Why Don’t Patients Trust Their Doctors Anymore?

Why don’t patients trust their doctors anymore?

I came across a really good post on The Daily Beast written by a pediatrician in New England, griping (appropriately) about parents who were unwilling to trust his judgment about vaccinating their children.  The led me to ask:  why have so many patients lost trust in their doctors?  You might challenge the assumption that patients used to trust their doctors more, and that would be a fair question.  I haven’t found any peer-reviewed studies on this, but if television is any guide to changes in culture over time, I refer you to Marcus Welby, MD vs. House.  Rather benign, certainly caring and competent, thoughtful and ethical, Dr. Welby seemed to represent how most folks viewed their personal physician back in the late 60’s.  Dr. House, on the other hand, came across as brusk, uncaring, addicted, untrustworthy, willing to violate his patient’s rights on a whim, a real 21st century smartass.   Accept for the sake of argument that the premise of this blog is generally true.  Did physicians in this country merit this transition in cultural perception from caring to untrustworthy (or at least indifferent) over 40 years, or were we the victims of cultural ambush?

You can certainly point to a lot of possible reasons why many patients no longer trust the physicians who care for them.  It is certainly difficult to maintain this trust when other physicians publically recommend that people should not trust their doctor.   Dr. Rost makes the argument that “most doctors are businessmen first and doctors second”, meaning that medical practice has transitioned from a profession to a crass, me-first money making operation.  I personally spent a lot of time working on keeping my ER group from sinking under the weight of our mission to care for the uninsured; but I never felt that this focus on reimbursement was more important that the mission itself.  Most of the docs I know care about caring, and serving the best interests of their patients; but I have to acknowledge that for more than a few docs, money matters a lot. 

The most obvious things that have changed the perception of medicine over these last forty years include high profile cases of physician fraud, drug abuse, drug pushing, malfeasance, gross malpractice, even murder.   What in the past was often hushed up, or discounted as highly unusual, have now become grist for the media mill.  To say that physicians’ images have been tarnished by these instances would be an understatement.  However, there are undercurrents that have also impacted public opinion, in a more subtle but powerful way.  Physician advertising probably reinforces the view of physicians as business entrepreneurs rather than caregivers.  The whole concept of capitation, not fully understood by the public but felt by patients every time their HMO provider hesitates about ordering a test or treatment and does it in a way that creates a sense of unease rather than confidence; this hits right at the heart of trust between doctor and patient.   Stories about physician researchers compromising their integrity at the behest of pharmaceutical companies; advertising by trail lawyers drumming up business by pointing to horrible outcomes from what initially seemed to be great medical and surgical breakthroughs; pontification by opponents of vaccination, birth control, Obamacare, virtually anything negative having to do with physicians or healthcare:  all of these reach into the fears and concerns of our patients and stoke them.  We are all exposed to a lot of negative press and adverse opinions about the practice of medicine, and some, frankly, is deserved; but there is not a lot of recognition for the positives in what physicians do.  Even TV shows like Mash and ER temper the good in medical practice by acknowledging, or even showcasing, the ‘human’ side to physicians and caregivers, i.e. the tragic failings of these ‘heroes of health care’.  I admit that even firefighters and paramedics get similar treatment nowadays in the media, and yet they continue to retain a favorable image in the public’s eye; which raises the question:  Are physicians doing something wrong here?

It is possible that we are.  If physicians sell their practice and go to work for a hospital or a large corporation; whose interests are they serving, especially if the interests of the corporation and the patient aren’t aligned?  Do you really need to be admitted to the hospital, or is the doctor just following the directive of the for-profit institution?  Is my doctor getting ‘incentivized’ to push this drug, or that test?  Are doctors spending more time doing paperwork, and less time in the exam room, because it is in the doctor’s best interests, or for the patients?  Do templated EMRs accurately reflect the individual patient’s responses and exam findings, or just help the doctor ‘move the meat’.  I think it is not as much that patients are having these concerns, per se; but that these kinds of activities and practice patterns have an impact on the way doctors think about themselves, and their work.  Perhaps we don’t trust ourselves as much anymore.

Ok, “enough of this”, you might be saying.  Didn’t a Gallup poll recently reveal that trust in doctors moved to an all-time high of 70% over the last ten years?  That’s true.  Perhaps all of this hand wringing I just went through is based on an incorrect assumption:  we still have the trust of our patients (especially compared to the public’s trust in lawyers, stockbrokers, and members of Congress).  Great.  I hope this poll is accurate:  but members of Congress are at the bottom of the poll at 7%, and yet they all keep getting re-elected.   Perhaps those polled were thinking ‘I love MY doctor, but I’m not sure about those other guys’.  

Regardless, I think it is incumbent on physicians to recognize they need to earn this trust, and not take it for granted; to watchdog their profession and those who practice it; to monitor themselves and how incentives impact their behavior and their care; to promote respect from the public and the media; and to guard against the insidious intrusion of the business of medicine on the practice of medicine.  As someone who advocates actively for fair payment for physician services; I can assure you this is no easy task.

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6 Responses to Why Don’t Patients Trust Their Doctors Anymore?

