A crisis of trust: When patient satisfaction is not enough

July 5, 2017 / By Steve Delaronde

Is it more important for patients to be satisfied with their health care or to trust those who provide it? It would seem that these are related—satisfied patients trust their caregivers—but that may not be the case. A 29-country survey ranked Americans as 3^rd in satisfaction with their medical treatment, but 24^th in trust of their doctors. While doctors have ranked high relative to other professions on honesty and ethics, only 34 percent of Americans in 2012 indicated they have great confidence in their medical leaders compared to 73 percent in 1966.

Enhancing the patient experience is one component of the Triple Aim, along with improving outcomes and reducing cost. However, satisfaction is only one piece of the patient experience—trust is another—and the two are not necessarily correlated. Chiropractors have enjoyed high patient satisfaction rates, but have not been highly rated on honesty and ethics. Only 38 percent of respondents in a recent Gallup poll rated chiropractors (which was the same for psychiatrists) as high on honesty and ethical standards compared to 65 percent for medical doctors.  It’s troubling that the healthcare specialists that treat two conditions that comprise nearly half (44 percent) of the years lived with disabilities in the United States—mental health and musculoskeletal disorders—receive such low ratings on honesty and ethics.

The essential elements of trust include reliability, ability, and truth. 

Reliability – Patients can typically count on their doctor to diagnose and treat their complaints consistently. However, physicians who are increasingly less accessible, may also be deemed as less reliable. Patients may be more likely to encounter a physician assistant or APRN during a primary care appointment, and certainly receive more time with nurses when in the hospital. This may contribute to nurses being the highest rated profession on honesty and ethics for 15 consecutive years. While this is good news for those healthcare professionals whose skills have typically been underutilized, it is not good news for the doctor-patient relationship.

Ability – While physicians are better trained and have access to more technology than ever before, this reliance on technology may be undermining patient confidence. Patients have more access to medical information through other sources, such as the Internet, and are more likely to see their primary care physician as a means of obtaining a lab test, diagnostic image, prescription, or specialist referral. The desire for a patient to be understood and heard can be further strained by the electronic medical record, which can lead physicians to be more focused on data collection than actively listening to their patients.

Truth – Trustworthiness is ultimately based on a feeling that someone is being honest and treating you with respect.  While most medical students enter the profession out of the desire to help others, the American healthcare system has not historically aligned financial incentives between patients and providers. An example is reimbursement, which can be based on the relative value unit (RVU), the number and intensity of tests and procedures delivered, the place where a lab test is ordered, or the percent of the price of drugs administered in the office—yet none of these have helped instill trust in doctors or make patients feel they are being totally honest with them. Even if a physician has no direct financial incentive, such as prescribing a brand drug rather than a generic, there is still concern that they could be influenced by the pharmaceutical rep that brings them lunch while touting the benefits of the latest (and more expensive) drug.

Trust is much easier to lose than it is to keep. The conditions for maintaining trust in healthcare rest on a system that aligns the incentives of payers, providers and patients. Since patients are ultimately concerned about their own well-being—physical, mental and financial—this is where alignment needs to begin. Improving patient satisfaction scores is necessary, but not sufficient, for improving the patient experience and meeting the goals of the Triple Aim.

Steve Delaronde is director of analytics for populations and payment solutions at 3M Health Information Systems.