A Secondary Research on Placebo Use in Medical Practice Analysis

This report presents a secondary research based on a literature review focusing on placebo use in medical practice, and its impact on physicians' knowledge, attitudes, and practices. The study explores the ethical implications of placebo use, including patient deception and the potential for the nocebo effect. The report discusses the positive and negative effects of placebo administration, emphasizing the importance of informed consent and proper training for physicians. The research also highlights the significance of considering a patient's psychological state when using placebos, and recommends that physicians plan diagnosis procedures before proceeding with placebo treatments, particularly for patients with chronic conditions. The report concludes with recommendations for improving the implementation of placebos in medical practice and suggests that both patients and their families should be informed to handle potential negative consequences. Overall, the research underscores the need for a balanced approach to placebo use, taking into account both its benefits and potential risks.

Introduction chapter
Placebo Use in Medical Practice among
Physicians: Knowledge, Attitudes and Practices

ABSTRACT
Placebo are substances that tends to lower the pain by altering the psychological conditions
patients but it does not contain any active pharmaceutical ingredient that can produce therapeutic
effect on the body. A secondary research based on literature review has been conducted which
mainly focused on placebo use in medical practice and the impact of placebos on knowledge,
attitude and practice of physicians in medical use. Discussion based on placebo studies stated that
there are positive effects noticed when a patient is administered with placebo. There are many
physical and psychological changes that takes place hence, a patient needs to be informed before
he/she is being given placebo treatment. Conclusion and recommendation stated that all the
physicians should be given proper training so that placebo can be successfully used in medical
practice. Further patients and their family members should be informed so that they are able to
handle if any negative consequences occur.
Description of the results were discussed in the research which implied that knowledge,
practice and attitude of all the physicians change when they are implementing placebo treatment to
a patient in different condition. Further it can also be clearly inferred that it is very necessary to plan
a diagnosis procedure before proceeding with the placebo procedure because if a person who is
supposed to be given placebo treatment is suffering from chronic medical condition than this can
certainly lead to complications and adverse health outcomes. At last certain recommendations were
also suggested so that implementation of placebo to patients can bring positive results.

Table of Contents
BACKGROUND .................................................................................................................................3
PROBLEM OF THE STUDY..............................................................................................................3
SIGNIFICANCE OF THE STUDY.....................................................................................................4
RATIONALE........................................................................................................................................5
AIMS AND OBJECTIVES OF THE STUDY.....................................................................................5
DISCUSSION.......................................................................................................................................5
CONCLUSION AND RECOMMENDATIONS..................................................................................8
Introduction.................................................................................................................................8
Conclusion..................................................................................................................................9
Recommendation......................................................................................................................10
REFERENCES...................................................................................................................................12

BACKGROUND
The use of placebos has gained a greater attention in the field of research as compared to any
other field of medicine (Colloca and et.al, 2015). In general placebos can be defined as substance
that do not have any therapeutic importance or pharmacological effect on the body of an individual
who is treated for the different medical issues. Although it is ethically inappropriate to use placebos
without the consent of patient but physicians administer placebos so that they are able to calm down
the signs and symptoms which are causing distress in patients. The placebo effect is generally
produced when a patient starts expecting a pharmacological response when a placebo is
administered in their body (Bishop and et.al, 2014). They expect a pain relief or classical
conditioning which is not possible in the case of placebos. After the incorporation of placebos in
the body when a person starts expecting, it leads to biochemical reactions in the brain. This leads to
activation of various neurotransmitters. Physicians state that they administered different types of
placebos ranging from vitamin tablets, low dose drugs and in many cases they also prescribe
simple sugar pills (Franz and et.al 2013). In a research it was notified that 20 % of doctors in all the
healthcare setting give placebos to patients so that they are able to calm down the symptoms of
distress in them . On other hand 15% of physicians prescribe placebos so that they can satisfy
patients and 6% physicians give them placebos so that they can stop patients from complaining. The
effect which eases the suffering and produces alterations in the body process is known as placebo
effect (Vincent and et.al, 2013).
Knowledge, practice and attitude of physicians towards placebo treatment
Placebo treatment in medical and clinical practice is generally so that physicians are able to
comply with the desires and wishes of the patient or for the purpose of treating a person without
producing any harm to the patient. In the first case, the procedures are initiated by the physicians as
per the interest of the patients without considering the conflicts that can take place in medical
profession. In the another case, the physicians assumes that the patients have not been informed
about the treatment which is to be given to them. Sometimes this type of treatment may affect the
patient-physician relationship to a higher extent. Hence, it is very necessary to understand the
attitude and knowledge about using placebos in various situations.
PROBLEM OF THE STUDY
There are ethical as well as technical issues associated with use of placebos in clinical
practice and research related to medicines (Leigh, 2013). In majority of the cases the doctors use
placebos without the consent of patient and believe that this medical intervention is necessary to
treat the patient in best possible manner. But now if physicians deceive patients by giving them pills
that are not pharmacologically active then they compromise the trust and increase the risk of

