Context as a drug: some consequences of placebo research for primary care

Abstract

Objective: On the basis of emerging research evidence, this review aims to discuss the importance of the context surrounding the doctor–patient encounter for the success of treatment.

Design and setting: Discussion paper based on placebo–nocebo and pain studies conducted in the western world.

Main outcome measures: Literature-based theory about impact of communication elements on seriousness of symptoms in clinical practice.

Results: The therapeutic outcome seems to be impacted by rituals around a clinical encounter and by the doctor patient communication and relation. A warm, friendly and empathic attitude is crucial in the first contact with the practice and during the consultation as it influences the patient’s perceived outcome. It is important to raise positive expectations when discussing the prognosis, conducting treatment and prescribing medications as the effect may be reduced if the physician expresses doubt about the effectiveness of the medication. Additionally, overly focus on side effects in the doctor–patient conversation about proposed treatments seems to influence the magnitude of perceived side effects in the patient. Thus, shared decision-making might be a desirable tool for ensuring better expectations in the patient and successful symptom relief.

Conclusions: The context of the doctor–patient interplay matters. Placebo–nocebo research provides strong evidence for this link. The therapeutic context induces biomedical processes in the patient’s brain that may enhance or reduce the effects of chosen interventions. The context thus works as a drug, with real effects and side effects.

KEY POINTS

• Increased awareness of the context drug may help GPs alleviate symptoms and better motivate patients for treatment.

• Treatment is affected by multiple types of context, as also confirmed by placebo–nocebo research.

• The therapeutic context influences the biomedical processes, which may enhance or reduce intervention effects on symptoms.

• The impact of context should be considered in daily general practice as it may serve as a drug, with real effects and side effects.

Keywords:

• Placebo
• nocebo
• context
• doctor–patient relation
• symptoms
• shared decision-making
• general practice
• Denmark

Acknowledgements

We would like to thank Lone Niedziella for her linguistic help.

Ethical approvals

According to Dutch and Danish legislation, approval by an ethical committee is not required.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding

The work was supported by the Research Unit for General Practice, Department of Public Health Aarhus University.