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Survey shows sharp drop in trust, rise in consumerism
Patient trust in physicians is eroding dramatically as patients wonder whether doctors, under pressure from managed care, are truly putting their interests first, according to new survey data.
In a national survey of 170,000 households conducted by National Research Corp. (NRC) of Lincoln, NE, just 18.3% of respondents said they had a "very high" level of trust and confidence in their physicians. That was a decline from 26.8% in 1998.
"The error range on this study at a national level is 0.2%," says NRC spokesman Phil Richmond. "When you see an eight-point movement in scores, something’s going on out there."
Loss of trust may seem an inevitable byproduct of a system that creates restrictions on both doctors and patients to improve cost-effectiveness. But physicians can take steps to reassure patients and rebuild trust, says David Thom, MD, PhD, an assistant professor of medicine at Stanford University School of Medicine in Palo Alto, CA, who has conducted extensive research on the issue of trust. "The fundamental issue is to be worthy of the patients’ trust — to be competent and to put the patient’s interests first," says Thom, who is a family practice physician. "Most physicians do that. But it isn’t going to create trust unless you give patients a reason to do so [by demonstrating those qualities]."
Even small gestures can bring a wealth of goodwill, he says. "Probably the most powerful thing a doctor can do to make a patient feel he or she is acting in the patient’s interest is to do something above and beyond. [It could be] a follow-up phone call that the patient didn’t feel the doctor had to do but the doctor did anyway. Looking up information for a patient. Staying late to see somebody."
While trust may develop over time, with each visit the physician has a chance to shape that relationship,1 Thom says.
Trust isn’t just a feel-good issue. Trust — or the lack of it — lies at the core of an emerging consumerism among patients. More than 80% of Indiana consumers said they were "likely" or "very likely" to change providers if they didn’t get their needs met, according to the "Indiana Eye on Patients" study sponsored by the Indiana State Medical Association, the Indiana Hospital & Health Association, and the Indiana University School of Medicine, all in Indianapolis.
"Trust is actually a stronger predictor of whether patients stay with their physicians than satisfaction," says Thom, although he points out that satisfaction and trust are highly correlated. "[Trust] is what matters most in their satisfaction with their relationship with physicians."
Not surprisingly, in focus groups, health care consumers expressed concerns about how managed care affected their relationships with doctors. "People more and more are looking at their health care experience through the prism of their health care coverage," says B. Lee Zacharias, president of The Zacharias Group, a public opinion research firm based in New Gloucester, ME. "They perceive that it has changed their relationship with their doctors."
They don’t like choosing doctors from a list, and they worry that cost and insurance coverage influences the medical advice the doctors provide, says Zacharias.
The concern about just who is making the health care decisions emerged from American Hospital Association focus groups as well, says AHA Senior Vice President Rick Wade.
"All of the hassles with insurance translates into a view of people being much more skeptical about who is on their side and who they can relate to," says Wade, who spearheaded the "Reality Check" studies in 35 states over three years. "They don’t feel anyone is their advocate anymore. That’s leading to the emergence of a much more independent or aggressive individual who is there on behalf of themselves or someone they care about."
In this climate, even prudent decisions about which tests or procedures are necessary may seem suspect. "The medical establishment has nobody to blame but itself for this problem," says Zacharias. "For years and years, it has told the public more is better when it comes to health care. Now things are changing, and the public is suspicious. They see something taken away from them as opposed to a more judicious use of medical resources."
Meanwhile, frustrations caused by impersonal and inefficient aspects of large group practices can further erode trust, says Zacharias. Patients often view these medical groups as medical bureaucracies, she says.
"One of the things that frustrates patients more than anything is the phone system," she says. "’Thank you for calling the XYZ Group Practice Association. Press one for this; press two for that; press three for that.’ People hate that." Instead of creating efficiency, patients perceive such "improvements" as barriers.
Growing or merging into a large organization isn’t a problem in itself, stresses Zacharias. "There are many other businesses in this country that run huge, huge businesses that are very customer-oriented."