placebos in patients. If trust between patients and physicians is not maintained then this may lead to
less satisfaction. Further this can lead to decrease the reputation and image of particular physician
or healthcare settings (van Bodegraven and et.al, 2014).
Moreover, patients may not follow or adhere to all the recommendations related to
treatment for particular medical condition (Benedetti and Amanzio, 2013). The deception caused
while providing placebos in place of therapeutically active medicines can lead to greater harm and
risk to patients who are undergoing treatments. One of the best example of problems related to
placebo use is that it can mask and potentially delay the medical treatment which is followed to
reduce down the symptoms and signs related to the health issue. On other hand, the chances of
patients encountering adverse reactions and side-effects increases after administrating placebo. It
can lead to severe headache and nausea and this effect is also known as Nocebo phenomena in
which a negative consequence is produced due to the administration of placebo in the body (Bingel,
2014).
The use of placebo is generally unethical and should not be used because deceptive use of
placebos is not only meant for the convenience of physicians and it does not promote health and
well-being of patients in any way (Benedetti, 2014). In many cases the use of placebos is also
beneficial when the physician is able to comfort and reassure the patients that the existing problem
will not appear in the future. It is very necessary to consider both positive and negative impacts of
placebo use in medical practice because it can also improve the health outcomes and it can also
produce adverse drugs reactions in patients.
SIGNIFICANCE OF THE STUDY
In recent times, placebos are not only used for experimental use but they are also used to
produce better health outcomes (Colloca and et.al, 2015). In many pharmaceutical companies and
industries these placebos are used so that they are able to influences the effect of medicine on
human body. In case control studies related to placebos, one group is administered with active
group whereas one group is given the same treatment but the active drug in the placebos are absent.
In such type of studies the researchers mainly focus on active ingredient of the drug and do not
study placebo effect (Bishop and et.al, 2014). Placebos are generally used in clinical trials were
many patients are informed about the use of placebos for experimental purpose.
If a patient is administered with placebo without informing then it is highly unethical and
against the patient's rights (Franz and et.al 2013). In many studies physicians do not consider the act
of deception against the patient and continue to conduct clinical trials but it has also been observed
that in several cases joint decision after consulting with patients is taken so that they are aware
about the type of treatment given to them. For example if a physician is able to convince the patient
that his/her medical condition will be more easily understand after administrating drugs that are not

pharmacologically active then placebo treatment can be given to patients (Vincent and et.al, 2013).
Placebos are also used for conducting single patient controlled trials when they face
significant clinical and diagnostic uncertainty (van Bodegraven and et.al, 2014). Sometimes the
study related to placebos are beneficial because they tend to produce better health outcomes as
compared to any other medicine in medical practice.
RATIONALE
Placebo effects are beneficial in majority of cases but according to research it has also been
reported that nocebo effect can also be produced in many cases if the treatment is not appropriate.
Placebos are used so that physicians and other healthcare professionals are able to relieve the signs
and symptoms of patients who are suffering from various mental and physical trauma (Colloca and
et.al, 2015). This study is undertaken because no effective studies based on the use of placebos have
been conducted in past. It is very necessary to determine the benefits associated with the research. It
is also very important to conduct studies on this topic so that various disadvantages produced due to
use of placebo can be identified and mitigated. This will also help in adopting various strategies so
that placebos can be used in medical practice to treat patients in successful manner (Bishop and
et.al, 2014).
AIMS AND OBJECTIVES OF THE STUDY
Aim
“ To interpret knowledge, attitude and practice of physicians for using placebo in medical
practice ”
Objectives
 To understand the concept of placebo use in medical practice by physicians.
 To determine the importance of placebo in medical practice
 To critically evaluate relationship between knowledge, attitude and practice of
physicians in Placebo use and in medicine use
 To understand negative as well as positive impact of placebo use in medical
practice.
RESULTS
After carrying out analysis it has been gained that the greatest percentages of the physician’s
characteristics were 56.5% for the age group 20-29, 61% for males and 80.7% for Jordanian
Certificate. Further in addition to this it has been attained that speciality characteristics of the

