# Understanding and leveraging placebo and nocebo effects in perioperative care: a cross-sectional survey of German-speaking anesthesiologists

## TL;DR

German-speaking anesthesiologists use expectation-based interventions often, but lack systematic knowledge of placebo and nocebo effects, suggesting a need for better education and guidelines.

## Contribution

First systematic survey assessing anesthesiologists' knowledge and use of placebo and nocebo effects in clinical practice.

## Key findings

- Anesthesiologists report moderate knowledge of placebo effects but limited understanding of nocebo effects.
- Expectation-based communication is widely used, but deliberate application of placebo/nocebo strategies is rare.
- Most consider placebo effects acceptable, but only a minority apply them systematically.

## Abstract

Placebo and nocebo effects, beneficial or adverse responses shaped by patient expectations, modulate perioperative outcomes including pain, opioid requirement, recovery, and complication risk. Although harnessing these mechanisms may improve patient care, their routine use by anesthesiologists remain unexplored. This study systematically assessed anesthesiologists’ knowledge, perceived relevance, and clinical use of placebo and nocebo effects, to identify educational needs and opportunities for enhanced patient care.

An observational cross-sectional online survey, was conducted in April-May 2024 among German-speaking anesthesiologists, covering diverse clinical settings and career stages. The questionnaire evaluated theoretical knowledge, perceived relevance, clinical application, attitudes toward placebo interventions and feasibility of specific strategies to enhance placebo responses and minimize nocebo effects in clinical practice.

Of 650 respondents (436 complete), self-reported knowledge of placebo effects was moderate (median = 6; 0–10), and lower for nocebo effects (median = 5; p < 0.001). Placebo mechanisms were deemed most clinically relevant in pain management (78%) and palliative care (82%). While 72% considered the use of placebo effects as acceptable and 18% essential, only 35% reported deliberate application of placebo knowledge, and 23% used nocebo mitigation strategies. Contrastingly, 92% routinely employed communication strategies to shape expectations. Placebo utilization included open-label (27%), impure (e.g., subtherapeutic analgesics; 58%), and deceptive placebos (48%).

Anesthesiologists frequently integrate expectation-based interventions widely, however gaps in theoretical knowledge and deliberate systematic application remain, particularly regarding nocebo effects. Targeted education and evidence-based guidelines may foster ethical, systematic integration of placebo and nocebo effects in perioperative care and improve patient care and safety in anesthesiology.

The online version contains supplementary material available at 10.1186/s12871-025-03579-w.