In my chosen doctor I trustBMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7480.1418 (Published 16 December 2004) Cite this as: BMJ 2004;329:1418
- David Mechanic, director ()
- Rutgers, State University of New Jersey Institute for Health, Health Care Policy and Aging Research, 30 College Avenue, New Brunswick, NJ 08901, USA
The season of goodwill provides the occasion to consider the importance of trust in facilitating social intercourse and a well functioning society.1 Trust provides the glue that makes cooperation possible without costly and intrusive regulation. Trust has declined in all social institutions in recent decades2 and medical leaders in the United States elicit as little public confidence as leaders in government and business.3 Trust in doctors has also diminished with the explosion of public information on betrayals of trust, failure to follow evidence based standards, and poor quality care, but patients remarkably retain much trust in their personal doctors.4 Such trust encourages sharing of intimate feelings, cooperation in treatment, and adherence to medical advice.5 Patients may have assimilated some of the negative media images of doctors and health organisations but they typically believe their doctor is different. Choosing one's doctor and care settings, continuity of care, and good communication contribute importantly to such trust and to the quality of health care.
When trust erodes, public authorities may appoint expert commissions and introduce new rules and regulations to control substandard and unethical behaviour. They do this to assure the public that health services meet high standards, and that doctors can be trusted. These measures may help, but rarely do they have the high credibility that trusted doctors have in guiding and reassuring patients.6
Trust in doctors is built on patients' beliefs that doctors are technically proficient, on interpersonal competence, and on indications that the doctor is their ally.7 Typically, patients cannot judge technical competence but assume that educational and certification requirements ensure this. They also use interpersonal cues to judge competence, such as how the doctor questions them, communicates about their illness, and answers questions. Some patients judge competence—sometimes incorrectly—by the course of their illness and their responses to treatment. Central to patients' trust is how doctors communicate and whether they listen and are caring. Patients do not expect intimacy but they do seek respect and responsiveness. The kinds of communication skills patients value are teachable skills. Finally, patients want to know that their doctors are committed to protecting their interests. Patients in varying contexts may be more or less aware and willing to accept that their doctors are allocators as well as givers of care, but they must feel that their doctors are on their side. The availability of choice reinforces trust in the doctor as agent.8
We still know little empirically about the transfer of trust between personal doctors and managers, consultants, hospitals, and the larger health system. Doctors are the gateway to organisational trust. Health plans in the United States elicit trust through the qualifications and reputations of affiliated doctors. Whether the failures of these larger organisations diminish their doctors as well is less clear. In instances where the organisation is held in high public regard, as is the case with the Harvard Medical School, Johns Hopkins Medical School, and the Mayo Clinic, affiliated doctors may also gain in reputation. Doctors and managers stand to benefit by collaborating in building trust in clinicians and in larger systems.
Most patients view medical care in terms of the personal doctor-patient relationship and are not sophisticated about organisational structures and strategies, such as managed care, and how they work. But they want their own doctors, not managers, to control their medical care. This creates a dilemma for managers seeking to reduce variations in care, eliminate inefficiencies, and introduce evidence based standards of care. Managers have to tread carefully, sensitive to the importance of the doctor-patient alliance and the value of trust on which it is often based.
Patients may trust blindly when some scepticism is warranted. Much care that is needed is never provided, and ineffective and inappropriate care is common.9 As more information is available for patients in the media and on the internet they often encounter conflicting advice. Patients have many questions about their care and, in the United States, advertising of pharmaceuticals and medical treatments directly to the consumer leads to even more questions.10 Few primary care doctors have the time to respond adequately and to make the patient a true partner in care.
Health administrators and managers attempt to deal with such challenges by providing accessible and reliable information to patients, by putting in place disease management programmes that make effective use of nurses and other health professionals, and work with doctors to help them improve their practices.11 Electronic information systems offer opportunities to improve communication, avoid errors, and help patients become proactive in their own care.12 Managerial interventions carelessly introduced can diminish trust among both health professionals and patients. But if pursued collaboratively they offer potential to promote quality and trust and contribute to satisfaction of both patients and clinicians.
Competing interests None declared.