physicians has comprised speciality category, residency level and specialization. It has been
determined that The highest percent of the number of years in clinical practice was 77.2% for the
(0-9) category, as per number of days per week in clinical practice; it was 45.2%. The (5-10)
category was the highest for number of hours per days in clinical practice 64.1% and less than 99
patients treated per week was the highest percent (58.6%). It has been gained that positive attitude
was by the majority for placebo is not acceptable when it involves patient deception and when it
endangers the relationship among doctor-patient. The report presents that the majority has an
average level for KAP; 61.8%, 70.8%, 72.0% had an average level for pure placebo KAP
respectively, while 76.1%, 62.9% and 66.1% had an average level for impure placebo KAP
respectively. From the literature review accurate outcomes have not been attained. Thus the gap is
the past investigations have been fulfilled in the present investigation.

CHAPTER 5: DISCUSSION
Discussion is defined as the information which can be collected through current knowledge
and substantial findings of the methods of the people through which the current and substantial
finding of the methodological has been associated with the studies. According to Hull & et al. 2013,
treatment of Placebo and the intervention are defined as the ineffectual handling the treatment of a
specific disease through which it is possible to find the medicine for the patient. Two major
treatments are there which are given by Placebo treatment to give actual treatment to the patient.
Other than this, it is also checked that whether this treatment is making good impact on the health of
the person or not (Abou-Mrad & Tarabey, 2015). On contrary to this, Kisaalita, Staud, Hurley &
Robinson, 2014 argued that placebo is a person's positives attitude is also required for the getting
relief in the treatment. Placebo is used for medical research through which the pills such as inert
tablets, vehicle infusion and sham surgery has been done which help them to treat the patient. Along
with this, the current chapter will discuss the findings of the results which will help in making final
conclusion for the current research.
5.1 Background characteristics of physicians and predictors factors
As per the above discussion author has used a sample of physicians for determining
knowledge, attitude and perception towards Placebo. Sample size for the current research is 272 in
which 140 were belonged to JU hospital and 132 were selected from KAU hospital. More than 50%
physicians were so young age group of 20-29 years. On the other hand, 70 sample units were from
30-39 years age group. Overall, demographic characteristics have reflected that research sample has
included physicians from every age group (Aljumaih , Al-Kadhim Al-Seraya Nicolls and Al
Sayyaria 2011). Therefore, it has helped researcher in getting viewpoints of experienced and fresher
physicians about Placebo. In research sample, mail sample units were high as compare to females.
But, in case of this subject view point of physicians matters rather than their age, gender and other
demographic characteristics. Along with this, sample unit has included different participants from
distinct countries such as Jordan, Other ME countries including greater, USA, UK, Canada, Europe,
etc. therefore, it has helped in analysing the knowledge, perception and attitude of physicians of
distinct countries. Findings of the special characteristics have research sample has comprised 705
participants from residential physicians. Along with this, study has also collected view points from
specialist, fellow and GP. These groups have increased the efficiency of results and conclusion of
the research (Babel, 2012). Each and every physicians has belonged to different specialization such
as ENT, Paediatrics, Family Medicine, Internal Medicine, Neurosurgery, General Surgery, Urology,
Neurology, OB/GYN, Dermatology, Orthopedic, Ophthalmology, Psychiatry and Emergency

