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Introduction
Medicine cannot be perceived without a physician-patient trusting relationship, as it constitutes an essential aspect that influences and even determines the prosperity and permanence of that link. However, it is difficult to build this essential component and very easy to make it disappear [1-4]. As the patients’ health is the purpose of this relationship it is even more important to know which factors influence it, and above all, to be conscious of the consequences that may ensue. This motivated this narrative review to enquire about this element that, although very fickle –as any human relationship– can be a powerful and valuable resource in the physician-patient relationship.
The importance of examining this subject lies not only into knowing and understanding the factors that affect trust and their consequences for patient`s health, but also in educating about its importance and opening a discussion about how we could contribute as professionals so that trust be present, consolidated and a priority when entering into a relationship with our patients.
This is then the purpose of this narrative review.
Method
We performed a narrative review. This is a strategy to develop a broad overview of a topic, and it is different from a systematic review because it does not use a predefined structured protocol. This approach seems to be adequate for this review because it aims to identify factors related to the physician-patient relationship and not to document exhaustively what scientific publications are publishing about it [5].
Results
What is trust?
Trust is defined as the expectation that an individual will carry out a well-meaning, or in good faith, to behave according to the covenants engaged into, be honest and not take advantage of others, even if there should be an opportunity to do so [1]. Therefore, it is a requisite when seeking health care, both for physician and patient [2] since patients become voluntarily vulnerable to physicians [3]. Without it how could a physician hope that patients would mention all their relevant medical history, accept physical examination or act according to the recommendations based on tests, or follow therapies [2]?
Trust comprises multiple dimensions [3]. It implies positive expectations of integrity, willingness to accept vulnerability, or both [1]. Patients have identified the attributes of the physician in the domain of trust which are grouped as: technical competence, interpersonal competency, fidelity, honesty and confidentiality [4].
At present, the tools to measure the concept of trust are limited, mostly based on questionnaires applied immediately after the medical consultation. The leader among them is the Trust in Physician Scale (TiPS) created by Anderson in 1990 [6]. Some variants have derived from it, such as the Pedi-TiPS scale [7], a very similar scale applied in paediatrics and where the informants are the parents or tutors, or the Wake Forest Trust Scale [4], which in essence keeps to the same categories initially proposed: fidelity, competence, honesty, confidentiality and ‘global trust’.
Other tools [8-10] have been developed, however, they have not met with the expansion of the above-mentioned.
Factors related to trust
Among the factors that influence trust placed on physicians is their physical condition. Studies of the United States showed that, generally, when people are advised about healthy lifestyles, sedentary habits prevention or decrease of body mass index to adequate values, healthy nutrition and physical activity, as to reduce the incidence of cardiovascular and metabolic diseases, are more likely to follow these recommendations when they are given by physicians with normal body mass index, or that at least their image should display it [11].
Nowadays technology has greatly transformed our lifestyles and the physician-patient relationship is not an exception to this innovation. The easy access to these technologic resources, both for patients and physicians, strengthens the need to analyze phenomena of the current times. Specifically, those linked to the new social structures built by the Internet social networks. One of the factors that has been added recently and is relevant when placing trust in a physician, is what is published in the professionals’ social network. Physicians who publish racist remarks, anecdotes about their patients, photographs showing them drunk, remarks including foul speech, show a significant loss of trust from their patients [12].
Finally, the factor that most strongly influences trust is the communication style of the physicians [4,13-15], which includes behaviors such as active listening, emotional support, clear and full information, asking for the opinion of the patients for decision-making about treatment and provide sufficient time for the patients to ask questions.
All those factors have diverse consequences on patient’s health, with greater or lesser impact. For this reason, it has been suggested to take communication and trust fully into consideration, to lessen the perceived risk of uncertainties occurring in medical treatments [1].
In 2005, a study leaded by Piette in the United States linked trust to the adherence to treatment by diabetic patients. Those patients who reported a decrease in the levels of trust in the physician had a significantly higher risk of lesser use of medicaments due to their cost, than patients using medicaments of similar cost, but with greater trust in their physicians [16]. Similarly, in the same country, another study of trust in the physician linked it positively and significantly to adherence in hemophiliac patients with depression who used therapy on demand [17]. This same principle is replicated in a study by Nguyen in 2009, with patients suffering from inflammatory intestinal disease, finding a strong increase of adherence to treatment linked with a greater trust in the physician [18].
