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.