31 August 2018

Trust is good for the body as well as the soul

Communication General practice Patients

recently saw “new patient” listed in my Best Practice appointment schedule under the name Dorothy McMillan.*

I did not make much of it until my receptionist informed me that I had treated her 35 years ago under the name Dorothy Browne.* All of a sudden I recalled the circumstances. She was a single mum caring for three children under the age of 12. 

I discovered she had Cushing’s syndrome. I was a young GP at the time, most of my training had been in internal medicine, so when she presented with four rib fractures with minimal trauma and hypertension at the age of 35, with a chest X-ray showing generalised osteoporosis, Cushing’s syndrome rang bells for me. 

I investigated her and she was found to have an adrenal adenoma successfully removed surgically. I continued to look after her and the kids for several years until they moved to another seaside suburb 25km from our practice.

Naturally they found another GP and I never saw them again, until Dorothy’s unexpected recent consultation. 

She explained the several reasons for her visit. The first was to thank me for “saving her life 35 years ago”, the second was to inform me that she now had 12 grandchildren and finally she had acquired a list of medical conditions and, given the trust she had in me, she would like my opinion on their management. 

Naturally I was delighted and somewhat flattered to see her, but had to quell my enthusiasm and curb her feelings of trust by pointing out that she really needed a good local doctor who, unlike me, was both available and accessible.

Trust in medical diagnosis is one thing, trust in ongoing management is another. I certainly could not provide the latter. I work part-time and my practice was a very long way from her home.

This encounter made me think about the significance of “trust” in the GP-patient relationship, and more broadly trust in the relationship between the community at large and the medical profession.

This is timely as the current Royal Commission into the Banks and Financial Institutions, as well as the recent Royal Commission into Institutional Child Abuse, have revealed the consequences of abuse of trust and deleterious effects of misplaced trust in people who are meant to care for our children or act responsibly in managing our hard-earned money. 

So how does the medical profession stack up in terms of public trust and does trust in one’s doctor lead to better clinical outcomes?

In 2016, the Medical Board of Australia proudly announced that, based on social research commissioned by the board, doctors and nurses are the most trusted professionals, with 90% of community members surveyed trusting doctors and nurses, 85% trusting pharmacists and only 7% trusting politicians. 

The most effective tool for building trust was effective communication, with doctors providing adequate advice on both diagnosis and management. This is not surprising as most complaints about doctors emerge from poor communication.

In 2014, Blendon et al published results of a multinational study in the New England Journal of Medicine1 on public trust of physician leadership and the profession as a whole. In response to the question: “All things considered, doctors (in your country) can be trusted”. 

Australia ranked 10th, with 73% agreeing with the statement. The top three were Switzerland, Denmark and the Netherlands. The  United States ranked 24th   with 58% agreeing, only ahead of Chile, Bulgaria, Russia and Poland. 

The study involved 29 countries.

In 1966, 73% of Americans said they had confidence in the leaders of the profession. By 2012, that number had dropped to 34% and confidence in the healthcare system in 2014 had dropped to 23%. 

The lack of a universal health insurance system and the marginalisation of the poor in terms of healthcare may contribute to the poor rating of the US.

Nevertheless, the US still ranks highly in terms of patient satisfaction with their own physician and with their physician’s ethics and integrity. 

In Australia, it is common for patients to trust their own GP more than they trust the system. The ambivalent response to the government’s attempt to enlist the nation into My Health Record is a reflection of this. 

The vexed question remains: Does trust in one’s doctor improve clinical outcomes? 

Anecdotally, we as GPs would often think it does. Certainly compliance with treatment programs and medication seem to be enhanced when trust is present and that should result in improved clinical outcomes.

In 2017, Birkhauer et al2 published the result of a meta-analysis examining trust in healthcare professionals and health outcomes and reported “from a clinical perspective patients reported more beneficial health behaviours, less symptoms and higher quality of life and to be more satisfied with treatment when they had higher trust in their health care professional”. 

In general practice we spend much time building a long-term relationship with many of our patients and with families. It is reassuring that, in the main, we are trusted and that this trust has clinical benefits that transcend the relationship itself. 

* Names have been changed

References:

1. Blendon RJ, Benson JM, Hero JO Public Trust In Physicians-U.S.Medicine in International Perspective N Engl J Med 2014; 371: 1570-1572

2. Birkhauer J, Gaab J, Kossowsky J, et al PLOS  One 2017 https//doi.org/10.1371/journal.pone.0170988

Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years

Do you have any similar professional experiences you would like to share? Please email: [email protected]