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Invited Commentaries

Building Patient–Physician Trust: A Medical Student Perspective

Gupta, Nikita; Thiele, Cameron M.; Daum, Joshua I.; Egbert, Lena K.; Chiang, Jennifer S.; Kilgore, Anthony E. Jr; Johnson, C.D. MD

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doi: 10.1097/ACM.0000000000003201
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Abstract

Patient–physician trust is shaped by various factors, including the professional caring relationship, and has been defined in many ways.1,2 However it is defined, trust is dependent on the caregiver’s professional experience, professionalism, competence, credibility, and availability.2,3 Experiencing health care as just, nondiscriminatory, and equally accessible to all prompts patients to feel that respectful care is guaranteed and thus to place trust in physicians.2 In turn, high levels of patient trust in physicians can lead to increased adherence to treatment and improved outcomes, fewer disputes with the physician, and increased perceived effectiveness of care.4–8

In the United States, public trust in physicians has declined over the last 50 years. A review of historical polling data published in the New England Journal of Medicine found that 73% of Americans expressed great trust in leaders of the medical profession in 1996, while in 2014, only 34% expressed this view.9 Though public trust has declined, satisfaction with the care received has not followed this trend.9 That is, among 29 industrialized countries surveyed by the International Social Survey Programme from 2011 to 2013, the United States ranked 24th in the proportion of adults who agreed that “all things considered, physicians can be trusted.”9 In that same survey, the United States ranked third in terms of the proportion of adults who reported satisfaction with the care received during their most recent physician visit.9 As demonstrated by these data, although related, patient trust and satisfaction with care are not identical. While patient satisfaction is generally retrospective, patients’ trust in physicians can also be about expectations of future care. Therefore, trust is more integral to the long-term patient–physician relationship than satisfaction with care.10

The disconnect between patients’ satisfaction with care and level of trust in physicians highlights an important aspect of how patients view the health care system. Gallup opinion polls from 2014 showed that only 23% of survey participants expressed great confidence in the U.S. health care system, suggesting that patient trust in physicians may be associated with the public’s trust in the health care system.9 Future physicians will need to address this lack of trust in the health care system and physicians by actively removing barriers to individual patient care and responding to the problems facing the U.S. health care system.9

As physicians aim to change the future of patient trust in health care, they must look to where future physicians are trained: medical schools. In 2013, the American Medical Association launched its Accelerating Change in Medical Education initiative to incorporate further training in the arts of communication, leadership, and policy. A variety of medical schools at institutions such as the Mayo Clinic; University of California, San Francisco; and Vanderbilt have joined the Accelerating Change in Medical Education consortium.11 In conjunction with the Accelerating Change in Medical Education initiative, our medical school, Mayo Clinic Alix School of Medicine (MCASOM), implemented the Science of Health Care Delivery (SHCD) curriculum, a 4-year curriculum in 2015. The curriculum emphasizes interdisciplinary training across 6 domains: population-centered care; person-centered care; team-based care; high-value care; leadership; and health policy, economics, and technology.12 Previous work has outlined the role of this curriculum in teaching health systems science.12 The purpose of this medical student perspective is to describe aspects of the SHCD curriculum that have the potential to address many of the issues that have eroded patient–physician trust in the past, specifically through training in health equity, cultural humility and competence, shared decision making, patient advocacy, and safety and quality of care.

In the modern-day U.S. health care system, practitioners are becoming responsible for the care of increasingly culturally diverse subpopulations and individuals with varying levels of trust in physicians. African Americans, for example, report higher levels of mistrust in their physicians and the health care system than other races report.13 This mistrust has the potential to lead to racial disparities and inequity in care delivery. The SHCD curriculum aims to narrow gaps in health equity through focused lectures on cultural humility and competence and mistrust in medicine, implicit bias training, and patient simulation experiences. Students engage in lectures on cultural humility and competence in medicine within the first week of medical school. These lectures are followed by an assigned Implicit Association Test to supplement individual reading of Blindspot: Hidden Biases of Good People.14 The purpose of these activities is to make students aware of their own biases and offer strategies to reduce them to improve patient trust. In addition to these activities, faculty deliver targeted lectures on historical and current mistreatments in medicine, which have led to decreased patient–physician trust in various subpopulations. Students then participate in simulation experiences with standardized patients with the purpose of identifying patients’ particular barriers to receiving equitable health care. For example, one simulation included a patient of Muslim faith who was hesitant to receive an intravenous contrast dye for a pulmonary embolism workup because she was fasting for Ramadan. In this case, the student needed to navigate the interface between the patient’s faith and the urgency of her medical condition and to learn how to bring religious leaders into the conversation. Peer and faculty feedback throughout the simulations offers continual opportunities for learning and growth. The hope is that as a result of the SHCD curriculum, future physicians will be able to share accurate and culturally sensitive medical information with diverse patient populations. It is expected that these skills will improve patient trust in physicians among various communities and populations.15

