Intended for healthcare professionals


Making mindset matter

BMJ 2017; 356 doi: (Published 15 February 2017) Cite this as: BMJ 2017;356:j674

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  1. Alia J Crum, assistant professor of psychology1,
  2. Kari A Leibowitz, doctoral candidate,
  3. Abraham Verghese, professor of medicine1
  1. 1Stanford University, Stanford, CA, USA
  1. Correspondence to: A J Crum crum{at}

Alia Crum and colleagues argue that acting on the growing evidence about the influence of patient mindset and social context on response to healthcare can improve outcomes

The current standard for evaluating medications and treatments, the randomised controlled trial, involves identifying the effects of active ingredients by subtracting out effects produced by placebo. This model effectively isolates medical treatment by comparing it against “medically superfluous,” forces of healing, including social context (eg, medical ritual, patient-provider relationship, institutional reputation, branding), mindset of the patient (eg, the patient’s conscious or embodied expectation to heal), and the body’s natural ability to heal itself with time.

The randomised trial is a good and rigorous standard for testing the efficacy of new medications. But what this model obscures is that, in the practice of medicine, the psychological and social elements underlying placebo effects remain an influence in active treatment (fig 1). Indeed, medical diagnoses and treatments are never isolated from patient mindsets and social context.

Fig 1

The psychological and social forces of healing are typically viewed as in competition with drug effects in placebo controlled trials (top) but in everyday practice they underlie all treatment effects (bottom). Relative percentages of placebo response and drug responses vary across drugs and conditions

When interacting with patients, physicians communicate scientific evidence within the framework of subjective judgments, expectations of treatment outcomes, and perceived patient preferences. Patients are influenced by their trust in physicians and how their physicians listen to, engage, and inform them. Context or environment, such as the branding, price, and advertising of drugs, or the hospital or doctor’s credentials, also have an influence. Rather than being incidental to treatment, these psychological and social elements play crucial roles in determining clinical outcomes.123

From this perspective, the whole meaning of placebo effect changes. It’s no longer …

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