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Source: The Edelman Trust Barometer 2011

Members of the  American public are frequently surveyed about their trust in various professionals.  Doctors and nurses usually wind up near the top of the list, especially when compared to lawyers, hairdressers and politicians.  Trust in professionals is important to us: they possess expertise we lack but need, to solve problems ranging from the serious (illness) to the relatively trivial (appearance).

How much professionals trust us seems irrelevant: our reciprocity is expressed in the form of payment for services rendered or promised, our recommendations to friends and families and repeat appearances.

So I was surprised to read an article in the Annals of Family Medicine describing a new scale to measure doctors’ trust in their patients.  This scale, based on input from focus groups and validation surveys of physicians, was developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”

Hmmm. I hadn’t really thought about trust being a two-way street in my relationship with the doctors and nurses who take care of me.  But given the push for us patients to become actively engaged in our health care, it’s not surprising that questions would arise about how dependable we are as partners. And it is a sign of the times that as clinicians increasingly face incentives to deliver evidence-based medicine and are held accountable for our health outcomes, our trustworthiness as partners has become professionally, if not economically, important to them.

While this new scale is only a research tool, its creation nevertheless raises interesting questions about how traditional notions of trust in medicine are changing in the new clinician-patient relationships that the media urges us to forge. So let’s examine it as a reflection of the idea of physicians’ trust in their patients.

Here are nine of the 18 items of the trust scale.   Clinicians are asked:

How confident are you that this patient will:

  • Understand what you tell him/her?
  • Accept your medical judgment?
  • Tell you about all the medications and treatments he or she is using?
  • Believe what you say?
  • Follow the treatment plan you recommend?
  • Be actively involved in managing his/her condition/problem?
  • Respect your time?
  • Provide all the medical information you need?
  • Not make unreasonable demands?

Far from reflecting the new kind of partnerships we are encouraged daily to develop with our doctors and nurses, these questions presuppose that we are trustworthy only if we assume that old-fashioned passive position relative to our clinicians’ authority.

As someone actively engaged in my care, I ask a lot of questions: Sometimes I don’t understand the explanation or directions I’ve been given.  I prefer to come to an agreement about a treatment plan, rather than just follow my doctor’s directions, and agreeing on the plan takes time.  Does this mean that I am making unreasonable demands and disrespecting my clinicians’ time? If I am sufficiently knowledgeable to be wary of my clinicians’ possible conflicts of interest, am I questioning their medical judgment?  If so, am I untrustworthy?

Consider also how my recent treatment for stomach cancer would affect my oncologist’s rating: I was too woozy to be a good historian about my symptoms or a good reporter about my medication taking.  I wobbled frequently in my adherence to my treatment plan and frequently misunderstood what I was told due to the fog of illness and treatment. My appointments often ran over their allotted time because we were discussing complicated changes in my treatment.  Have I therefore misunderstood what I was told?  Have I disrespected his time?  In short, am I trustworthy?  Apparently not.

This scale is a work in progress for use only as a research tool.  It is notable primarily as a bellwether. Its development elicited fairly broad agreement from physicians that we patients are most trustworthy when we cede unilateral authority and control of our care to them.

But the scale does identify a technical challenge for future efforts to measure our clinicians’ trust in us. While the dimensions of our trust in physicians are well established (technical competence and fiduciary responsibility, that is, moral obligation to place patients’ interests above his own), the components of our clinicians’ trust in us are tougher to nail down.   Questions must be sufficiently robust to accommodate enduring characteristics of personality, culture and communication style that vary among individuals in our willingness and ability to engage in our care as well as account for those that vary within individuals as we cycle through sickness and health.

Maybe it is premature to measure clinician trust in patients.  Maybe all of us – patients and clinicians — just don’t have enough experience yet to identify the dimensions of trust that are relevant to these new partnerships.  There is evidence that many people are deeply ambivalent about being active and engaged in their care, and many of us lack the skills, knowledge, resources and confidence to become so.  It is easier to be passive, especially when we are ill.  And if the small, non-random sample of physicians who contributed to the development of this scale is any indication, clinicians are similarly ambivalent about changes to this familiar dynamic.

But as the requirement that patients participate actively in preventing illness and getting well has become more consequential, it is clear that patients and clinicians alike must recognize that we share these aims and that we are mutually dependent on one another to reach them.  We patients are no longer just the recipients of our clinicians’ ministrations.  Rather, in order to benefit fully from our care, must share in making decisions about it and take responsibility for carrying out the treatment plans during the 99.999 percent of the time when we are on our own, unsupervised by health professionals.

Only when such partnerships become more common and the evolving relationships between physicians and patients become better established will the matter of physicians’ trust of their patients become relevant and interesting.

