Harnessing Placebo Effects in Primary Care: Using the Person-Based Approach to Develop an Online Intervention to Enhance Practitioners' Communication of Clinical Empathy and Realistic Optimism During Consultations

Abstract

Background: Empathic communication and positive messages are important components of “placebo” effects and can improve patient outcomes, including pain. Communicating empathy and optimism to patients within consultations may also enhance the effects of verum, i.e., non-placebo, treatments. This is particularly relevant for osteoarthritis, which is common, costly and difficult to manage. Digital interventions can be effective tools for changing practitioner behavior. This paper describes the systematic planning, development and optimization of an online intervention—“Empathico”–to help primary healthcare practitioners enhance their communication of clinical empathy and realistic optimism during consultations.Methods: The Person-Based Approach to intervention development was used. This entailed integrating insights from placebo and behavior change theory and evidence, and conducting primary and secondary qualitative research. Systematic literature reviews identified barriers, facilitators, and promising methods for enhancing clinical empathy and realistic optimism. Qualitative studies explored practitioners' and patients' perspectives, initially on the communication of clinical empathy and realistic optimism and subsequently on different iterations of the Empathico intervention. Insights from the literature reviews, qualitative studies and public contributor input were integrated into a logic model, behavioral analysis and principles that guided intervention development and optimization.Results: The Empathico intervention comprises 7 sections: Introduction, Empathy, Optimism, Application of Empathico for Osteoarthritis, Reflection on my Consultations, Setting Goals and Further Resources. Iterative refinement of Empathico, using feedback from patients and practitioners, resulted in highly positive feedback and helped to (1) contextualize evidence-based recommendations from placebo studies within the complexities of primary healthcare consultations and (2) ensure the intervention addressed practitioners' and patients' concerns and priorities.Conclusions: We have developed an evidence-based, theoretically-grounded intervention that should enable practitioners to better harness placebo effects of communication in consultations. The extensive use of qualitative research throughout the development and optimization process ensured that Empathico is highly acceptable and meaningful to practitioners. This means that practitioners are more likely to engage with Empathico and make changes to enhance their communication of clinical empathy and realistic optimism in clinical practice. Empathico is now ready to be evaluated in a large-scale randomized trial to explore its impact on patient outcomes.

Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients’ musculoskeletal pain and enablement

“…EMPathicO is an evidence-based, theoretically grounded digital e-learning package for practitioners routinely seeing patients frontline in primary medical care, including GPs, nurse practitioners and first-contact physiotherapists 24. EMPathicO helps practitioners enhance their communication of clinical empathy and realistic optimism, is consistent with major consultation models including Ideas, Concerns and Expectations (ICE)37 and incorporates behaviour change techniques.…”

“…Multiple behaviour change techniques were used to achieve these functions, including demonstration, information provision, goal-setting, action planning and instruction. For a complete behavioural analysis of EMPathicO, see supplementary material in our intervention development paper 24…”

“…Clinical empathy and positive messages are not routinely reliably optimised in clinical care but can have statistically and likely clinically significant effects on pain, patient satisfaction and other outcomes with no evidence of adverse effects 22. Our intervention planning determined that enhancing practitioners’ communication of clinical empathy and realistic optimism was feasible, measurable and likely to have a significant impact 23 24. Even brief interventions can improve communication skills, including interventions concentrating on empathy skills such as active listening and expressing warmth at appropriate times,25–27 which take no additional time in the consultation 27 28.…”

Harmful communication behaviors in cancer care: A systematic review of patients and family caregivers perspectives

“…[7][8][9][10][11][12] These helpful communication behaviors are increasingly incorporated into medical education. [13][14][15][16][17] Nevertheless, what is perceived as harmful communication is less clear, even though dissatisfaction with communication remains an important topic in patient-driven second opinions 18 and many complaints within the medical system are about communication. 19,20 It has also been shown that harmful communication might increase unnecessary psychosocial distress.…”

“…responding to emotions, reassuring, providing tailored information) has been shown to consistently improve feelings of trust, satisfaction, recall of information and can decreases anxiety 7–12 . These helpful communication behaviors are increasingly incorporated into medical education 13–17 . Nevertheless, what is perceived as harmful communication is less clear, even though dissatisfaction with communication remains an important topic in patient‐driven second opinions 18 and many complaints within the medical system are about communication 19,20 .…”