Medicine. Therefore, these things have helped in obtaining findings from different types of
physicians. It has helped in getting facts and figures about the importance of Placebo in each and
every specialization. According to the experience characteristics most of the physicians were highly
experienced of clinical practices and they used to do practices 5 days or 160 hours in a week.
Selected participants deal with approximately 100 patients per week. As per the results and findings
all age group patients receive placebo on an average but most of the physicians suggest this
treatment to adults (Bąbel, 2013). Mostly patients were associated with the moderate economic
status which may affect their placebo treatment. Including this, as per the physicians experience
most of the patients have average health education status. As per the physicians there is no needs to
be informed to patients that they are receiving placebo because most of the patients will be agree to
take this treatment but most patients may refuse for the same. Overall, results and findings have
reflected that patients do not have appropriate knowledge about Placebo.
As pre the findings and analysis researcher has disclosed some basic viewpoints of
physicians about placebo which have helped in attaining aim and objectives in effective manner.
According to the results most of the physicians do not accept and use any treatment for their own
and family’s health problems because they think it predominantly works by non-specific action.
Overall, as per the results physicians believe that no one should accept or use such kind of treatment
which mainly works for basic actions (Fässler, Gnädinger, Rosemann & Biller-Andorno, 2009).
According to the primary data collection and analysis researcher has found that in medical studies
most of the physicians do not sufficient information about that placebo use in medical practice.
Therefore placebo is not a very important part of medical education but still it is used by physicians.
Along with this, most of the participants have believed that term placebo is neutral. Along with this
they provided their view about the same with reference to the effect of placebo. Therefore,
background demographic characteristics and analysis have helped in determining the view point of
physicians and patients about placebo and its use at the time of treatment.
5.2 Knowledge of the physicians
Results chapter of the current research has included quantitative analysis for examining facts
and figures in effective manner chi square test was specifically used by researcher for testing
hypothesis relevant to the every question (Fässler, Gnädinger, Rosemann & Biller-Andorno, 2011).
It is one of the important non-parametric test which have helped in making comparison between
observed and expected frequency of every research question. It has also helped in accepting and
rejecting appropriate hypothesis for making final conclusion for the current research. As per the
results and findings level of significance for every chi square test was 5% and degree of freedom
was n-1 (3-1=2). So, critical value of chi square on 5% level of significance and 2 degree of

freedom is 5.991. Therefore, comparison of tabulated and calculated value researcher has accepted
and rejected different hypothesis (Goldberg, Leigh & Quinlan, 1979). These assumptions have
helped in making final conclusion about the knowledge, attitude and perception of physicians about
placebo. Results have reflected that most of the time calculated value of chi square is higher than
tabulated value. So, author needs to reject the null hypothesis accept the alternative one. So, as per
the hypothesis testing of pure and impure knowledge of all participants.
As per the research objective researcher needed to analyse the level of knowledge of each
and every physicians about placebo. Regarding this, author has included some questions in
questionnaire about relationship of placebo with psychological and biological effects. Along with
this, researcher also wanted to determine the knowledge of physician influence of placebo on
mental and physical health of patients. After analysing facts and figures author has found that
placebo mechanism of action is psychological and most of physicians have pure knowledge about
the same (Hassan, Fauzi & Hasan, 2011). Therefore, every participant has believed that placebo
affects the psychological stage of individuals rather than physical. Regarding this, participants have
pure knowledge and experience. Along with this, results of the research has also found that placebo
mechanism of action is not biochemical in nature because most of the participants were agreed with
the same. Along with this, placebo mechanism of action is unexplained and most of the participants
have pure knowledge about the same. Including this, results of the current research has concluded
that Placebo has positive influence on general subjective symptoms such as stress reduction,
relaxation and most of the participants have pure knowledge about the same. Along with this, pure
knowledge of highest number of participants have believed that Placebo has positive inspiration on
disease-relevant subjective symptoms such as decrease of pain and itch. Including this, findings
have reflected that there are number of functions relevant to human body which do not have
positive influence of Placebo and these are improvement of vegetative and biochemical or
immunological functions (Hróbjartsson & Norup, 2003). Therefore, physicians have positive
knowledge towards the same. As per the knowledge of physicians most of the physicians have
believed that Placebo intervention is not usually effective and its effects may change as per the
individual’s characteristics. Along with this, according to the knowledge of physicians Placebo has
varied effect when the context/condition is changed. Overall, results have reflected that most of the
physicians have appropriate knowledge about the Placebo and its effects on different type of
patients and their disease.
5.3 Attitude of the physicians
Results of the research have reflected that the majority of physicians were of the opinion
that prescribing placebo shall maximize the benefits and a few of them opposed this thought and

