Public Trust and Initiatives for
New Health Care Partnerships
to plan and manage the course of treatment; and to gain the patient’s
understanding, cooperation, and adherence to treatment. Despite uni-
versal recognition of the importance of communication, the demands of
attention to their communication skills than to what are commonly
viewed as more pressing medical and economic concerns. Rapid changes
in health care organization and medical practice also diminish effective
communication, which is essential to the cultivation of patients’ trust in
their doctors and their health institutions. Many medical institutions
and practitioners now are seeking new ways to engage patients in their
own care and to command their trust and loyalty. In this article I will
examine the social forces that are changing medical relations and will
describe recent institutional initiatives for developing new health part-
nerships of patients and providers.
physician to understand the patient’s expectations and concerns;
to obtain accurate information, thereby facilitating diagnosis;
The Milbank Quarterly, Vol. 76, No. 2, 1998
© 1998 Milbank Memorial Fund. Published by Blackwell Publishers,
350 Main Street, Malden, MA 02148, USA, and 108 Cowley Road,
Oxford OX4 1JF, UK.
Medical Authority and Placebo Effects
In recent years medical authority has been under attack, not only by
health care managers but also by patients, many of whom are better
educated, more sophisticated, and better informed than patients of past
years. Traditionally, doctor–patient relationships have been paternalis-
tic, exemplified in medical sociology by the Parsonian model of the sick
selves in the hands of physicians, believing that their professional train-
problems and prescribing treatment. The accepted cultural authority of
physicians allowed them to define illness, authorize their patients’ re-
lease from daily responsibilities, and serve as gatekeepers to important
secondary benefits. Moreover, the patient’s acceptance of medical au-
thority facilitated the physician’s influence and the placebo effect. This
effect, deriving from the therapist’s credibility and the patient’s belief in
his or her doctor’s ability to effect a cure, has long been recognized as a
and Frank 1991).
Theoretically there are many reasons to believe that placebo effects
are less powerful than they were in the past, although no direct empir-
ical study has been done on this issue. As their education increasingly
centers on biomedical science, and as they more commonly are guided
by randomized, controlled studies, most young physicians are trained to
based medicine, they are probably more detached and less committed to
the effectiveness of their treatment strategies. Trained to be candid with
their patients, and aware that patients are now more informed and
sophisticated than before, they are likely to convey a tentative attitude
toward unproven treatments. Physicians tend toward optimism in their
prognoses (Christakis 1995), but improved scientific training and the
weakening of prohibitions about sharing doubts and uncertainties with
patients probably diminish the influence of suggestion.
The placebo effect is also probably diminished by the ready availabil-
ity of information about treatments and by the uncertainty that is often
conveyed about the effectiveness of various medical interventions. Pa-
tients can now turn to an extraordinary amount of often conflicting
treatment advice from newspapers, magazines, books, television, and
the Internet (Impicciatore et al. 1997; Silberg, Lundberg, and Musac-
chio 1997). These sources promote uncertain and untested remedies and
challenge many established practices. Moreover, there is a continuing
stream of information on practice variations, unnecessary care, poor
quality of care, fraud and abuse, care inappropriately withheld, and lack
of continuity or comprehensiveness of care. While patients have more
information than ever before, much of it is a confusing melange, not
necessarily applicable to their particular circumstances.
The old way—of using the authority of physicians to reinforce ex-
the biological factors that underlie belief and hope—had its built-in
advantages. A therapeutic advantage now is less likely to come from
patients’ belief in the omnipotence of physicians but is, rather, more apt
to be drawn from the ability of clinicians to develop relationships of
mutual trust. These relationships are characterized by empathy and
caring and are driven by technical competence and by actions that help
patients cope constructively with the uncertainties of illness and the
gaps in our medical knowledge. In short, changing conditions require a
different model of clinician–patient relationship.
