Friday, October 24, 2014

Improving trust in the profession

The New England Journal of Medicine
October 23, 2014
Public Trust in Physicians — U.S. Medicine in International Perspective
By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero,

One emerging question is what role the medical profession and its
leaders will play in shaping future national health care policies that
affect decision making about patient care.

Research suggests that for physicians to play a substantial role in such
decision making, there has to be a relatively high level of public trust
in the profession's views and leadership. But an examination of U.S.
public-opinion data over time and of recent comparative data on public
trust in physicians as a group in 29 industrialized countries raises a
note of caution about physicians' potential role and influence with the
U.S. public.

In a project supported by the Robert Wood Johnson Foundation and the
National Institute of Mental Health, we reviewed historical polling data
on public trust in U.S. physicians and medical leaders from 1966 through
2014, as well as a 29-country survey conducted from March 2011 through
April 2013 as part of the International Social Survey Programme (ISSP),
a cross-national collaboration among universities and independent
research institutions.

In 1966, nearly three fourths (73%) of Americans said they had great
confidence in the leaders of the medical profession. In 2012, only 34%
expressed this view. But simultaneously, trust in physicians' integrity
has remained high. More than two thirds of the public (69%) rate the
honesty and ethical standards of physicians as a group as "very high" or
"high" (Gallup 2013).

Today, public confidence in the U.S. health care system is low, with
only 23% expressing a great deal or quite a lot of confidence in the
system. We believe that the medical profession and its leaders are seen
as a contributing factor.

This phenomenon does not affect physicians in many other countries.
Indeed, the level of public trust in physicians as a group in the United
States ranks near the bottom of trust levels in the 29 industrialized
countries surveyed by the ISSP. Yet closer examination of these
comparisons reveals findings similar to those of previous U.S. surveys:
individual patients' satisfaction with the medical care they received
during their most recent physician visit does not reflect the decline in
overall trust. Rather, the United States ranks high on this measure of
satisfaction. Indeed, the United States is unique among the surveyed
countries in that it ranks near the bottom in the public's trust in the
country's physicians but near the top in patients' satisfaction with
their own medical treatment.

Part of the difference may be related to the lack of a universal health
care system in the United States. However, the countries near the top of
the international trust rankings and those near the bottom have varied
coverage systems, so the absence of a universal system seems unlikely to
be the dominant factor.

The United States also differs from most other countries in that U.S.
adults from low-income families (defined as families with incomes in the
lowest third in each country, which meant having an annual income of
less than $30,000 in the United States) are significantly less trusting
of physicians and less satisfied with their own medical care than adults
not from low-income families.

In drawing lessons from these international comparisons, it's important
to recognize that the structures in which physicians can influence
health policy vary among countries. We believe that the U.S. political
process, with its extensive media coverage, tends to make physician
advocacy seem more contentious than it seems in many other countries.
Moreover, the U.S. medical profession, unlike many of its counterparts,
does not share in the management of the health system with government
officials but instead must exert its influence from outside government
through various private medical organizations. Moreover, in terms of
health policy recommendations, the U.S. medical profession is split
among multiple specialty organizations, which may endorse competing

Nevertheless, because the United States is such an outlier, with high
patient satisfaction and low overall trust, we believe that the American
public's trust in physicians as a group can be increased if the medical
profession and its leaders deliberately take visible stands favoring
policies that would improve the nation's health and health care, even if
doing so might be disadvantageous to some physicians. In particular,
polls show that Americans see high costs as the most important problem
with the U.S. health care system, and nearly two thirds of the public
(65%) believes these costs are a very serious problem for the country.
To regain public trust, we believe that physician groups will have to
take firm positions on the best way to solve this problem. In addition,
to improve trust among low-income Americans, physician leaders could
become more visibly associated with efforts to improve the health and
financial and care arrangements for low-income people. If the medical
profession and its leaders cannot raise the level of public trust,
they're likely to find that many policy decisions affecting patient care
will be made by others, without consideration of their perspective.


Comment by Don McCanne

Another unique feature of the U.S. health care system that sets us apart
from other nations: "You just can't trust doctors nowadays, but my
doctor is really good." What can we make of this?

In general, individuals are relatively satisfied with their personal
care. Low-income individuals are less satisfied, but that is likely
related to the deficient financing of their care and the consequences of
that - a characteristic of our fragmented, dysfunctional system of
financing health care. But, overall, our system is capable of ensuring
patient contentment.

It is the confidence in physician leadership that has deteriorated. The
authors of this article suggest some possible explanations, but it is
more likely that the image of the profession at large has changed from
that of the dedicated personal physician steeped in the Hippocratic
tradition, to that of the high-tech, entrepreneurial agent of the
medical-industrial complex. Combine that perspective with the very high
costs of health care today - costly care which physicians orchestrate -
and it is no wonder that the public is no longer as trusting of the
profession. Only "my doctor" is immune to this.

When you look at the role that the AMA had in the enactment of the
Affordable Care Act, it is evident that they were not there to represent
patients; they were there alongside the other elements of the
medical-industrial complex - especially the insurance, pharmaceutical
and hospital industries - to be sure that they got their own share of
the action. The only patient advocates present were the consumer
organizations that chose the default option of "political feasibility,"
becoming "strange bedfellows" of the private insurance industry.

There are many dedicated individual physicians and other health care
professionals who clearly place patients first. They are well
represented in organizations such as Physicians for a National Health
Program. They are also well represented in the AMA and the various
specialty organizations, but, as a collective voice, they are
ineffective in communicating the tradition of caring; rather they
passively communicate the acceptance of the medical-industrial complex -
a very sterile advocacy position.

Let's indulge in a fantasy. Let's imagine that our professional
organizations all joined together in a clarion call for comprehensive,
affordable, high-quality care for absolutely everyone - including those
low-income individuals who distrust the profession today. Single payer
would bring us such quality that is truly affordable.

With a voice unified in support of the patient, what do you think would
then happen to the level of confidence that the public has in the
medical profession? Physicians would once again relish respect as a
noble profession advocating for their patients. As an aside, it would
also mean that they would have a very pleasant work environment and be
adequately compensated for their efforts. If the system works for
patients, it will work for physicians.

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