considered the use of placebo unfavorable. It is important to note here that the patients in the
present times are well informed and aware of about various issues and hence it is always advisable
to not conceal anything from the patients (Kermen, Hickner, Brody & Hasham, 2010). Generally,
the doctors before prescribing placebo make sure that the patient is not suffering from any chronic
disease and prescribing placebo would be beneficial for her/him. It is important to understand that
the relationship of a doctor with the patient is very sensitive and hence is required to be handled
with care. The patient before approaching a doctor has full belief in them and so undertakes the
prescription the way it is given by the doctor without investigating about the same. This calls for the
responsibility of the doctor to adhere by the values and principles of the profession and not violate
the trust of patient.
On the other hand, primary data analysis have reflected that practitioners do not have
positive attitude towards placebo but they are completed disagreed with the statement that placebo
is usually better than no treatment (Linde, 2013). Along with this, physicians do not believe that
placebo is prescribed usually because the patient explicitly requested a therapy because practitioners
have some kind of positive attitude towards the same but it is not prescribe by doctors on the basis
of patient’s request. Along with this, all participants do not have positive attitude towards that
placebo is prescribed usually because of a possible psychological treatment effect and to gain a
therapeutic advantage through the placebo effect. It means it is not an effective treatment for
psychological treatment.
Most of the physicians have believed that placebo is not prescribed usually for patients with
symptoms that could not be ascribed to any particular disease. Along with this, it not feasible to
calm the patient. Including this, Results have reflected that placebo prescription is not acceptable
when used only for their psychological effect (Linde, Friedrichs, Alscher, Wagenpfeil Meissner &
Schneider, 2014). On the other hand, placebo prescription is not satisfactory when clinical
experience has shown a benefit, so at the time of prescribing placebo physician needs to have
appropriate clinical experience. Analysis of the data has reflected that most of the participants have
completely disagreed with the statement that placebo prescription is not acceptable when it involves
the dishonesty of the patient and when it endangers the trust between doctor and patient agree.
Therefore, physicians needs to develop a positive attitude towards the development of effective
relationship and understanding about the placebo treatment else it will not effective for physical and
mental health of patients. Along with this attitude of physicians has reflected that Placebo is not
beneficial for infectious and chronic diseases (Meissner, Höfner, Fässler & Linde, 2012).
5.4 Practice of the physicians
For attaining aim and objectives researcher wants to analyse the practice of the physicians

also. And data analysis and results have reflected that Placebo is generally used by practitioners
during their practice. But, overall frequency of prescribing pure placebos is not prescribed by
physicians. Along with this, at the time of practice maximum participants do not prescribe prepared
placebo tablets such as sugar pills/artificial sweeteners as well we they do not prescribe injections
with saline solution. Therefore, results have reflected that these placebo medicines and injections
have negative impact on physical and mental health of patients so, they do not use these practices
for regular basis (Shah, Panchal, Vyas & Patel, 2009). Further, findings of frequency distribution
have reflected that maximum practitioners never prescribe therapies that might be effective but
whose effectiveness is not evidence-based. Including this, sub-clinical doses of effective
therapies/medications are also not prescribed by physicians. Including this, off-label uses of a
potentially effective therapies / medications are also not a part of clinical practice of placebo.
According to the result chapter physicians do not prescribe antibiotics for suspected viral
infections because it has negative impact on health of patients at the time of some specific
situations. Including this, frequency distribution has reflected that at the time of clinical practice
physician are generally not prescribed antibiotics for suspected viral infections because it may have
negative reaction on health of individuals. Including this, results have also reflected that physicians
do not prescribe analgesics, probiotics for diarrhea and peppermint pills for pharyngitis. Therefore,
at the time of prescribing placebo physicians need to focus on different types of diseases which are
associated with placebo treatment else it may have negative impact on physical and mental health of
individuals (Sherman & Hickner, 2008). As per the results researcher has disclosed that physician
cannot prescribe placebo more than once for the same patient in the last 12 months else it may have
negative impact on health of individuals.
At the time of prescribing placebo usually physician do not make appropriate document or
report in the medical file about the actual diagnose when prescribing placebo. Including this,
findings have also shows that physician only prefer to use placebo for 1% patients in the last 12
months. Therefore, it has reflected that physicians generally used to avoid prescribing placebo for
patients. Similarly, if physicians provide placebo treatment to any patients then they make sure
about that patients are not received a placebo more than once in the last 12 months. According to
the research findings placebo is rarely effective drug/ therapy and this treatment does not promote
self-healing process (Cahana & Romagnioli, 2007). Overall, analysis of clinical practices of
selected physicians have reflected that most of the practitioners do not prescribe Placebo for general
treatment and prescribe this for the rare case and in case of high requirement else it may have
negative impact on physical and mental health of patients.