  1. Jim Salwitz says:

    While the issues you raise are valid (i.e. factors that diminish the warm glow that has historically surrounded the medical profession), I suspect a key issue is patient empowerment. Due to a cultural change emphasizing that patients can and should be better health consumers, combined with the massive data access of the Internet, patients are better able to understand, interact with and challenge their doctors. If physicians hear this as a “loss of trust,” then perhaps they need to open their minds to the idea that the conversation must go both ways. For that matter, how much do we “trust” our patients?

    • Shielding things from the patient and not listening to their concerns about info they found online will only lead to more distrust. The empowered patient is looking for professional advice but wants to be part of a team and even captain of it. After all, they have more at stake than the physician, their life.

  2. FickleFinger says:

    Jim, I agree. In fact, my wife said almost exactly the same thing when she read my post. If you haven’t already, read the blog on The Daily Beast that is the first link on this post. I am all for shared decision-making in medicine, a-la Choosing Wisely and the like, but it still seems that physicians are losing some of their mojo. All that education, training, and experience ought to count for something in these dialogues with patients, but in this age of the internet and patient empowerment, it is too often discounted out of hand. No parents are better informed or empowered than those in Marin County, CA, one of the wealthiest in the Country, where the incidence of Pertussis is appallingly high. That is the tradeoff when anecdote is valued as much as the scientific method.

  3. Consumer distrust of doctors, CEOs, and politicians may all relate to subtle changes in the corporate charter over decades. Where once corporations were granted relief from legal liability in exchange for serving public interests, now corporate officers are legally bound to serve the investment interests of shareholders, not public interests. (http://www.mhealthtalk.com/2012/07/corporate-behavior-and-rising-health-care-costs/)

    This evolution has led to a focus on quarterly earnings, short-term decision-making, relaxed accountability, and perverse incentives. Tort Reform and changes to oversight within medical boards, for example, have arguably contributed to medical errors and patient distrust. And the medical industrial complex, which profits immensely from illness and injury, has come to view patients as paying customers and works to keep them … paying … by managing disease and treating symptoms, with far less interest in promoting health & wellness and avoiding the need for medical care in the first place. They even spend twice as much on lobbying as the military industrial complex, because they don’t want to lose any of the $2.8 trillion in revenue that they get each year.

    American consumers have come to know that they pay twice as much for medical care than peers in other nations but still live sicker and die younger. That’s largely because this whole Health Reform discussion made this clear. Any defensive posturing by the medical industry, however, only makes that worse, because consumers also know how to “follow the money.” They’ve also noticed that their annual visit with the GP is now less than 10 minutes, that there seems to be more emphasis on treatment than prevention, that they can’t seem to get cost estimates up front, that bouncing from one specialist to another often results in conflicting treatments and compromised accountability, that prices vary considerably from one facility to another, and that it’s often cheaper and safer to go offshore for procedures.

    Today’s health consumer is much more engaged in their health care, thanks largely to the high-deductible insurance policies that puts more of their skin in the game and enabled by the Internet. Get over it.

  4. David Dressler, BA, RMT says:

    I have treated 10,000+ patients in Canada, spanning 30 years. I have seen trust in our health care system and in MDs, in particular, deteriorate. In 1999 the Fraser Institute studied what was then called Complementary and Alternative Medicine (CAM) to determine public opinion. The number one CAM practice was massage therapy (which in Canada is a medical type practice within the funded medical system in several provinces) and the second most popular was chiropractic. The British Columbia Medical Association (BCMA) at the time had a semi-secret plan nearing completion, known as “Project 2000″, which named massage therapy and chiropractic as targets for elimination by the year 2000, by an elaborate lobbying campaign by doctors of government, physicians, public, and media. This plan was launched 16 years earlier, in 1984. The BCMA saw very early the emerging popularity of the CAM professions generally. Suffice to say, their stealth project failed in the year 2000 but did have some effect as coverage for CAM became limited by action of the Minister of Health in 2001. The BCMA continues its project under a new name now. My point in this discussion is, first, that public trust is swinging toward alternatives and away from conventional medicine in Canada and probably in the US.

    My second point is frighteningly pragmatic. In 1999 over 110,000 people died in the US due to CORRECTLY APPLIED drugs and surgery, not counting malpractice. And even more shattering to public confidence is this: “Only 10-15% of all medical procedures are proven to do more good than harm.” Who said that? None other than the “father” of evidence-based medicine, Dr. Kerr White of Virginia Beach, Va., in his interview with me in 1999 in my investigation of Project 2000. I corroborated his statement by researching studies on the subject of medical efficacy and risk in several countries. Think about this: 85-90% of all medical procedures are of unknown risk or benefit.

    Yet, every afternoon on nationwide television, The Doctors airs and doctors strut out with music blasting, lights flashing, an audience composed mostly of young women standing and cheering…. It is like a rock concert! There is something jarringly incongruous between those statistics and these celebrity Doctors.

    Me, I’ll take Dr. Greg House any day. He’s got the worst bedside manner, doesn’t shave, is addicted, but I can trust him to solve my case because he gets his personal satisfaction from figuring out “the puzzle.”

    • FickleFinger says:

      Appreciate the comments. House is a great diagnostician, but you don’t have to be grossly inappropriate or indifferent to suffering (or insufferable) to be a great diagnostician. Myles

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