The patient-provider relationship is among the most intimate relationships in an individual’s life. In fact, the details shared with one’s doctor are those which may not be shared with anyone else.
However, regardless of its importance, trust can also be lost easily. Unfortunately, patient trust in physicians is not at its maximum potential, as discussed in the first post of this column.
As we seek to understand this phenomenon, there are many subjective variables that contribute to the trust between patients and providers. Measuring trust in a reliable and consistent fashion is challenging in itself. With these limitations in mind, three salient factors are involved in the decline of patient trust in physicians: one, a commodified health care system; two, lack of quality time spent with the patient; and three, racial influences on the patient-provider relationship.
Universal health care is defined by the World Health Organization (WHO) as meeting three criteria: equity in accessing services, good quality of care and protection from harmful financial burden. The United States spends more on health care per capita than any other wealthy country. In 2019, the U.S. spent approximately $11,100 per person on health care; collectively, Americans borrowed roughly $88 billion to pay for health care costs. Despite these astronomical costs, American health outcomes are far worse than those of developed counterparts as measured by metrics such as infant mortality, life expectancy and unmanaged diabetes. These statistics demonstrate that the U.S. health care system neither guarantees its citizens protection from financial harm nor access to quality care.
The ill-effects of such a system percolate down to individual relationships between patients and providers. Countries with high levels of commodification such as Chile, Germany and the United States were associated with lower scores on indexes for public trust in physicians. In this study, and for the purposes of this article, commodification is defined by three components: financing from individual payment or private insurance, service with the primary intention of profit and distribution of this service based on ability to pay.
While the inverse association between commodification and trust is not necessarily causal, it can be explained as such. Commodification might transform the patient-provider relationship from one of intimate care into a less intimate consumer-provider dynamic modeled like a business transaction. Historically, physicians operated as independent providers much more often than today. It was not until 2016 that the number of practicing doctors who owned their own practice sank to less than 50%. The one-on-one relationship slowly morphed into larger scale, less intimate service, leaving personal trust between patient and provider in its wake.
America’s profit-based health care model has also deteriorated patient trust by altering physician behavior in practice. Large pharmaceutical companies have had a discrete, but powerful, influence on the advice that doctors give to patients. Multiple controlled studies have found that, regardless of the efficacy of a drug, physicians given gifts, vacations and expensive samples by pharmaceutical representatives were much more likely to prescribe those drugs to patients. Such financial conflicts of interest are additional damaging factors to the patient-provider relationship. Patients are much more likely to question whether the behavior of their provider is based on factual health benefit or financial gain.
Even if the commodification of our health care system was hypothetically no longer an issue, the amount of time, or lack thereof, is still problematic. Health care delivery is also often conducted as a business transaction. Specifically, the decreased amount of time physicians are able to spend with patients has transformed provider care almost into assembly lines.
More than half of all U.S. primary care physicians spent less than 17 minutes with their patients — and neither party is happy with that. In fact, a study cited by the American Academy of Family Physicians (AAFP) reported that only 11% of patients and 14% of physicians “felt that their visits offered all the time needed to provide the highest standards of care.” One of the factors draining physicians most of their time is bureaucratic tasks such as paperwork and documentation in electronic health records (EHR). In fact, 49.2% of physicians’ time during the office day was spent on EHR and desk tasks. Even within the exam room, 37% of their allotted time with the patient was spent on recording information in the EHR. It comes as no surprise then that this limit on time is translating to drastically lower rates of patient satisfaction and subsequently less trust.
For a relationship as important and intimate as a provider’s with their patient, these numbers are concerning because they place undue pressure on providers and decrease patient satisfaction. In a survey conducted by AthenaHealth, more than half of practicing physicians feel rushed at least once per week, if not daily. Of those that felt rushed, nearly 70% also reported signs of burnout. Additionally, patient perception of time spent with their provider is a determinant of patient satisfaction; in other words, when patients felt less time was spent with the provider than was expected prior to the visit, encounter satisfaction was significantly lower.
As a second-year medical student, I am privileged to spend an entire week with a team of seven other colleagues, an M.D. preceptor, and a basic science Ph.D. faculty member deconstructing no more than two cases through small-group learning. While this is nowhere near a realistic amount of time to spend on a real patient, the learning experience has at least taught me that having ample time is a benefit for the diagnostician in terms of reducing pressure. It is also beneficial for the patient when explaining their condition, answering questions, addressing family members, and discussing next steps. Naturally, adequately addressing all of these matters becomes increasingly difficult with stricter time constraints.
Outside of health care commodification and reduced time spent with patients, the race of the physicians and patients also affects the patient-provider relationship. It plays a large role in the type of care given and received, the amount of trust placed in the provider and the health outcomes of the patient. While other socioeconomic factors play big roles in these disparities, a lack of diversity in providers certainly does not help. The diversity profile of active American physicians as of 2018 is 56.2% White, 17.1% Asian, 5% Black or African American and 5.8% Hispanic. This is particularly concerning since Black and Hispanic patients have historically had worse health outcomes than their White counterparts.
Dr. Ryan Huerto, a family physician and health disparities researcher from the University of Michigan, stresses the importance of trust in securing better outcomes for minority patients. There is a growing body of evidence demonstrating that patients who share the same race as their physician experience improved tangible outcomes such as medication adherence, understanding risks and treatment decisions. One of the best ways to address the issue of limited provider diversity is to train budding and practicing physicians on self-awareness and implicit biases as well as cultural sensitivity. More importantly, the medical field must increase diversity among providers. This raises further questions regarding medical school admissions, affirmative action, model minority myths and medical education in general. The role of race in patient-provider trust will be explored further in the next installment of this column.
While the trust between a patient and a provider is often difficult to measure, it is still an imperative predictor of patient outcomes. From commodification of our health care system to insufficient time spent with patients to lack of racial diversity among providers, there are unfortunately numerous obstacles in the way of improving this trust. However, with improvements in the aforementioned areas — changing policies in both the practice and education of medicine — it is still very possible for physicians to reinstate their collective reputation in their communities, a reputation of compassion, competency and trust.
Featured image courtesy of the author, Faiz Saulat
Forgotten Roots: Rediscovering Humanity in Medicine
Medicine has advanced in many ways except the ones that count the most. The following column invites you to question whether physicians still hold true to values of altruism, compassion, and humanity. We will explore the patient-provider relationship, the causes of distrust, disparities in medicine, and improvements in medical practice and education.