The use of “essentially placebo” treatments by GPs: An interview with Fabian Wolters

 

General practitioners (GPs) sometimes prescribe treatments they don’t expect to work through any real medical effect. These so-called “essentially placebo” treatments are controversial because they may pose medical risks and undermine trust between patients and doctors.

A recently published international study led by Fabian Wolters, PhD candidate at the Interdisciplinary Center for Placebo Studies, found that while “essentially placebo” prescriptions are rare during individual consultations (0.67% of visits), most GPs (84%) have prescribed them at least once. The survey included nearly 1,000 GPs in 21 countries. Men, more experienced doctors, and those working fewer hours were slightly more likely to use them. The study warns of medical and ethical risks and calls for more research into doctors’ motivations and the impact on patients.

We asked Fabian what counts as a placebo, what surprised him most, and what these findings mean for patients and policy.

 

How did you decide what counts as a placebo or a placebo-like treatment?

“I deliberately kept my definition broad. There’s a lot of debate in philosophical circles about what counts as a placebo, and definitions often differ between philosophy and medical research – two worlds that rarely communicate.
In earlier studies, researchers often distinguished between a “pure placebo” – something with no medical effect at all – and an “impure placebo,” which is an actual medicine but given to someone who doesn’t need it at that moment. That distinction has been criticized: philosophers argue it isn’t very clear-cut, and most doctors don’t even have pure placebos in their dispensary, so they’re rarely used.

So for this study I came up with my own definition: “essentially a placebo,” leaving room for the doctor’s own judgment. If they think what they’re prescribing isn’t medically effective, then to me it counts as a placebo, regardless of what else it might do. The vast majority of respondents agreed with this approach and understood what we meant. A philosopher involved in the project thought it was a neat solution, and one of the reviewers was also really enthusiastic about it. Since philosophers are usually very precise and strict about definitions, that felt like a real compliment.”

 

Did anything in the results surprise you?

“What surprised me most was that sometimes strong medications with potentially serious side effects – like benzodiazepines and antidepressants – were prescribed as placebos, even though this was only a small minority of cases. What also stood out is that this seems to happen more often in some countries than in others. Our dataset isn’t ideal for country-by-country comparisons since some countries had far more participants than others. Despite this, you can still see certain patterns, which I’d like to explore further.

In some countries there also seems to be more prescribing of pseudoscientific treatments, like acupuncture, and even within that, certain forms are much more popular in certain places. The same goes for those stronger medications. I hadn’t expected that at all, but in hindsight it makes sense when you consider that each country has its own history and its own healthcare system. These factors are hard to know without local context, so I was very glad we could collaborate with local doctors who helped us interpret the responses.”

 

What do these results mean for the doctor-patient relationship? How might patients react if they discovered they’d been given a placebo?

“I think these kinds of treatments do pose a risk to the doctor–patient relationship, although we’d need more patient-centered studies to be sure. Studies have shown that patients may accept that doctors sometimes make decisions without full disclosure, but there are limits to that tolerance – and I think this situation might cross those limits.

I’d expect the biggest problems among patients who already struggle with the medical system – for example, people with medically unexplained symptoms, or those who’ve had bad experiences in the past. For them, this might reinforce the feeling that they’re being abandoned. That is, if they actually find out; many patients will probably never look up what they were prescribed or whether it was appropriate. And if you already trust your doctor, you might just assume they’re prescribing something off-label for a good reason, since that happens often enough. So I think the main risk is with people who already have reasons not to trust their doctor.”

 

Fabian hopes future research will focus on patients who already feel vulnerable in the healthcare system, exploring what they believe doctors should – and shouldn’t – be allowed to do, and informing future policies to protect patient trust.