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Introduction
Although fulfilling the role of physician most of the time, it is quite probable that a professional in this field may also have been a patient at some time. Therefore, it could be thought that physicians do know the factors that increase trust in them and therefore, they know how to put them into practice. But are the physicians really conscious about these factors? This article is a narrative revision of the scientific literature dealing with the phenomenon of patients' trust in physicians and seeks to systematize advice based on evidence so that physicians may increase the trust that their patients put on them.
Methods
What is trust in the physician?
A revision done at the beginning of the century already mentioned the significance of the trust in physicians; this was positively associated with the observance of treatment, keeping the treating physician, willingness to recommend the physician, fewer disputes, not seeking second opinions, perception of greater effectivity of care, and improvement in health self-perception [1].
Trust can be defined as a state of favorable expectations concerning the actions and intentions of other people [2]. Specifically, trust in the physician can be defined as the optimistic acceptance by the patient of his vulnerable situation and the certainty that the physician takes care of his interests [1]. In a study with severely sick patients, the meanings most associated to trust were honesty, receptivity, having good intentions and be able to feel vulnerable without fear of being hurt [3].
Hall et al pointed out that trust would be configured by five aspects, fidelity, competence, honesty, confidentiality, and global trust. However, empirically, trust in physicians behaves as a unidimensional construct, which suggest that, although it has different aspects, people do not clearly differentiate them [1].
On the other hand, the physician-patient relationship has historically been paternalistic [4]. But during the past decades, the patient began to be an active and autonomous agent in decision-making [5]. Together with the decrease of the physicians' protagonism within the health team and the technologic and social development, contemporary medicine has been faced with a deep trust crisis [6].
Studies concerning trust
In Chile, according to the International Social Survey Programme Health, 56% of the interviewees trusted the physicians, while only 23% felt satisfied with the treatment received the last time they visited a physician [7].
There are multiple instruments to measure trust in physicians. A systematic revision done in 2013 identified seven instruments to do so [8]. One of the first was Anderson and Dedrick's Trust in Physician scale [9]. In general, all tend to find high trust in physicians, because there is high sensitivity in the available measurements and a ceiling effect of those. This would be the basis of an evidence that results insufficient to conclude about the effects of interventions on the trust in physicians [10].
Factors associated to trust
Among these factors, some depend on the patient and other on the physician (see Table).
Table. Factors related to patients' trust in the physicians.
| Factors associated to trust | ||
|---|---|---|
| Of the patient | Sociodemographic antecedents | |
|
| ||
| Health condition | ||
|
| ||
| Selection of the physician | ||
|
| ||
| Experience in the system | ||
|
| ||
| Satisfaction | ||
|
| ||
| Symmetry of perspectives | ||
|
| ||
| Of the physician | Sociodemographic characteristics | |
|
| ||
| Online information | ||
|
| ||
| Physical appearance | ||
|
| ||
| Communication | ||
|
| ||
| Emotional intelligence | ||
|
| ||
| Humility | ||
Patient's factors
Some are inherent to the patient and others depend on context, and it is vital to identify them from a bio-psychosocial viewpoint [11].
Socio-demographic antecedents of the patient. Patients' characteristics are not generally strong trust predictors. Excluding age, studies have found inconsistent, weak or no trust relationships with most demographic characteristics [1].
Patients' health condition. Healthy people trust their physician more, either because they have a better perspective on life or because their treatment has been more efficacious. Likewise, vulnerable patients or those with an anxiety outlook are more inclined to develop trust in their physicians [1].
Selection of the physician. One of the stronger trust predictors is that patients feel that they have had sufficient freedom to choose their physician and on what basis he was selected. [1]
Experience in the system. Confidence is oriented to the future although past experiences and other forms of knowledge influence it [12].
Patients' satisfaction. Patients' satisfaction refers to the general assessment of the beneficiaries of medical care [13]. A greater satisfaction predicts a greater trust in the provider of that care [14].
Symmetry of perspectives. Patients feel that they are at a disadvantage during their medical treatments, as the medical personnel usually has superiority of information. This can result harmful for the relationship with the patient, as he can provide misleading or inexact information [15]. On the contrary, the information provided by a patient that does trust his physician may be more acceptable to the physician as objective, competent and responsible [15].
Physician's factors
Socio-demographic characteristics. Most of the socio-demographic and professional characteristics of the physician are not great predictors of the trust level of the patients, independently of the similarity of the demography between them, or lack of it.