Jessie Gruman, PhD, is the founder and president of the Washington, DC -based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on the Prepared Patient Forum.

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8 Responses for “Does My Doctor Trust Me (and Does It Matter)?”

  1. lynn says:

    Interesting questions, I’m going to ask my PCP if she trusts me? A great way to start a dialogue (even if a brief one).

  2. susan says:

    It is a great conversation starter and one that will lead to a better exchange between both parties. Here are some other thought-provoking ideas: http://whatstherealcost.org/video.php?post=five-questions

  3. Jessie,

    Fascinating topic; I’m glad I found this.

    As someone who has studied trusted advisor relationships in business for 15 years now, I find this mildly disturbing.

    I say “mildly” because trust is a two-way street, and of course physicians have to understand how trustworthy their patients are.

    But I say “disturbing” with much more emphasis. Trust is a bilateral relationship that requires different things of each party. To trust someone is one thing; to be the one trusted, worthy of trust, or trustworthy, is very different.

    The one doing the trusting is the one taking the risks. The propensity to trust evolves gradually, over generations, and is a very basic psychological attitude. Trustworthiness, on the other hand, while usually based in values, is also something that can be learned and improved.

    For trust relationships to improve, the burden has to fall mainly on those who would be trustworthy–the doctors in this case. They are not the ones taking the risks (defensive medicine and malpractice suits notwithstanding–try comparing the threat of malpractice with the threat of loss of life).

    This survey takes questions that are properly asked of the physician–”will the patient trust the doctor”–and transforms them into questions asked of the patient. The emphasis is largely wrong.

    If a doctor runs across someone who is generally untrusting, he or she needs to take that into account in their treatment of that patient–from a point of view of patient service, not from a point of view of the physician being able to blame or protect him or herself from “untrustworthy” patients.

    It is not clear what the motives behind this survey on, other than your statement that it is “developed for research purposes on the grounds that trust is a “feature of the clinician-patient relationship that resonates with both patients and clinicians.”” Motives matter here.

    If the purpose is for doctors to better understand their patients’ psychological propensities so that their treatment can be improved–great. But it doesn’t sound that way. It sounds like the purpose is some variation on defensive medicine, or some justification of how hard it is to be a doc.

    To the extent that’s the motivation, it sounds no different than accountants coming up with black lists of ‘bad’ clients, or financial planners’ unspoken rule of ‘never take on a client who has sued a previous financial planner.’ It is self-aggrandizing, self-centered, and non-client oriented. It rhymes with ‘blame the victim’ mentality.

    For many years, “First, do no harm” has served as a good guideline. I don’t think the profession will be well served by changing it to, “First, don’t get harmed.”

  4. SignatureMD says:

    Jessie – you make some really relevant points about the importance of trust in a physician/patient relationship. We were so inspired by your post, we developed some supporting commentary on our blog today. Thanks for sharing. http://www.signaturemd.com/how-trust-plays-a-part-in-healthcare/

  5. John says:

    Do Doctors Trust their patients… my experience is it depends. The same behaviors that help us trust the Dr. help the Dr. trust us.

    – Do we listen?
    – Do we ask clarifying questions?
    - Are we sincere in our desire for wellness or do we just want a pill?
    - Are we informed?

    When one reads of all of the mis-diagnosis and the side effects of engaging the health profession MRSA, etc I think patients are ,by nature of the visit, extending a certain level of trust and vulnerability.

    I am fortunate, My physician and I can have a robust dialog and we both listen to each other and make informed decisions. As a result my health stats have steadily improved and I have referred 5 patients to the practice.

    As patients we have a responsibility too. We have to research, we have to ask questions and we have to speak up when we see or feel something is amiss.

  6. Kristin says:

    Jessie,

    I wanted to congratulate you on having this post selected to be part of this month’s Trust Matters Review.

    The Trust Matters Review is a compilation of the top blogs or articles dealing with the subject of trust whether in business, politics or society.

    Your post really struck a chord and we’re glad to have it included this month. You can see the Review in its entirety at: http://trustedadvisor.com/trustmatters/the-april-trust-matters-review.

    Best,
    Kristin Abele
    http://trustedadvisor.com/trustmatters

  7. midlynn says:

    There’s a great product out there to help with your medication management needs. No more pill boxes or zip-lock bags for your pills. Check it out http://www.mymedbox.net

  8. Drprime says:

    I think it is absolutely essential for the patient to put trust in his or her doctor. However, it is refreshing to ask a question of whether or not the patient trusts me as his PCP. I do have surveys and feedback forms to track my patients’ opinions. I watch my reputation online. Healthcare is bout trust.

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