Shared decision making is also related to patient–physician trust.16 For many medical decisions, more than one reasonable treatment path exists; therefore, patient involvement in the decision-making process holds significant value.17 Effective shared decision making involves active participation from both the physician and the patient and requires that the physician elicit the patient’s values and preferences when determining the most appropriate course forward.17 Through case-based examples and group discussion, students in the SHCD curriculum are introduced to these concepts and taught the value of making the patient an important member of the health care team. It is also imperative that physicians recognize barriers to effective shared decision making. For example, low health literacy and cultural backgrounds that lack a tradition of autonomous decision making may present challenges during patient encounters. Therefore, it is crucial that physicians develop effective communication skills and have the ability to develop strong rapport with patients.18 To this end, the SHCD curriculum introduces students to decision-making aids, which have the potential to be effective tools in the shared decision-making process, as they can assist patients in absorbing relevant clinical information and evidence and developing informed preferences regarding their care.17 These tools can come in a variety of formats (e.g., video, print, online) with the goal being to inform the patient of all treatment options and their associated risks and benefits.19 Through case-based examples, group discussions, and decision-making aids, the SHCD curriculum helps students begin to recognize how they can help patients to participate in making informed health care decisions. This training on shared decision making can play a role in improving trust and building partnerships between patients and physicians.20

The SHCD curriculum has integrated shared decision making and patient advocacy by developing a framework delineating the forms of advocacy that can be implemented by physicians and those that can be implemented by patients. The curriculum emphasizes the development of a working knowledge of advocacy theory, which underscores the importance of patients directing decisions and making changes in their own lives to control the course of their medical condition. Training in advocacy theory in the curriculum is accomplished through studying cultural competence, practicing techniques for counseling patients (such as motivational interviewing), and recognizing other aspects of a patient’s background that may affect his or her health.12 Students are given the opportunity to navigate how to integrate advocacy directly into patient care during an experience called the Placement Game. In this experience, students are assigned to groups, in which one student acts out a patient scenario and the other students interview him or her to develop a care plan with physicians and social workers to address issues of cost, insurance, access to care, and other social determinants of health. Additionally, physician speaker panels in the SHCD curriculum have highlighted how physicians have integrated patient advocacy and education into their careers to facilitate patient trust. These facets of the curriculum have been developed with the goal of training future physicians in personalizing care to the individual, thus empowering patients and strengthening the patient–physician relationship.

Another important aspect of patient–physician trust is a high standard of quality and safety in care. Alrubaiee and Alkaa’ida demonstrated associations between certain dimensions of health care quality—including responsiveness (e.g., prompt service, friendliness), assurance (e.g., maintenance of confidentiality, feelings of safety), empathy, and satisfaction—and patient trust.21 A systematic review by Doyle and colleagues found links between patient experience (including their trust in the physician) and clinical safety and effectiveness.22 For example, the use of patient safety indicators, such as infections due to medical care, was found to be associated with positive patient experience.23 Additionally, technical quality of care and adherence to clinical guidelines correlated positively with patient experience.24,25 In a study exploring the quality of patient–physician communications and patient adherence to medical treatment, an important outcome of patient trust, Zolnierek and DiMatteo found that the odds of patient adherence were 1.62 times higher for physicians with communication training.26 These studies demonstrate the importance of including quality and safety didactics in the education of future physicians. Simulated patient experiences in the SHCD curriculum allow students to practice their communication skills in relaying information about the safety of clinical trials and medical tests. One scenario, for example, required students to help an immigrant patient navigate her distrust of medical “experiments” and reassure the patient that a routine colonoscopy screening is safe and effective. Such experiences must be integrated throughout students’ training, as medicine has a pervasive history of injustices toward vulnerable populations, such as the Tuskegee syphilis experiments.

The SHCD curriculum also focuses on quality improvement methods for improving clinical safety, including process engineering, creation and evaluation of metrics, and current safety best practices.12 One way the curriculum emphasizes this is through a team-based simulated learning activity centered around quality improvement. Students are placed in small teams and given a goal (e.g., triage 5 patients) and roles representative of those in an emergency department (e.g., admit team, discharge nurse), but poor instructions and team organization, which should lead to poor quality and efficiency of care. After learning quality improvement concepts (such as root cause analysis), defining team members’ roles, and organizing individuals into appropriate smaller teams, teams repeat the simulation and generally vastly improve their results. By giving students a way to put these concepts into action, it makes it more likely they will take the principles of team-based learning and quality improvement into their future practices.

The SHCD curriculum is an innovative curriculum that covers many facets of patient–physician trust. However, a core limitation of the SHCD curriculum is that the bulk of the content is presented in the fall of the first year of medical school. MCASOM attempts to address this by offering certain week-long and longitudinal “selective” experiences that supplement the SHCD curriculum. For example, the health literacy selective, a week-long selective, allows students to learn about health literacy and the impacts of low health literacy on public health. Students then interview friends and family about their difficulties in understanding health care professionals and reflect on the realities patients deal with when navigating the health care system. Longitudinal selective experiences include the quality improvement selective and working in the primary care clinic on Saturdays for 3 weeks, while other week-long selective experiences include an online public health selective and an advocacy selective at the Arizona Statehouse.

It is becoming increasingly evident that trust is at the crux of a fruitful patient–physician relationship and leads to improved long-term health outcomes.4–7 There is a need for physician leaders and the U.S. health care system to actively improve patient satisfaction and patient trust in physicians and the health care system. The SHCD curriculum at the MCASOM aims to instill these values in its medical students. As the health care system continues to evolve, it is becoming crucial that medical schools across the country develop longitudinal curricula that place an emphasis on improving patient–physician trust. As future leaders of health care delivery, we see our roles as being to learn skills in improving patient trust, apply them during training, demonstrate their effectiveness, and communicate these values to other physicians. We believe the SHCD curriculum is a logical and practical way to address the issue of eroding patient trust. It is our hope that novel medical education programs such as the SHCD curriculum will allow the nation’s future physicians to own their role in rebuilding and fostering patient trust in physicians and the health care system.

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