Indication and perception of online information. All patients must receive timely information about their illness [16] and in a context surrounded by technology, when needing information about health, most of the population prefers digital sources rather than consulting a physician [17].
Patients feel more confidence when consulting when they have used internet to find information about health and take it to the professionals [16,17] besides the relationship with the patient improves when they both discuss those findings [18,19].
Concerning this, the way in which the physician reacts when the patient shares his online findings is important: if the patient senses that the physician feels threatened, the relationship between them can be affected [18].
However, another aspect must be considered: a study showed that when the patient finds information online, he tends to ignore the physicians' experience [19].
The internet is an integral part of the multidisciplinary viewpoint in health care and it is to be considered that it will never replace the health professional [20]. Therefore, it must be considered as a positive complement of the patients' education [20]. In spite of its benefits, experience shows that patients frequently report that their physician has never recommended web pages for their information [17].
Physical appearance. In general, patients prefer physicians who use a white coat and formal attire; this favors trust and aspect is among the three most important variables that define trust in the physician [21]. In Chile it was found that patients trust more those who wear formal attire and a white coat, however, this association is mostly found in older patients [22]. On the contrary a study in Switzerland concluded that attire was not a priority. However, the author proposes that the difference with other studies could be due to several factors and would indicate that aspect would affect the perception that the patient has of his physician [23]. In the Chilean study it was found that the use of a white coat was associated to a perception of greater competence, trustworthiness and preferences on the part of the patient [22].
Communication. Communication is the basis of a good physician-patient relationship; effective communication abilities are necessary for the tasks of a good physician [24] and inspire more trust in the patient [25, 26]. Their effective use allows the physician to identify his patients' problems with greater precision and decreases litigation. The satisfaction level of the physician and patient increases, reducing the burnout syndrome in the physician [27].
Respect and empathy, competence and thoroughness, patience and honesty are factors positively linked to the patient's trust on the physician [28]. A study with cancer patients showed that they valued three elements in communication with the physician: competency, honesty and empathy.
Besides, in that study an improved expression of specific communication behaviors resulted in greater trust of the patient. Moreover, this trust reinforced the expectation of the patient and his willingness to recommend the physician [29].
Emotional intelligence. Emotional intelligence is conceptualized according to four basic abilities: perceive value and express emotions with exactitude; accede to and/or generate feelings that facilitate thought, understand emotions and emotional knowledge and control feelings, promoting an emotional and intellectual growth [30]. This concept has a clear forerunner in Howard Gardner's theory of multiple intelligences, specifically the intrapersonal and interpersonal intelligence where aspects related to self-knowledge and knowledge of the other are joined, and the individual considered as subject and object [31].
The benefits positively linked to high emotional intelligence in the physician are numerous: traits of leadership [32], greater psychological well-being, less emotional burnout, less depersonalization [33] and greater self-esteem [34].
A fundamental benefit associated to greater emotional intelligence is the strengthening of the patients' trust and the physician-patient relationship, as shown by a study carried out in Taiwan, with patients and 39 physicians plus nursing chiefs [35].
It has also been documented that training in emotional intelligence strengthens the abilities of the participants, specially impacting the interpersonal component [36,37]. Therefore, it is desirable that physicians should develop their emotional intelligence, benefitting their own well-being, the physician-patient relationship and strengthening trust.
Humility Humility is a multidimensional virtue. Its intrapersonal component includes having a clear vision of one's strengths and weaknesses and being open to new ideas an information. Its interpersonal component includes having egalitarian beliefs and orientation centered on the other [38]. In the medical field, to be humble means to distinguish between knowing the disease that the patient has, what it means and understand what is felt when suffering it.
For physicians, humility makes a difference between what is clinically indicated and the treatment options considered appropriate by the patients [39].
It was found in transversal studies that the humility of the attending physician consistently predicts the satisfaction and trust of his patient, independently from demography, the characteristics of the physician and the medical visit [38]. On the other hand, a study carried out by means of a website, where fictitious physician profiles were created, demonstrated that, even before the visit, the reference to the humility level of a physician predisposes interaction, increasing trust, satisfaction and adherence to treatment. However, this effect was moderated by references to the general efficiency of the physician [13].
As humble physicians know their strengths and weaknesses, they can be frank regarding matters of which they have limited knowledge, which increases the trust of the patient [38]. When physicians are humble, they focus on their patients and value them as partners in the care process; therefore, it is more probable that they involve them in motivating visits and/or decision-making. [38]. One experiment found as secondary result that the participants exposed to shared decision-making informed feeling more trust in the physician than those who did not [40].
