The patient-provider relationship is at the core of the health care system, and trust is central to this partnership. This is the fourth post in a series highlighting eight studies, managed by AcademyHealth and funded by the Robert Wood Johnson Foundation, which focus on trust and mutual respect. Earlier posts in this series have spotlighted studies focused on issues of trust between African American men and providers, trust and the use of technology, and trust in the hospital system.
Two teams under this grant program are looking at how to build and maintain trust between patient and provider. Working with an economically disadvantaged behavioral health population, Paul Crits-Christoph and Mary Beth Connolly Gibbons make up a team from University of Pennsylvania that has developed and validated an electronic feedback system for providers that measures trust/respect.
“While measurement-based care in behavioral health clinical practice in particular is a tried and true method to improve patient outcomes, none of the existing systems focused on trust/respect,” said Crits-Christoph.
He and Gibbons have developed a scale to measure patient trust and respect. Prior to an appointment, patients complete a survey. The provider receives real-time scores and can address the patient’s trust and respect concerns proactively.
“We know that patient outcomes are likely to be relatively worse if the patient does not trust or respect their provider,” said Crits-Christoph.
The team started their research well before COVID-19 came into the picture and have had to consider how the pandemic affects trust and respect in psychotherapy. In past viral outbreaks, there have been increases in mental health problems, and COVID-19 is following the same trend. With the likelihood of more patients engaging in psychotherapy, COVID-19 raises new questions on how trust affects the relationship.
“Trust might be eroded if a provider fails to validate, or explore in depth, the level of a patient’s concerns about COVID-19,” said Crits-Christoph. “Could such erosion of trust due to COVID-19 fears influence engagement in therapy or eventual treatment outcomes?”
His team is investigating ways to incorporate these questions as their research continues.
Any relationship is bi-directional and the bond between patient and provider is no different. A team at Public Agenda, led by David Schleifer and Rebecca Silliman, is investigating that factors that primary care physicians and patients with Medicaid say affect their trust in each other. Research and interventions focused on trust almost always focus on patients’ trust in physicians or other providers. Very little work has been done on physicians’ trust in patients. Yet providers need to trust their patients in many ways, including to provide reliable information, follow treatment plans and participate in making decisions.
In the representative survey of adults covered by Medicaid that the team conducted for this research, they found that 38 percent of people with Medicaid say that they have at some point received care from a primary care doctor who they did not trust. Most people in that 38 percent say that as a result of those negative experiences they have behaved in ways that could negatively affect their health such as stopping medications or delaying care.
The survey also found some important differences between patient and provider opinions on which factors most influence trust. And, while the survey was conducted prior to the COVID-19 pandemic, it yielded results relevant to the current climate. For example, the survey revealed that Medicaid beneficiaries prioritize doctors following basic safety measures such as checking which medications they are taking before prescribing something new and avoiding unnecessary tests. However, few primary care doctors rated basic safety measures as a trust building priority.
“Health care providers can make clear to their patients that they are doing everything they can to avoid errors and keep people safe – especially now in the context of the pandemic,” said Silliman. “While providers may well be adhering to safety protocols already, demonstrating that adherence to patients is crucial to building trust.”
Another place where discrepancies were found between patient and provider was around honesty. Those with Medicaid coverage listed doctors being honest and admitting to their mistakes as priorities for building trust, while doctors prioritized other behaviors as higher priorities for building trust, such as including patients in decision-making and considering patients’ finance and lifestyles.
The work of both these research teams point to the complex, reciprocal nature of trust and the full grant portfolio holds promise to help us better understand the level of trust patients have across the many facets of the health care system, with a particular focus on vulnerable populations. This blog post series has demonstrated the wide range of factors that need to be considered when it comes to trust – from examining the role of race and gender, technology and system vs. individual-level aspects. Upon their completion, these studies will surely result in better insights for how to build trust and mutual respect to address and overcome the health disparities and improve health outcomes for all.