Less attention has been paid to the other side of this equation: the physician’s trust in the patient. A rather intriguing new study, published recently in the Annals of Family Medicine, takes a look at trust from the other side of the stethoscope and attempts to define the requisite ingredients.
The researchers came up with a list of 18 things that can be scored on a scale to gauge patient trustworthiness. The list includes: providing all of the medical information the doctor needs; telling the doctor about all the medications and treatments the patient is using; understanding what the doctor is saying; following the recommended treatment plan; and being actively involved in his or her care.
There also are a few trust measures that address what, for lack of a better term, I’ll describe as relationship etiquette: respecting boundaries, respecting the doctor’s time, keeping appointments, not making unreasonable demands, and not manipulating the office visit for personal gain, such as obtaining a disability certificate or a prescription for narcotic painkillers.
Hmm. I’m fairly certain that most of us have missed the mark on at least one of these measures from time to time. Do patients always understand what the doctor is telling them? Probably not. Someone who’s ill or in crisis might not be capable in that particular moment of being an active participant in their care. If someone doesn’t follow the recommended treatment plan, perhaps it’s because they don’t agree with it, or don’t fully understand why the treatment was recommended or why they need it.
Some of these measures seem to be in the eye of the beholder. What makes a patient’s request unreasonable, and who gets to decide when this line is crossed?
Yet there also are times when the patient’s trustworthiness comes under suspicion for valid reasons. Doctors tend to learn this early in the training process, as an anonymous medical student summed up in an online forum: “… Don’t fool yourself, patients do lie. They’re embarrassed and scared, they have psychiatric conditions, they malinger for disability benefits and pain meds, they lie just for no reason at all. A good clinician can distinguish this, but when in doubt be objective.”
Does it matter whether the doctor is able to trust the patient? Although this issue hasn’t been extensively studied, the answer seems to be yes. A handful of studies have found that when clinicians don’t entirely trust their patients, the patient is less apt to receive optimal care.
The authors of the Annals article point out an especially important aspect: We’re less likely to trust people who aren’t like us, which can lead to unwarranted distrust simply because someone doesn’t look or talk like we do, have the same cultural background and values, or the same socioeconomic status. The authors write:
It may be that differences in sex, age, race, or culture between clinicians and patients can result, even unconsciously, in lower levels of clinician trust that in turn may contribute to health disparities. Identifying circumstances that lead to inappropriately low trust in patients may help clinicians avoid or mitigate adverse consequences.
The doctor’s trust in the patient also might be influenced by continuity of care and by shared decision-making, the authors wrote, suggesting these areas are ripe for further study.
The trustworthiness scale seems to still be a work in progress. Because it was developed with relatively small focus groups of doctors and patients involved in a pain study, it may not be representative of a larger population. Nor does it rank the items according to their importance. When there’s a betrayal of trust, how severe does it have to be in order to damage the relationship? Patients who don’t understand what the doctor is telling them might be committing a small transgression of trust, whereas lying in order to obtain a prescription for narcotics might be a deal-breaker, especially if the patient has a history of doing this.
The doctor-patient relationship, and the quality of clinical care, do seem to be facilitated more smoothly, though, when both parties are able to trust each other. After all, this is not a one-way street.
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