Results
Advice to increase trust in physicians
From the above results, it is possible to convey some advice that physicians could follow to generate more trust among their patients.
Be friendly to online information. Internet is an ally, not a threat when providing care, since a respectful and emphatic discussion about medical information available on the web increases trust and improves the relationship with the patients [18]. Even just the fact of indicating internet to gather health information increases trust in physicians [17]. The professional must avoid showing annoyance when his patient points out what he found on the web, and it is important to direct patients to trustworthy digital sources.
Take care of your personal aspect. One of the first details valued by the patients and at first sight, are elements like clothing. To dress formally and the use of a white coat generate a positive impact in the trust that the physician creates in the patient, especially if the patient is older [22], since it is associated to the image of the ‘ideal physician', attributing higher competence and trustworthiness [41]. Then, although the patient's profile must be considered, it is better to take care of one's attire, thinking of the scant time for attention, the weight of first impressions and the medical baggage of the patient. All as a quick mechanism to generate a better relationship to the benefit of the latter.
Show empathy, honesty, and competence. These three are attributes of medical professionalism [42] and at the same time vital communication elements that help to build the patient's trust. In this way, small variations in the manner of communicating with the patient can bring big changes in the relationship [29]: listen patiently to the problems, concerns and worries of the ailing patient, inquire deeply about the symptoms and explain health problems in detail [28].
Concerning empathy, it is important for the patients that the physician should greet them warmly and clearly answer their enquiries [28].
The patient values that the errors that may have happened during treatment should not be hidden [28] and that the limitations of medical procedures and one's own capacities should be underlined, always balancing to be realistic with keeping up the patient's hopes [29].
Actively include patients in decision-making. In the health field, it is very important to take epistemic humility into account, which means to recognize that medical judgments are always accompanied by uncertainty. This type of humility can foster trust and support decision-making with a deliberative focus, as it requires that the patient and the physician should cooperate to determine the most appropriate management strategies, agreeing with the patient's experience [43].
The interpersonal component of humility includes an orientation centered on others, that is, to see their value and put them before oneself [13]. Humble physicians, focusing on their patients and valuing them as partners in the health care process, can recognize that –although they are medical experts– the patients are experts in themselves [38].
Within every physician's practice it is essential to recognize that patients have useful knowledge to share, even if that knowledge contradicts what the physician believes, because in this way the humble physician can build a more trustworthy and effective relationship. [38].
We all make mistakes. An example of medical arrogance is what is known as diagnosis arrogance; this consists in the negation on the part of the physician to change his provisional diagnosis in spite of growing evidence that suggest he is wrong [44]. Epistemic humility does not ignore the clinical experience of the physicians. It rather recognizes the limits of clinical knowledge and experience to determine the most appropriate care plans [43]. Humble physicians do not become proud or demean themselves and the patients can trust that their physicians will not give wrong recommendations derived from arrogance or incompetence [38].
In order to increase trust in the physician and that the patient appreciate his honesty it is essential that the specialist should be able to recognize the limits of his mastery about a specific subject.
When physicians are humble, they are conscious of their own strengths and weaknesses. Paradoxically, patients have more trust in their physicians when the latter show their possible deficiencies. For example, satisfaction and trust in the physicians increased when the physicians shared their visit notes with them, even when the physicians thought that the notes contained documentation errors and that the patients would not agree with the notes [45]. This contradiction may reflect the conflict between the trust based on affect driven by emotional ties, in comparison with trust based in knowledge, based on rational evaluations of competency. Trust based on affect can be more effective than trust based in knowledge to build a successful interpersonal cooperation [38].
Therefore, a strategy to increase trust in the physician is to be transparent about the medical visit notes. Moreover, it increases the satisfaction and protection of the patient and it is an useful tool to correct errors [45].
Conclusion
Trust in the physician is an indispensable component of the physician-patient relationship and today it is in a deep crisis; therefore it is essential to develop it from medical practice and, as documented, small changes can have a great impact upon it. In this way, it is sought to improve the medical care process from a psychosocial viewpoint and therefore the patients' quality of life.
However, it is highlighted that when assessing how to develop trust in the physician it is unavoidable to find discrepancies among the strategies to develop it [10]. As most of the evidence is foreign, it is difficult to extrapolate the results to the Chilean population. On the other hand, it must not be forgotten that the physician-patient relationship is dyadic and that trust of the physicians on their patients is also a relevant factor [46].
These aspects should open the field for future research of our national reality.
