Physician Trust in the Patient: Development and Validation of a New Measure

I appreciate the comments from Drs. Tarrant, Kramer and Stepanikova. The space limitations of the article did not allow me to do more than briefly mention the contributions of these investigators, and several others, to understanding the antecedents, consequences and processes of mutual trust in the doctor-patient relationship. Interested readers would do well to access their publications related to this topic.

Mutual trust is an extremely rich construct for examining the patient -provider relationship, particularly, though not exclusively, in primary care. The importance of understanding the nature, and value, of this relationship is especially important in light of recent and impending changes in models of health care delivery as there is a risk that what is not measured or understood may be damaged or lost. I appreciate the Annals of Family Medicine providing an opportunity to advance our work in this area.

Competing interests:   None declared

By developing a scale for measuring physician trust in a patient, Dr. David Thom and his colleagues make a much needed methodological contribution. The emphasis on the patient side of the health care process evident in health care research during recent decades has necessarily limited our attention to physician-level factors. Yet, physicians still are (and likely will always be) important clinical decision makers. Physicians are human, and like for all humans, their decision-making is influenced by a complex array of factors, some clinical and some non-clinical. Trust in a patient is likely to be one prominent factor shaping both clinical decisions and the interpersonal care delivered to patients (both of which, in turn, contribute to patient evaluations of care).

The idea of the importance of physicians’ trust in a patient is not new -- see, for instance, a discussion by Cook et al. (1) -- but without a valid measure, we have not had the tools to empirically document its role in the clinical process. I am confident that Thom’s new measure will encourage research activity in this area. This research is needed to help us understand which factors shape physicians’ perceptions of patients and how these perceptions influence the care that patients receive. Such better understanding can help to develop practical tools and policies to improve the physicians’ ability to deliver clinically appropriate, high-quality care equitably to all patients.

(1) Cook K, Kramer R, Thom D, Stepanikova I, Bailey S, Cooper R. Trust and distrust in patient-physician relationships: perceived determinants of high and low trust relationships in managed care settings. In: Kramer R, Cook KS, eds. Trust and Distrust in Organizations: Dilemmas and Approaches. Thousand Oaks, CA: Russell Sage Foundation; 2004:65-98.

Competing interests:   None declared

Competing interests:   None declared

Thom et al are to be commended for their work to develop a measure of physician trust in patients. The doctor-patient relationship is a reciprocal, two-way relationship; if we only study patient trust in physicians, we are missing part of the picture.

The authors argue that physician trust is important, and this should not be understated. Physician trust can impact on quality of care and patient outcomes. GPs may be unwilling to invest time and effort in patients they do not trust, and patients are sensitive to cues that indicate they are not trusted by their doctor. Lack of mutual trust can be a barrier to developing a good relationship and working together to achieve optimum outcomes. Certain patient groups (such as homeless patients) may be more vulnerable to lack of trust from health care providers (1), and may be deterred from seeking essential healthcare as a result. An insight into levels of trust between patients and GPs may help in addressing such problems.

Evidence shows that continuity of care is associated with higher patient trust in their physician (2), and we now have the opportunity to explore whether this is also the case for physician trust in patients. In my qualitative work in the UK (3), GPs tended to feel they could trust patients more, and were more willing to invest in their care, as they got to know them better. They also felt that establishing continuity of care could help to build mutual trust, making it possible to engage the cooperation of initially ‘untrustworthy’ patients. It may also be the case that continuity of care allows physicians to become more discerning in their willingness to trust individual patients, enabling them to act appropriately – to know, for example, which patients can be trusted to self-manage their own care, or to legitimately request sick notes, and which patients might need more careful monitoring, questioning, or explicit contracts to engage their cooperation.

Further research into the relationship between processes of care, and mutual trust and cooperation, would greatly enhance our understanding of the dynamics of doctor-patient relationship, and help establish more soundly the role of continuity in the delivery of good quality primary care. If Thom et al’s measure can be shown to be generalisable to other populations, it will be a valuable tool for future research.

1. Lester H, Bradley CP (2001) Barriers to primary healthcare for the homeless: the general practitioner’s perspective. European Journal of General Practice, 7, 6-12.

2. Mainous III AG, et al (2001) Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Fam Med, 33(1):22-7.

3. Tarrant, CC (2006). Continuity, trust, and cooperation: a Game Theory perspective on the GP-patient interaction. PhD thesis, University of Leicester.

Competing interests:   None declared

Thom et al. contribute a valuable new scale for assessing physicians’ trust in their patients. As the authors of this study aptly note, the level of trust between patients and physicians plays a vital role in the quality of their relationship. As numerous studies have documented, trust can impact important medical outcomes in a variety of ways. Yet, as the authors point out, our understanding of the physician “side” of this complex and fragile equation has been hindered by inadequate theoretical elaboration and incomplete empirical evidence. Thom et al.’s new research advances our knowledge on both fronts. First, the original scale they introduce directs our attention to some of the major dimensions along which physicians’ trust in their relationships with patients should be conceptualized. Second, it provides solid empirical evidence of the usefulness of these measures with respect to a number of consequential outcomes in medical settings.

The addition of this instrument to the researcher’s tool-kit invites consideration of its possible uses for further empirical investigations and extensions of extant theory. As a social psychologist who studies the cognitive and affective antecedents and consequences of trust in organizational settings, I’ve been intrigued by the many ways in which low trust (or more accurately framed, active distrust) can inhibit individuals from taking the kinds of interpersonal risks that lead to the building of more effective, cooperative relationships. Applied to Thom et al.’s research, my research suggests that physicians might be less willing to fully express all of their concerns or might modify how they present or “frame” such concerns to their patients.

Along such lines, important research by Amy Edmondson has demonstrated the importance of what she characterizes as “psychological safety” in organizational relationships. Edmondson defines psychological safety in terms of “individuals’ perceptions about the consequences of interpersonal risks in their work environment.” Such safety, she goes on to elaborate, “encompasses take-for-granted beliefs about how others will respond when one puts oneself on the line, such as by asking a question, seeking feedback, reporting a mistake, or proposing a new idea” (p. 241). In climates characterized by high psychological safety, Edmondson has shown across a variety of settings (including medical), individuals are more likely to appropriate help, useful diagnostic feedback, self-disclose their concerns regarding possible errors or perceived problems, and engage in more creative, collaborative problem solving.

Thus, in addition to the “hard” behavioral concomitants of physician trust in patients that Thom et al. nicely document in their study, their new scale might be used to investigate more thoroughly such subtle determinants of psychological safety and their consequences.

References

Edmondson, A. C. (2003). Speaking up in the operating room: How team leaders promote learning in interdisciplinary action teams. Journal of Management Studies, 40, 1419-1952.

Edmondson, A. C. (2004). Psychological safety, trust, and learning in organizations: A group-level lens. In R. M. Kramer & K. S. Cook (Eds.), Trust in Organizations: Dilemmas and Approaches, pp. 239-274. New York: Russell Sage Foundation.

Kramer, R. M. (1999a). Paranoid cognition in social systems: Thinking and acting in the shadow of doubt. Personality and Social Psychology Review, 2, 251-275.

Kramer, R. M. (1999b). Trust and distrust in organizations: Emerging perspectives, enduring questions. Annual Review of Psychology, 50, 569- 598.

Competing interests:   None declared