The Consumerist Model
The paternalistic doctor–patient relationship is gradually yielding to a
more consumerist one that is based on a participatory ethic and a change
in the balance of power. This is hardly surprising because medicine both
reflects and influences the culture in which it is embedded. The cultural
context is changing in many ways, but two features are especially prom-
inent: First, medical activity must respond to the desire for autonomy
and self-determination that is so characteristic of people in Western
democratic nations and that manifests itself in patients’ demands to be
told about treatment options and to participate in decisions regarding
their care. Consumers now have a far greater voice in both the type and
the location of the treatment they receive, largely as a result of pressure
from groups outside of the medical establishment, including women
and disability and gay rights activists. These constituencies campaigned
which are now an integral part of mainstream medicine.
Health Care Initiatives and Public Trust
The second feature is the impact of changing patterns of disease and
disability. To the extent that much of the work of the doctor focused on
acute treatment and infectious disease, the attack on specific etiological
targets gave shape to medical approaches. Now that the daily work of
clinicians is more commonly defined by the management of chronic
disease and the prevention and modification of high-risk behaviors, the
practice of medicine has become intertwined with people’s conceptions
of their lives and the ways that their illnesses intersect their life stories
and aspirations (Mechanic 1995; Wagner, Austin, and Von Korff 1996).
In these matters patients are as much experts as their doctors, and
prescriptions for care have to fit meaningfully into the realities of their
daily lives. Early studies provided little evidence that consumerist be-
haviors were important aspects of doctor–patient interactions (Haug
and Lavin 1981). Although a consumerist model is now more common,
the transactions characteristic of this model still are in a minority (Roter
et al. 1997). This situation may change as health maintenance organi-
zations (HMOs) and preferred provider organizations (PPOs) become
more prevalent, as consumers are permitted to make meaningful choices
among potential health care options, and as patients participate more
fully in decision making. Health care information, particularly when it
pertains to quality, is in a formative stage and often does not provide the
specificity that most patients want. However, more information is avail-
able to more patients now than in the past.
Psychosocial Aspects of Care
The interconnectedness of life circumstances, psychosocial and behav-
ioral responses, and physical morbidity is widely recognized. More re-
search is now being directed to behavioral risk factors, the disabling
effects of depression, anxiety, and other psychological morbidities on
everyday activities, and the influence of distress on the cause and course
of disease and on illness behavior patterns. Moreover, the somatization
of psychosocial distress, and its presentation as physical illness, has
become recognized as an important part of the everyday practice of
primary care physicians throughout the world (Sartorius et al. 1990).
Such behavior is a major source of help-seeking and supports a costly
trajectory of investigation and assessment.
By the 1950s, Michael Balint, a psychoanalyst interested in general
practice, initiated what came to be called “Balint Groups,” in which he
and others of similar persuasion worked with general practitioners to
help them understand how psychosocial dynamics affected their medical
practices. In the United States, a broad interest in the patient, which is
usually traced to Francis Peabody, who wrote on this topic in the 1920s,
found expression in George Engel’s influential paper, published in Sci-
ence, on the biopsychosocial model (Engel 1977). Although basic ideas
about stress, coping, and social support and the effects of psychological
states on physical responses were well known by then, in more recent
years extensive investigation has documented such patterns more rig-
orously (Cohen, Tyrrell, and Smith 1991; Cohen et al. 1997). A large
gap remains between theory and findings and their translation into
medical practice. Despite uncertainties, medical practice still requires a
way of building on psychosocial processes and on the potential for mod-
ifying patient expectations and behavior (Cassell 1979, 1991). Trust in
The Bases of Trust in Physicians
Healing is achieved by the application of specific scientific interven-
tions and by the physician’s empathy, support, guidance, and care. Suc-
cessful healing depends on the physician’s credibility and the patient’s
belief in the provider’s competence and caring (Frank and Frank 1991).