A multinational study leaded by Zwingmann, using a prospective experimental design, researched the impact of the communication style of the physician at the time of giving bad news to cancer patients. The latter reported much greater trust in physicians who practiced a communication centered in the patient and a high degree of empathy, contrary to those whose communication was not emphatic and with less focus on the patient. What is significant is that this higher trust appeared independently from sex, age, or if they had previously been diagnosed with cancer [19].
Furthermore, trust is a strong predictor of continuity with the attending physician. It was found that after three months, only 3% of the higher trust quartile had abandoned their physician, as compared to 24% of the patients in the lower quartile [20]. Ernstmann, in Germany, found significant links between trust in the physician and changes in physical functioning after intensive therapies, such as surgery and chemotherapy in colon cancer, it being essential that these patients should have more trust in their physicians at the time of a good follow-up, since they were highly dependent and needed to be supported [21].
Negative consequences of trust in the physician are also reported, because in some circumstances the trust of the patient in the physician could lead to deficient care; it would be less probable that the patients would seek a second opinion, question an inappropriate recommendation of the physician, or change their unsuitable physician [22]. This effect that could cause an unfavorable outcome for the course of the pathology should be an error made in the diagnosis or treatment, or simply fall into the error of routine response. A better therapeutic response to the placebo effect has been also reported in patients with greater trust [23]. And when trust is broken, it is less probable that a patient seeks the help of that physician in future, which would negatively affect his long term well-being [1].
Discussion
According to this revision, trust in the physician is an essential element of the physician-patient relationship, and has been researched using an empirical viewpoint, mainly based on the experience of the health system users [24], allowing to build a clearer definition of trust, its associations and consequences. However, according to what has been revised, there are few studies in the literature using the physicians’ experience [25]. Where it would be assessed, how trust is built or on the contrary, how it is lost in the physician-patient relationship, which are the factors that positively or negatively influence it and the consequences that trust generates in them.
It is very important to enquire in this research perspective which has been overlooked, since it directly involves the object from which trust is born, or on the contrary, mistrust. It is necessary to assess the awareness level about this subject and find out if there is the will to effect a change in the physician-patient relationship. In this way we could ascertain if research concerning trust can have a fruitful result that would be applicable starting from theory.
In the same context, the absence of a standard scale validated in Latin-America seems relevant and disquieting. So as to measure the trust of the patient in the physician, adapted for use in our specific population, as it has been done in the Netherlands [25]. Furthermore, the habit of routinely and constantly measuring this parameter does not exist.
On the other hand, we do know that, before consulting, patients look for recommendations for physicians to choose the one that seems more adequate. This criterion ends being formed through opinions set out in web pages [26], where the work of each professional is assessed, or asking among family or acquaintances who have consulted that physician. This usual custom is based on the search for quality in health care and generates a snowball effect, where each, medical attention can affect the following or even more pertinent decrease the request for medical appointments from that professional.
We are in a digital era where the massive use of social networks and the large amount of time spent consulting them [27] constitute a relevant factor to be considered in clinical practice. Along this line, the physicians having the habit of publishing questionable contents, situations related to drug use and excess alcohol consumption or content referring to patients’ care can be judged by the population, and the physician-patient relationship become affected [12]. Therefore, social networks must be viewed as double-edged swords, because, although they can be used to carry out successful distance health care in contexts such as the present COVID-19 pandemic, they can also be used to discredit the professionals and as a result diminish trust on them.
Conclusions
This narrative review supports the importance of trust in the physician-patient relationship. To know the factors that influence it in-depth, such as anthropometric aspects, communication skills, empathy and information provided by the professionals themselves through informal online media allowed to value the consequences that may follow. One of those consequences, described in the literature and closely linked to clinical practice, is the adherence to treatment shown by the patients.
The state of the art does not exhibit sufficient volume of current research to allow an exhaustive one based on the changes that have occurred during the last decade. Those linked to technological advances and the strong influence of the social networks on present society, where 2.6 billion people use Facebook, Instagram or WhatsApp, where the last has been reported to be used by 90% of the population, according to some studies [27]. On the other hand, most of the research found has been developed in countries such as the United States [3], Germany [19], Netherlands [25], China [1], and there are no studies carried out in other parts of the world: Latin America, Africa or Central Asia. It would be productive to count on it to optimize the physician-patient relationship, improve adherence to treatment and consequently obtain better health indicators in general.
