Commentary

The Benefits of a Trusting Physician-Patient Relationship

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The Oxford English dictionary1 defines trust as firm belief based on experience, qualities such as honesty and veracity, and actions such as justice and strength of a person or thing. Two-thousand three hundred years ago the Hippocratic oath originally outlined appropriate trust-building behavior for physicians. The sustained use of the oath reflects how profoundly important physician behavior is for establishing trust in relationships with patients.

The study by Thom2 in this issue of JFP is grounded in a previous publication based on input from patient focus groups3 and identifies the physician behaviors that are most important to the patient for building a trusting relationship. As we review this work and others it is important to remember why trust between physicians and their patients contributes to an effective and affordable health care system. Thom has confirmed that the most important predictors of trust are similar to the predictors of patient satisfaction. Stewart4 found that the more patient-centered the interview and the more the physician and patient feel like equal partners, the better the outcomes for the patient’s health problem.

Trust, Watchful Waiting, and Partnership

Starfield5 found that 40% of all new problems presented to a family physician are nonspecific and never evolve into a defined International Classification of Diseases-9th revision or Diagnostic and Statistical Manual of Mental Disorders, 4th edition diagnosis. Undifferentiated problems can often be dealt with by competently reassuring and educating the patient and inviting return if the problem does not improve in a few days. The skill of accurately identifying conditions best managed by “watchful waiting” has been well developed by family physicians, and this policy is likely to work best in a trusting relationship. Trust enables the patient to accept the physician’s recommendation for self-monitoring and makes it less likely that the physician practices defensive medicine.

The potential for increased costs to the health system resulting from a breakdown of patient trust is substantial. Patients who do not accept a wait-and-see strategy from a physician whom they do not trust are likely to require potentially costly consultations. The usual outcome of investigating undifferentiated problems is an unsatisfactory nondiagnosis that heightens patient anxiety about the presence of serious disease. The risk of increased morbidity and mortality secondary to unnecessary testing cannot be ignored.6

Current research supports patient-centered decision making to enhance adherence to treatment regimens and improve outcomes. Even though patients did not value shared decision making very strongly in the study by Thom, Leopolde and colleagues7 emphasize the need to establish a partnership with patients as a means of increasing trust. The physician brings to the partnership knowledge and skills about health care that may be of benefit to the patient, while the patient brings values and beliefs from the context of his or her environment. Both partners search for common ground and negotiate the best course for the patient. Although the potential for increased system costs and negative outcomes from lack of trust is substantial, there is a paucity of research regarding managing undifferentiated problems.

Factors That Influence Trust

Thanks to the research of Thom and others, we know the behaviors that patients most strongly associate with enhanced trust. These include comforting and caring, demonstrating competency, encouraging and asking questions, and explaining. More surprising is that patients find less value in gentleness during the examination, discussing options and asking opinions, looking in the eye, and being treated as an equal. This information advances our understanding of the patient’s perspective on trust while also shattering some myths.

Focus groups in an earlier study by Thom and Campbell3 identified other factors influencing trust, including the age and sex of the patient, the training and professional appearance of the physician, positive recommendation by other patients and physicians, and the operation of the physician’s office. Staff courtesy, management of messages and laboratory results, and on-call arrangements that ensure accessibility are important in cementing trust in a relationship.2 System intrusions on the physician-patient relationship, such as mandating screening tests for all, disallowing the ordering of specific tests (usually expensive), or blocking prescribing of newer drugs, threaten trust in the physician-patient relationship. Organizations or governments giving physicians financial incentives to provide screening or other procedures tempt physicians to place their own interests before those of the patient. This point is illustrated in managed care organizations. Kao and coworkers8 found that the way physicians are paid influences the level of trust in the relationship. Physicians salaried by a health maintenance organization (HMO) were found to garner a lower level of trust than with fee-for-service private physicians. In addition to intruding in the decision-making process, long-term continuity of care is difficult in instances when the HMO provider is changed frequently and not allowed to build trust with patients.

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