1 Patient – Doctor Communications Shlomo Mizrahi Rutgers University

2 Patient-Doctor Communications – Main Arguments Patient-doctor communication should be analyzed in the context of trust relations. Trust - the belief of an individual in the good faith of others and their future intentions (Hosmer, 1995). US researchers tend to agree that trust in physicians consists of: loyalty or caring, competency, honesty, and confidentiality. In patient-doctor relations, the level of trust between the parties significantly influence the various dimensions of communication and treatment. Trust and communication are influenced by the structure of the healthcare system. A main factor that may increase trust is participation in decision making. Patients’ participation in decision making about their own treatment can contribute to the satisfaction and trust in the health care system in general. Thus, encouraging patient-doctor communication may also be the interest of health care organizations.

3 Patient-Doctor Trust Relations, Satisfaction and Performance Healthcare systems, and especially patient-doctor relations, are often characterized by uncertainty and risk. Trust can lead people who face uncertainty and risk to cooperate with the treatment procedures thus increasing its effectiveness.  Interpersonal trust between patient-practitioner may have therapeutic effects (Mechanic, 1998).  It has an indirect influence on health outcomes through its impact on patient satisfaction (Calnan & Rowe, 2004).  Trust can be regarded as a quality indicator because patients suggest that high quality doctor-patient interactions are characterized by high levels of trust (Safran et al., 1998).  Trust is also a more sensitive indicator of performance than patient satisfaction (Thom et al., 2004) and might be used as a potential marker of how patients evaluate the quality of healthcare. Trust can also increase organizational performance and satisfaction.

4 Trust in Physicians Surveys in Western countries show that physicians are usually highly trusted by the public as compared to employees in the public sector. A recent survey shows that in the US the average trust in doctors is 3.9 on a scale of 1-5 where the average trust in firefighters and soldiers is 4.36 and 4.16, respectively, and the average trust in members of congress is In the UK, patients have high levels of trust in individual clinicians, but lower levels of trust in healthcare institutions. Yet, in attempts to explain the determinants of the general public’s assessments of confidence in today's national healthcare system in the UK, the best predictors were aspects of patient-centered care while the weakest predictors were aspects of macro-level performance such as waiting lists, waiting times and cost cutting. Thus, the low level of confidence in managers does not necessarily reduce the confidence in the system and the organizations as long as patients trust their own doctor.

5 Organizational factors that Influence Trust in Physicians Allowing and encouraging patients to choose their physician. Giving patients sufficient continuity with the same physician to allow for the establishment of an ongoing relationship. Giving physicians control over decisions affecting their patients’ care. Ensuring that physicians are not under economic or other pressures to act other than in their patients’ best interests. Organizational structures that allow better communication between physicians and patients – for example, reporting test results or answering questions outside of the office visit – may help build trust as well. However, structural changes and retrenchment of the public components of the American healthcare system as well as insurance coverage pose significant threats to patient-physicians trust in most of these aspects.

6 Patient-Doctor Communication: The Active Involvement Dilemma High level of trust in physicians can explain why patients do not find it necessary to be engaged in active patient-physician relationship and to invest efforts in becoming involved in decision making about the treatment they get. The structure of the American health care system encourages such involvement due to the wrong reasons – pushing towards more tests and medications due to the moral hazard problem. Yet, a conscious patient involvement in decision making may increase trust in the physicians as well as in the system and allow reforms.

7 Participation theories usually praise the involvement of citizens in decision-making processes at various levels as a central instrument for increasing performance and satisfaction with administrative agencies. The main argument of these works is that citizen participation and involvement may increase trust in governance and potentially in administrative agencies because they enhance the information citizens have about various processes and their identification with policies and outcomes. Most of the theoretical and empirical research in the area of citizen participation emphasizes that such mechanisms are most effective at the local level and in small groups (Irvin & Stanbury, 2004; King et. al, 1998). Patients’ participation in decision making about their own treatment can contribute to their recovery process as well as to the satisfaction and trust in the health care system in general.

8 Models of treatment decision-making Paternalistic model Information transfer: One-way (doctor to patient) transfer of minimum medical information necessary for informed consent Deliberation: Doctor alone, or with other doctors Decision about implementing treatment: Doctor Shared decision-making model Information transfer: Two way: doctor provides all medical information needed for decision- making. Patient provides information about preferences Deliberation: Doctor and patient (possibly with others) Decision about implementing treatment: Doctor and patient Informed (patient) model Information transfer: One way (doctor to patient) transfer of all medical information needed for decision making Deliberation: Patient (possibly with others) Decision about implementing treatment: Patient

9 A Model of Patient Involvement in Decision Making (Entwistle and Watt, 2006)