Arnold Mark H, Finniss Damien, Luscombe Georgina M, Kerridge Ian
School of Rural Health (Dubbo/Orange), Sydney Medical School, Faculty of Medicine and Health, University of Sydney, NSW, Australia.
Department of Anaesthesia & Pain Management Research Institute, Royal North Shore Hospital and; Faculty of Medicine and Health, University of Sydney, NSW, Australia.
J Med Educ Curric Dev. 2020 Jun 22;7:2382120520930764. doi: 10.1177/2382120520930764. eCollection 2020 Jan-Dec.
Understanding placebo and nocebo responses (context/meaning effects [CMEs]) is fundamental to physician agency. Specific instruction in CMEs is often lacking in medical education. Patient-practitioner interactions may challenge medical students' understanding of biomedical causality and the nexus between this, practical ethics and professionalism across various conceptual and applied aspects of CMEs. This study compared the corpus of knowledge and phronesis related to CMEs between Australian graduate medical students and rheumatologists to gain a sophisticated understanding of this relationship to inform curriculum development.
In 2013 and 2014, the authors surveyed third-year medical students undertaking a graduate programme in an Australian medical school and Australian rheumatologists to ascertain their understanding of placebo and nocebo responses. The survey ascertained (1) the alignment of the respondents' understanding of CMEs with accepted facts and concepts; (2) opinions on the ethical status of CMEs; and (3) responses to 2 scenarios designed to explore matters of biomedical causality, practical ethics and professionalism.
There were 88 completed surveys returned, 53 rheumatologists and 35 students. Similar proportions within each group identified CMEs, with most (n = 79/88 [89.8%]) correctly recognising a placebo (rheumatologists: 50 [94.3%], students: 29 [82.9%]) and approximately three-quarters (n = 65/88 [73.9%]) correctly recognising nocebo effects (rheumatologists: 39 [73.6%], students: 26 [74.3%]). Statistically significant differences between practitioners and students were observed in relation to the following: placebo responders and placebo responsiveness; placebos as a 'diagnostic tool'; placebos usage in clinical practice and research, and nocebo effects.
Physicians require an awareness of CMEs and the fact that they arise from and influence the effective agency of health care professionals. Curricular emphasis is needed to permit an honest assessment of the components that influence when, how and why patient outcomes arise, and how one's agency might have neutral or negative effects but could be inclined towards positive and away from negative patient outcomes.
理解安慰剂和反安慰剂反应（情境/意义效应[CMEs]）是医生行为能力的基础。医学教育中往往缺乏对CMEs的具体指导。医患互动可能会挑战医学生对生物医学因果关系的理解，以及在CMEs的各种概念和应用方面，生物医学因果关系、实践伦理和专业精神之间的联系。本研究比较了澳大利亚医学研究生和风湿病学家关于CMEs的知识体系和实践智慧，以深入了解这种关系，为课程开发提供参考。
2013年和2014年，作者对澳大利亚一所医学院的三年级医学研究生和澳大利亚风湿病学家进行了调查，以确定他们对安慰剂和反安慰剂反应的理解。该调查确定了：（1）受访者对CMEs的理解与公认事实和概念的一致性；（2）对CMEs伦理地位的看法；（3）对旨在探讨生物医学因果关系、实践伦理和专业精神问题的两个情景的反应。
共收回88份完整的调查问卷，其中53份来自风湿病学家，35份来自学生。每组中识别出CMEs的比例相似，大多数（n = 79/88 [89.8%]）正确识别出安慰剂（风湿病学家：占94.3%[50/53]，学生：占82.9%[29/35]），约四分之三（n = 65/88 [73.9%]）正确识别出反安慰剂效应（风湿病学家：占73.6%[39/53]，学生：占74.3%[26/35]）。在以下方面观察到从业者和学生之间存在统计学上的显著差异：安慰剂反应者和安慰剂反应性；安慰剂作为一种“诊断工具”；安慰剂在临床实践和研究中的使用，以及反安慰剂效应。
医生需要了解CMEs，以及它们源于并影响医疗保健专业人员有效行为能力这一事实。需要在课程中加以强调，以便能够诚实地评估影响患者结果何时、如何以及为何出现的因素，以及个人行为能力可能产生中性或负面影响，但如何倾向于产生积极而非消极的患者结果。
