Measuring physician trust in patients

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 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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  • Trisha Torrey

    Jessie has nailed the bias in this survey done by the Annals of Family Medicine. How ridiculous those questions are when trying to determine mutual – provider AND patient – trust!

    If you don’t get it – then you’re a part of the problem. As an experiment, imagine if husbands were asked those questions when trying to assess their relationships with their wives. They begin to sound ridiculously one-sided, don’t they?

    There is no room for such bias in a relationship that works well. The only professionals who provided useful input to the Annals were the ones that refused to participate, having recognized the biases in the questions.

    Trisha Torrey
    Every Patient’s Advocate

  • Kristin

    I agree that describing what this scale is measuring as “trust” may be an issue, but I have some issues with your response. It’s worth noting that the development process is interesting–they started by asking physicians, many of whom were PCPs, what led to trusting relationships. This kind of exploratory research is very common in Psych; what other approach would you suggest that they use?

    Additionally, there’s a distinction to be made between trusting a patient as a person, and trusting them as a patient. If you’re living with a fog because of medication, I might trust you completely as a person–I would trust you to watch my kids–but still not trust you as a patient: I might not believe that it was likely that you would remember to take your medications. That looks a lot more reasonable than making the blanket statement that I don’t trust you. And if I don’t believe that you’re likely to remember your medication, it’s more likely that I would want to insititute a follow-up plan or monitoring plan to ensure that you’re still getting the care you need than if I believed that you were going to understand and remember the instructions.

    Similarly, someone can respect your time and still use a lot of it. I might be annoyed at being thrown off my schedule if you want to talk to me to make sure you understand your treatment, but I don’t think that would qualify as not respecting my time–not respecting one’s time would look more likely making repeated demands for drugs or testing that are not advised and about which we’ve already talked. Unfortunately, the study’s authors are not sufficiently clear about their definitions to make it obvious what they meant.

    It’s also worth noting that the testing was conceived of and done in a population of patients with chronic pain. With chronic pain, physician watchfulness in terms of the potential for substance addition is warranted. A more paternalistic attitude than I would generally find tolerable in medical care may be acceptable.

    Additionally, the population in question was indigent. I find it unlikely that the people who allowed their PCPs to participate in this study have much in common with you–they probably aren’t educated to the same extent, and they probably don’t have many of the tools that would allow them to contradict their doctors with a meaningful degree of knowledge. They don’t know their doctors’ conflicts of interest. They don’t know which questions to ask.

    So I agree that this scale is a starting point, not an end in and of itself. It will probably not translate well to other clinical applications. The article underlines the importance of being clear with definitions from the beginning–a word like “trust” is loaded and not particularly descriptive.

    The most troublesome item that I see is the item about accepting medical judgment. I wonder what the interviews looked like where that came up, and whether the researchers will correlate it with any measure of quality of care. Accepting your doctor’s medical judgment is only a good thing if they’re right.

    • AustrianSchool

      Well said. It shouldn’t be a power struggle.

  • Lynn Hanessian

    While I am not sure that “trust” is the right word, it is the case that physicians appropriately consider a patient’s capacity and even perhaps reliability as part of the therapeutic alliance formed with the patient.

    In our first postpartum pediatrician visit for my first (and only) son, the pediatrician was naturally sizing me up and assessing my capacity to keep the little wonder alive. He gasped when I mentioned that my son had slept 6 hours straight the night before noting that obviously he had missed a feeding. It was only when the ped returned after a visit to the scale with the little wonder having discovered that he had been putting on the ounces quite nicely that I received a pass for my neglect. My parenting of a second or third child would not have received that level of inquiry.

    It is the case that patient compliance is critically important whether healing and recovering or just staying well. More and more we know that it is not just what happens in the doctor’s office that impacts our health and well-being. Fostering a strong partnership btw the physician and the patient is critical, but is might make sense to find a term that is less loaded with the possible interpretation that it is a personal opinion and instead find one that gets to the heart of the matter: the physician’s assessment of the patient and what is possible in the therapeutic alliance.

  • Zal Press

    Patients are a diverse bunch. It seems presumptious doesn’t it, that doctors – i.e. the service providers – should question their patients – ie. customers – level of trustworthiness. After all, patients are at different levels of literacy, evolution, and critical abilities. Not to mention cultural and social differences. Doctors need improved skills of being able to identify how much of a participant a patient can be.
    When I told a doc I’m “militant” about my health care he told me no doctor wants a “militant” patient in his office. He missed the point that the militancy is against a life long battle against an incurable chronic illness.. I don’t come to my doc’s office looking for a conflict – I’ve already got one inside of me.
    Instead I’m coming to consult with a member of “my” health team. And as a commando in the battle against my disease the principles I follow include exemplary execution of a plan, team support and respect, eyeballs in the back of my head, meticulous planning research and constant reassessment of the prevailing circumstances.
    Central to this philosophy is that all members of the team must trust each other, and trust that they’re all after the same ojbective.

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