In the National Research Corp. survey, people who understood the concept of health systems and networks expressed concerns about the impact on doctors. The survey first asked if the respondent was aware of hospitals, doctors, and health plans in their area that had merged to form large health systems or networks. Among respondents who said they were aware, 44.6% said becoming a part of such systems weakened a doctor’s effectiveness.
"I think that clearly indicates that people want their doctors to be able to make decisions auto-nomously," says Richmond. "They don’t want their doctors to have to call a plan and find out if it’s OK to pursue a course of treatment."
In the same survey, almost one in four respondents said that doctors were "most interested in making a profit" as opposed to being most interested or equally interested in providing quality care.
|Patients' Trust and Confidence in Doctors|
|A national survey by the National Research Corp. calculated scores for trust and confidence in physicians based on a scale of 0 to 100. The national average was 68.5. Here are the cities that had the highest and lowest levels of trust:|
|1. Madison, WI||73.4|
|2. Birmingham, AL||72.7|
|3. Ann Arbor, MI, and Rochester, NY (tied)||72.4|
|4. Wichita, KS||71.9|
|5. Providence, RI||71.9|
|1. Las Vegas||62.6|
|2. West Palm Beach, FL||64.3|
|3. Lakeland, FL, and Daytona Beach, FL (tied)||65.2|
|4. Melbourne, FL||65.7|
|Source: National Research Corp., Lincoln, NE.|
While physicians can’t alter the fundamental shifts in insurance coverage or mergers, they can act to heal their relationship with patients, says Thom. Trust can be measured along with patient satisfaction, and physicians can make changes to respond to the findings, he says.
Based on various scales designed to measure patient trust, Thom recommends adding statements to patient surveys such as:
• I trust my doctor to put my medical needs above all other considerations, including cost.
• My doctor is well-qualified to manage medical problems like mine.
• I have complete confidence that my doctor will always act to provide me with the best medical care possible.
Such questions expand the patient survey into a new realm, says Thom. "Trust is fundamentally different from satisfaction. Trust implies a relationship between two people. Satisfaction is more mechanical in a sense of whether certain things were done or not done. Trust is something that applies over time, while satisfaction applies to a given visit or event."
While trust may seem more nebulous, it can be the focus of improvement efforts. For example, better communication can, in turn, boost trust, notes Thom. Physicians who explain why a test wasn’t ordered may reassure patients that the decision was based on need and not cost pressures.
If there is a positive spin on this trend toward more skeptical, less loyal patients, it lies in an evolving consumerism. As patients become their own advocates, they are also more informed and involved in their own medical care.
"I think consumers are going to become more savvy users of health care," says Zacharias. "They’re going to question more."
With the vast information now available to consumers via the Internet, patients will be coming to office visits with new expectations. Meanwhile, allowing patients to become partners in their care creates a quick basis of trust even in the absence of long-standing relationships with their doctors, says Thom. "Patients are going to be more comfortable if they feel they are involved. The doctor explains what’s going on. They are being listened to. Things aren’t being done that they don’t understand or [that they] have doubts about.
"Involving patients in a partnership will go a long way toward reassuring them and helping them develop some trust," he says. "If you’re in a position where you’re totally dependent on somebody else and you don’t have much information about what they’re doing, you’re going to be more uncomfortable and have a lower level of trust."
In the course of treatment, physicians also need to be careful not to make promises that they may not be able to fulfill. For example, Thom recalls the case of a patient who thought her family practice physician had promised to deliver her baby. When the doctor had other commitments and wasn’t able to be present at the delivery, the patient felt betrayed.
"There’s a tendency sometimes to over-promise to people to meet their needs or their demands," says Thom. If you later aren’t able to fulfill that, "then they don’t know what else you said that you aren’t going to be able to live up to."
1. Thom DH, Campbell B. Patient-physician trust: An exploratory study. J Fam Pract 1997; 44:169-176.