Future Research Directions
My brief review suggests a number of requirements for advancing knowledge of the placebo response. The greatest advances will come from multidisciplinary research teams set up to integrate qualitative measures of meaning and perception with quantitative measures of biochemical mediators and bodily change.
Intriguing studies conducted in psychology laboratories27 must be replicated and expanded in the less controlled environment of clinical practice.
Creative use of brain imaging techniques, such as positron emission tomography and functional magnetic resonance imaging may be used to identify which neuroanatomical centers’ activation correlates with placebo responses.
Carefully designed meta-analyses may increase our understanding of selected facets of the placebo response.
Integrating Science and Practice
The [ Figure] suggests how the scientific elements reviewed here can be interwoven into a causal account of the placebo response that can guide physician behavior. Although all elements are of interest for research, the meaning model is most helpful for suggesting therapeutic interventions, since it describes those parts of the process that the physician can most easily influence.
Practice implications
This review suggests a number of therapeutic strategies for office practice that many sensitive and astute clinicians are already using. The available evidence suggests that although we do not fully understand why or how these strategies work, they are relatively inexpensive and notably nontoxic, so no barriers exist to their employment.
Although the focus here is on specific techniques, the importance of the background rituals of medical practice, such as listening to the heart with a stethoscope and writing a prescription, should not be forgotten. History and culture have imbued these rituals with multiple layers of meaning, and their simple predictability may bring great comfort to a frightened patient.
Sustained Partnership
Perhaps the best single concept of how to structure one’s interactions to maximize the placebo response is that of the “sustained partnership” between physician and patient.28 Sustained partnership consists of 6 physician characteristics:
- Interest in the whole person
- Knowing the patient over time
- Caring, sensitivity, and empathy
- Viewed as reliable and trustworthy by the patient
- Adapts medical goals of care to the patient’s needs and values
- Encourages the patient to participate fully in health decision making
These 6 elements were selected because empirical studies link them to superior health outcomes in practice settings. Relating to patients in this way leads to measurable improvements in the patient’s health and an ethically sound (as well as cost-effective) practice. Sustained partnership is a nondeceptive mode of practice, so the ethical problem created by the use of sugar pills and other dummy remedies never arises-the placebo effect is present without the placebo.29
Meaning Model
The meaning model suggests that physicians will obtain the best therapeutic results if they listen carefully to patients’ accounts of their illness, offer explanations that fit with patients’ world-views, express care and concern, and help patients feel more in control of their symptoms (or of their lives, despite the persistence of their symptoms). This will happen more often if the clinician spends sufficient time with the patient, so it is not surprising that good health outcomes correlate with the length of the primary care visit.30,31 Family physicians must act as advocates for their patients with today’s financial managers by bringing these data forcefully to the managers’ attention.
Mastery
Of the different elements of meaning, perhaps the most challenging to achieve when treating chronically ill, somatizing, or depressed patients is the heightened sense of mastery and control. Malterud32 has summarized an encounter plan to deal with one difficult population, women presenting with pelvic complaints without detectable organic cause, suggesting 4 basic questions:
- What do you most of all want me to do for you today?
- What do you yourself think is the reason for your problem?
- What do you think I should do about your problem?
- What have you found so far to be the best way to manage your problem?
Malterud points out that previous physicians, by approaching these patients in “rule out organic causes” fashion, have firmly cemented the idea of victimhood in the minds of these women. Malterud’s strategy is designed to make each encounter an exercise in seeing oneself as potentially worth listening to, potentially wise about one’s bodily needs and their management, and thus potentially powerful. Physicians can achieve progress with some of the most difficult patients when they curb the urge to supply a diagnosis and therapeutic plan before the patient has a chance to speak.
A more formal strategy has been suggested for family counseling that seems readily applicable to daily practice.33 This entails asking at each visit, “How much is [the symptom or problem] in control of your life, and how much are you in control?” Patients can readily assign a percentage score to this variable. It is not unusual for a suffering patient to state at the first visit in which this question is asked that the problem controls 80% of his life and he feels in control of only 20%. In keeping with the mastery goal, it is critical to allow the patient, if at all possible, to choose the name of his problem. (One of my patients elected to name her complex entanglement of psychosocial stressors her “box of rocks.”) The follow-up instruction is, “Between now and the next visit, see if you can discover things that you can do, on at least some days, to make you feel more in control.” It is again desirable, unless forced, to stifle the advice-giving urge, as that can subtly undermine the patient’s sense of potential mastery.