering advice rather than an outpatient appointment acceptable to you? Yes/No philia Centre. We wondered whether a written reply to Was the advice given helpful to you? Yes/No the general practitioner would provide the same qual- Would you be satisfied with a written response in the ity of healthcare advice more quickly, and with less inconvenience to the patients, than seeing patients in a Do you know if the patient was satisfied with a written Methods and results
One consultant (TL) received 274 letters of referral example, a mild macrocytosis (mean cellular volume less between 1 November 2001 and 1 January 2003 and than 105 fl) without accompanying cytopenia was the wrote a response to 121 (table). We subsequently sent commonest referral for which TL sent a written each of the general practitioners who had received a response. In all patients, the blood film had been exam- written response a questionnaire (box) with a copy of ined (and was normal apart from the mild macrocytosis) their original referral letter and a copy of the written and advice was offered about checking for possible causes of macrocytosis (including vitamin B-12 or folate TL sent written responses if the patient neither deficiency, liver disease, hypothyroidism, drug related required further investigation (such as a bone marrow causes, and excess alcohol consumption), if these factors biopsy) nor treatment that would better be done in thehaematology department and if no evidence indicated a This article was posted on bmj.com on 1 October 2004: http://bmj.com/ serious underlying illness, such as malignancy. For cgi/doi/10.1136/bmj.38253.703553.F7 BMJ VOLUME 329 23 OCTOBER 2004
Congenital Cardiac Abnormalities S i m u l a t e d C l i n i c a l E x p e r i e n c e ( S C E ™ ) O v e r v i e w L e a r n i n g O b j e c t i v e s Location: General Pediatrics Unit 1. Uses history and assessment fi ndings to plan, prioritize, and provide developmentally appropriate care to the infant patient with Down History/Information: syndrome (trisomy 21) and congeni