Back-to-back consultations
Authors:   , Sanders Ariëtte Reina Johanna 
Published: July 2023

Placebo effects, also known as context effects, can be partly explained by expectations and trust between patient and professional. Context effects play an important role in recovery from illnesses that are characterised by the symptoms but do not have a specific pathophysiological substrate. Patient participation in general practice could play a key role in optimising these context effects in for instance low back pain (LBP) complaints.
We investigated in subsequent studies whether the care for patients suffering from non-chronic LBP can be improved by incorporating the expectations of patients in the management plan for their complaint. Thirty-four General practitioners (GPs) were trained to in shared decision-making (SDM). After deciding on the treatment plan, GPs were asked to reinforce the therapeutic choice. GPs were each asked to include and video-record 10 patients suffering from a new episode of non-chronic LBP, performing SDM and positive reinforcement (SDM&PR). Another 34 GPs (the control group) were asked to video-record consultations with patients suffering from non-chronic LBP for whom they provided the usual care.
All participating patients completed questionnaires immediately and and at 2, 6, 12 and 26 weeks after the consultation. In those questionnaires, they were asked how they perceived the consultation had gone (patient perspective) and how fast they recovered from pain or disability due to non-chronic LBP.
Of all 34 trained GPs, 23 video-recorded a total of 86 consultations with patients suffering from non-chronic LBP. These observations were compared against 89 video-recorded consultations by 19 GPs providing the usual care. The trained GPs scored significantly better on the OPTION scale (0-100), a validated instrument for measuring shared decision-making (SDM), with an average of 38.53 (95%-CI 35.31–41.74). The control group scored an average of 23.66 (95%-CI 20.25–27.08). The trained group showed significantly more patient participation (an average score of 1.74 (se 0.11) compared to an average score of 0.86 (se 0.11) in the untrained group.
Trained GPs (25) included 112 patients for the trial and untrained GPs(22) 116 patients. Most patients recovered with 14 days. The small differences in favour of the intervention group at most of the measurement moments, were not only non-significant but, even more importantly, non-relevant.
We could not detect a significant correlation between recovery and level of performance of SDM perceived from the patient’s perspective or the observations at either 6 or 26 weeks.
In the cost-effectiveness estimation of the intervention, healthcare costs were €50.75 per patient lower in the intervention group than in the control group over the whole study period of 26 weeks. Investment in SDM&PR training for patients suffering from non-chronic LBP seemed cost-effective from the social perspective.
To summarize all study outcomes conclude that training GPs in SDM&PR did not increase the recovery of patients suffering from non-chronic LBP. We hypothesise that the performance of trained GPs was insufficient to have patients’ positive expectations implemented in the treatment decision. We therefore do not think that patients’ positive treatment expectations were reinforced.
It might be the case that healthcare providers consider it less professional to use placebo effects to alleviate patients’ suffering. If this is true, it would imply that SDM training needs a discussion about the professional’s role, considering patient participation and placebo effects.