Educating Medical Students Regarding the Use of Placebo in Clinical Practice and Research [Letter]

Dear editor

I read with interest the article by Bayoumy et al¹ discussing the knowledge and attitudes by medical and nursing students regarding the use of placebo. Bayoumy found that overall knowledge was poor and attitudes varied depending on the speciality within which the placebo was used. As a medical student, I believe this is an important topic to discuss as placebo plays a vital role in research and clinical practice, however wanted to address certain aspects of the paper.

The sample size used included 91 male medical students who had received prior ethics teaching. This means that it could have exhibited response bias,² suggesting that the study lacks internal validity, as the knowledge of placebo in this group may be higher than that within the general population. Furthermore, the inclusion criteria included students who had “finished professional years and started professional years of study” – clarification of this is needed to explain the level of study at which these students are. Additionally, all of the students were at an educational level of 5 and above; it is unclear what it is equivalent to in other countries. Nonetheless, the results indicate that students entering clinical years lack knowledge on placebo. These results can inform universities that teaching on placebo should be introduced at pre-clinical level and subsequently assessed during clinical years in the format of verbal role-play examinations. This would provide students with not only sufficient knowledge on the ethical considerations associated with placebo, but also increase its effectiveness if used as the authors found that ‘listening carefully and expressing true concern for patients’ increased its effectiveness – all traits that can be assessed in an exam setting.

The authors found that medical students displayed significantly less knowledge about placebo compared to nursing students (P=0.029), despite doctors often being in charge of prescribing compared to nurses. For example, Howick et al³ found that 97% of primary care practitioners had used placebo at least once in their career. This indicates that doctors are potentially prescribing medications that they are not sufficiently educated about. The General Medical council currently does not issue any guidance on the use of placebo in clinical practice,⁴ therefore it may be beneficial to implement guidelines to provide standardised guidance to all doctors in order to tackle ethical dilemmas surrounding its use.

Of note, the study was cross-sectional and therefore cannot explain at which point students gained knowledge of placebo, although 26% of medical students stated that they received their knowledge from “college”⁵ More detail is required to inform the audience of when and how the students received their education on placebo in order allow universities to introduce suitable methods of delivering teaching on the subject.

In conclusion, this research has highlighted a gap in medical and nursing school curricula. I believe that teaching on the use of placebo should be embedded into the curriculum and examined to increase its overall effectiveness in clinical practice. I also believe that national guidelines should be implemented to provide clarity to healthcare professionals regarding its use.