Trust in healthcare: Aligning HCPs and patients in a long-term partnership

Jul 17, 2018 - reading time 7 mins

By Dr. Ranjana Srivastava

Dr. Ranjana Srivastava is a medical oncologist with a special interest in geriatric oncology, which explores the unique needs and preferences of elderly cancer patients. She has a keen interest in mentoring medical trainees in the public health system. She is also a Fulbright scholar and an award-winning writer on medicine and society encompassing the important issues of doctor-patient communication and patient empowerment. She is a visiting faculty member at the University of Chicago where she delivers a series of talks on the art of medicine. She is graduated from Monash University with first class honors, completed her postgraduate training in Melbourne, Australia and is a fellow of the Royal Australian College of Physicians. In 2004, she was awarded the prestigious Fulbright award to undertake a fellowship in medical ethics and doctor-patient communication at the University of Chicago's MacLean Center for Clinical Medical Ethics. She was awarded the Distinguished Alumni Award by Monash University, where she is an adjunct associate professor. In 2017, her contribution to the field of doctor-patient communication was recognized with an Order of Australia. Dr. Srivastava is a widely-published writer and public speaker and has won several writing awards. She is the author of four books and was shortlisted for the NSW Premier's Literary Prize. Her book, Dying for a Chat: The Communication Breakdown between Doctors and Patients won the prestigious Human Rights Commission Literature Prize. She has written two books on navigating a diagnosis of cancer and surviving its aftermath and is currently working on a fifth book. Dr. Srivastava is a frequent contributor to the New England Journal of Medicine, where she has published more than a dozen essays on the art of medicine. A former writer for Fairfax Media, she is now a regular columnist for The Guardian on medicine and humanity. Her columns appear worldwide and are used to train healthcare professionals.

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The word ‘trust’ comes up frequently in medical practice. In fact, everything hinges on trust. It determines whether a patient adheres to prescribed medication, accurately reports symptoms, seeks a second opinion, complies with management and agrees to be discharged from hospital – or indeed, be admitted to one.

Trust is a pillar of a good doctor-patient relationship, from which beneficial individual and societal outcomes arise. We know this, yet establishing trust is not easy. My work as an oncologist constantly brings me to bear on issues of trust. When patients are faced with life and death circumstances, establishing and keeping faith with them is vital to their care and comfort. On the other hand, a breakdown of trust can lead to lingering consequences for the patient, loved ones and providers.

Some of my elderly patients recall poor experiences when assisting their loved ones, typically a spouse or a friend, through cancer. The resulting mistrust of the healthcare system can color their attitude so deeply that it compromises their own care. In speaking to them, I realize how important it is to not lose trust in the first place.

I am sure there are many ways to build trust between healthcare providers and patients but I like to focus on two things I can remember and teach.

Knowledge of the subject matter

Patients go to see a physician for the knowledge he or she possesses. This knowledge is accumulated over a lifetime of practice. When a patient is confronted with a problem, the first question is, “what is wrong with me?” followed by, “who is the best person to treat me?” Medical training emphasizes the importance of a good bedside manner, but many patients simply get their trust from an accurate diagnosis and treatment, to the exclusion of other elements. “He doesn’t even talk to me, but that’s okay. I don’t need the surgeon to be my friend,” one patient complained brusquely. “He has fixed me, that’s good enough.” This attitude may serve those who are one-time patients only, but in an era of chronic disease that begets multiple presentations, we need stronger doctor-patient relationships. Incidentally, when this patient’s cancer returned some years later, he chose a different surgeon – one he felt comfortable talking to.

If immediate trust is based on the confidence displayed by a physician, meaningful care occurs when the physician has a sound knowledge base that can be articulated to a patient. But there is a problem – in the modern era which sees nearly 400,000 articles published in medical journals each year, it is an impossible task for anyone to keep up with the pace of change and be knowledgeable about every aspect of a patient’s problem.

From the start, medical students and trainees should be taught innovative methods of learning and given the tools for the kind of life-long learning that medicine requires.

This exciting time of change should not be an excuse for doctors feeling disempowered. It is said that a doctor obtains his or her most important education after receiving their medical degree, but the thousands of meetings and medical education events that take place each year don’t always give healthcare providers the clinical information and insights that can help them better deliver patient care. As one oncologist recently complained at a conference, so much time was spent discussing molecular pathways and future directions that he nodded off before he could glean anything on how to help his current patients. I remember my own medical education and training as a mountain of facts – this sort of learning may help one clear exams, but is not a firm basis from which to learn much about patient care.

From the start, medical students and trainees should be taught innovative methods of learning and given the tools for the kind of life-long learning that medicine requires. The traditional medical curriculum most evolve in thoughtful and productive ways – and this shift can be made possible by engaging experts in clinical medicine and learning.

Knowledge of the patient

All the knowledge in the world is wasted, though, if the patient does not trust the doctor. Initial confidence can be established by demonstrating a command of the subject matter and telling the patient how a condition ought to be treated – this may be described as doctor-centered care – but deeper trust arises from its opposite, a patient-centered approach to healthcare.

Patient-centered care has lately become a catchphrase across many parts of the world. Unfortunately, it’s not been easy to implement because it seeks to alter the traditional, paternalistic style of medicine. While we are making slow progress on this front and the autonomy of patients is now an accepted tenet of medicine, we have yet to achieve a model of care where there is active collaboration and partnership between doctors and patients.

The doctor-patient relationship is sacrosanct – and trust is a vital element of this relationship.

In my own practice, I rely on trust to keep patients out of hospital and feeling well at home. New patients, in particular, tend to be anxious, but unnecessary trips to the emergency room can be avoided if sufficient time is invested up-front to explain to them the full range of support services available to them. It is vital that the patient can feel that the provider is competent and that they are a partner in their care. When these two conditions are met, the individual and the healthcare system are better served – patients can benefit through earlier detection of illnesses and prompt attention by the providers, and institutions can benefit from the enhanced HCP morale, patient satisfaction, and more appropriate resource and cost allocation even if the care isn’t necessarily less costly.

The doctor-patient relationship is sacrosanct – and trust is a vital element of this relationship. It is by developing strong trust with patients that we will ultimately be able to honor the mission of medicine as envisioned by Hippocrates – to cure sometimes, relieve often, and comfort always. There is no overnight solution that will help us achieve the perfect healthcare model, but to convert the vision of patient-centered care into reality will require institutional emphasis on ideas such as communication training for providers, using better technology to help patients navigate appointments and results, and transparency regarding the cost of care.

Using empathy and allowing sufficient time to address concerns are key features of patient-centered care. Developing trust between doctors and patients is also important to ensure there is two-way communication. When done correctly, this model of care has the potential to satisfy both the patients and the providers, and pave the way for more cost-effective care.