Time constraints on physicians: Potential threat to patients’ trust
Executive Summary
Time constraints placed on physicians is a potential threat to patients’ trust, according to bioethicists. There is insufficient evidence to conclude that any intervention may increase or decrease trust in doctors, concludes a 2014 study.
• Medical schools have increased their focus on cultivating communication skills.
• Hospitalists may be perceived as pursuing the institution’s, rather than the patient’s, best interests.
• Certain racial and ethnic groups are distrustful of physicians generally.
Greater focus on the way physicians communicate
Until there are changes that address the system-level problems in our increasingly stressed health care delivery system, "physicians will be caught, at the individual level, in behaviors that can breed distrust," says Charity Scott, JD, MSCM, Catherine C. Henson Professor of Law at Georgia State University College of Law in Atlanta, GA.
Trust is essential for the provision of high-quality, appropriate care, says Scott, as if patients don’t trust their doctors, they won’t seek treatment in the first place. "Even if they go into the doctor’s office, mistrustful patients may withhold key information that could be critical to providing the right care under the circumstances," she says.
Trust depends on honesty, transparency, and integrity, notes Scott. "I’m not sure that physicians need remedial classes on these virtues, so much as they need to be supported by systems of health care delivery that promote the opportunity to behave in these ways," she says.
Connecting with patients
Many medical schools have increased their focus on cultivating communication skills with colleagues and patients. "Connecting with patients on a personal level that effectively conveys care and concern for the patient’s well-being is a skill that requires persistence and refinement over years of practice," notes Ben A. Rich, JD, PhD, professor and School of Medicine Alumni Association Endowed Chair of Bioethics at University of California — Davis Health System.
There is much a greater emphasis on physicians’ ability to communicate and understand patients’ needs, says Patrice M. Weiss, MD, chair of the Carilion Clinic and professor at Virginia Tech Carilion School of Medicine, both in Roanoke, VA.
"Medical education is now problem-based and case-based, as opposed to the traditional memorization of drugs, bugs, and metabolic pathways," she says. "Physicians and trainees are being educated in emotional intelligence, not just medical facts."
A 2014 study reviewed 10 randomized, controlled trials which assessed the effects of interventions intended to improve patients’ trust in doctors. These included providing physicians with additional training, providing patients with education, and providing patients with additional information about doctors in terms of financial incentives or consulting style.1
The study found that overall, there is insufficient evidence to conclude that any intervention increases or decreases trust in doctors.
"The review was a little surprising. To date, there is no convincing evidence that much of what we do increases trust," says Brian McKinstry, MD, one of the study’s authors and director of the Health Services Research Unit, The University of Edinburgh.
"Doctor education, with personalized feedback in terms of improving empathic skills, may increase trust," says McKinstry. "But there is little other evidence that short courses on communication make much difference."
Rich says he is unaware of any persuasive evidence of a significant erosion in patient trust of physicians in recent years. "There was such evidence two decades ago, with the rise of managed care," he adds.
At that time, patients’ perception was that physicians’ independent exercise of clinical judgment and discretion in the pursuit of their patients’ best interests had been co-opted by managed care organizations, in pursuit of their goals of reducing costs and minimizing expensive therapies and specialty care.
"This widespread patient perception actually led to significant changes in the policies, procedures, and protocols by which managed care organizations operated," says Rich. "The most draconian cost-limiting measures were either eliminated or significantly moderated." Here are some current challenges to establishing effective patient-physician relationships:
• Time constraints are increasingly being placed on clinic visits.
This is occurring across all health care delivery settings except concierge practice, says Rich, and poses difficulties for developing and maintaining an effective patient-physician relationship.
"This is the greatest threat to patient trust in physicians at this time, in my view," says Rich.
Physicians today are feeling inordinate pressures on their time and their finances, says Scott. These stem from fear of lawsuits, administrative and payment headaches, technology glitches, and overwhelming workloads.
"These and other stresses strain their abilities to do the right thing by patients," she says.
• The rise of hospital medicine created a new category of physician — the hospitalist — who is responsible for the general medical management of inpatients.
"This dramatic change in inpatient care has rendered primary care physicians who manage their patients when hospitalized an artifact of history," says Rich.
Understandably, hospitalist physicians find it challenging to engage with sick patients whom they encounter for the first time upon admission, says Rich, and whose responsibilities to the patient will in all likelihood come to an end upon discharge.
"For inpatients who require specialty care such as surgery, there is always the potential for mixed messages or even serious misunderstandings concerning the patient’s medical status," says Rich. Since hospitalists are often hospital employees, they may be perceived by some patients as merely agents of the hospital pursuing the institution’s, rather than the patient’s, best interests, he adds.
• Certain racial and ethnic groups are distrustful of physicians generally, based on previous difficulties encountered in seeking and receiving medical treatment.2,3
This is particularly relevant when a patient’s condition warrants a shift from disease-directed to palliative measures, according to Rich.
"Those who have felt marginalized by the health care system may fear that the shift in the goals of care is not the product of an objective medical judgment but a determination that this particular patient just is not worth continuing high cost care," he explains.
These groups may be extremely reluctant to discontinue life-sustaining interventions or to agree to changing the patient’s status from full code to do not resuscitate, says Rich. "Gaining their trust in such circumstances can pose a significant challenge," he adds.
- Rolfe A, Cash-Gibson L, Car J, et al. Interventions for improving patients’ trust in doctors and groups of doctors. Cochrane Database Syst Rev 2014;3.
- Doescher MP, Saver BG, Franks P, et al. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med 2000;9(10):1156-1163.
- Boulware LE, Cooper LA, Ratner LE, et al. Race and trust in the health care system. Public Health Rep 2003;118(4):358-365.
- Brian McKinstry, MD, Director, Health Services Research Unit, The University of Edinburgh. E-mail: [email protected].
- Ben A. Rich, JD, PhD, Professor and School of Medicine, University of California — Davis Health System. Phone: (916) 734-6135. E-mail: [email protected].
- Charity Scott, JD, MSCM, Catherine C. Henson Professor of Law, Georgia State University College of Law, Atlanta, GA. Phone: (404) 413-9183. E-mail: [email protected].
- Patrice M. Weiss, MD, Chair, Carilion Clinic, Professor, Virginia Tech Carilion School of Medicine, Roanoke, VA. Phone: (540) 266-6146. E-mail: [email protected].