Increasing competitiveness in medicine and the demand for improved
efficiency and productivity create barriers to communication. Sufficient
time and continuity of care are important for effective communication,
but as patients shift among plans and doctors, and as physicians are
pressured to see more patients, the satisfaction of both may suffer. Also,
as physicians increasingly are responsible for allocating care as well as
treating their patients, and as potentially perverse financial incentives
associated with such allocation become widely known, patients have
more occasions to doubt their physicians (Mechanic and Schlesinger
1996). Their skepticism is heightened when they are denied services
they consider essential and when the perceived financial inducements
for withholding services are large.
Careful attention to allocation issues is necessary and inevitable, and
managed care in one form or another is here to stay. The idea of a
Health Care Initiatives and Public Trust
personal physician has itself been called an archaic notion, and it has
been suggested that new, highly specialized group organizations will
deal with patients’ needs, drawing on variously trained personnel to
fulfill different functions, and that “smart systems” of care will reduce
the need for specialized expertise (Hurley 1997). In this sense, medicine
would come more closely to resemble organizations in which the per-
sonnel are differentiated by function but are viewed as interchangeable
within their areas of expertise. The analogy has been made to the small
shopkeeper, who may at one time have provided expertise, caring, and
special consideration, but who is rapidly being replaced by discount
outlets and superstores that lack some of the earlier amenities but offer
similar products at reduced prices. Such superstores may employ staff
with comparable expertise, but their sheer size and impersonality reduce
the likelihood that customers will find an informed person to help them
with any out-of-the-ordinary requests.
This analogy, while having a certain plausibility, is not entirely apt.
Some patients will trade a close personal doctor–patient relationship for
reduced costs and convenience, particularly in dealing with routine
illnesses and concerns (witness “docs in the box”). However, when they
are seriously ill and are facing the uncertainties and difficult decisions
associated with such illnesses, most patients want to be cared for by a
clinician they trust. They may require referrals to other clinicians, but
often the specialist’s credibility is contingent on the patient’s trust in
the physician who makes the referral. Trust is to some extent transfer-
able, which allows the specialist the opportunity to build on confidence
achieved by proxy.
A trusting relationship also facilitates patient disclosure and coop-
eration in treatment, makes it easier to modify unhealthful behavior,
and reduces the likelihood of disputes, complaints, and lawsuits. It
also contributes to the clinician’s sense of being appreciated and pro-
tects against frustration and burnout. Trust, and the openness of
communication that it encourages, increases the human sensibilities
of both patient and doctor and heightens the quality of their inter-
actions. Trust has costs for both parties because it binds each to obli-
gations that may at times be inconvenient or risky. A violation of trust
can result in extreme hurt, anger, humiliation, and even retribution.
However, as in any other important personal relationship, trust becomes
an investment in the continued possibilities for human learning and
Responses of Physicians and
Health Care Institutions
If organizations seek longevity in a community, they appreciate that
trust is a valuable investment. They can build it at a social level
through initiatives designed to convey to the public that they are
high-quality institutions committed to the welfare of the community
and that they recruit, train, and supervise their personnel with this
commitment in mind. Health care plans, hospitals, and medical groups
are now aggressively marketing their services to the general public,
highlighting their capacities and quality and emphasizing their trust-
worthiness. The goal is to evoke the image of an institutional man-
agement whose quality is so high that the public can only infer an
equally superior level of performance by its various personnel. Alter-
natively, institutions and plans often herald the accomplishments of
their doctors and other staff members as indicators of overall institu-
A good reputation is useful to have, but people generally are most
influenced by their personal experiences and by those of their rela-
tives and friends. There are exceptional institutions (e.g., the Mayo
Clinic, the Harvard Medical School, or the Johns Hopkins Hospital)
that have long-established national reputations for excellence. In most
communities, and in most everyday care, however, people make selec-
tions on the basis of informal knowledge and experience (Mechanic
A hospital or health plan relays as its most powerful advertisement
the message that its physicians and nurses are not only competent
and accomplished but also caring and committed to patient interests.
Competence and caring are the essential tools of medical care and
must take center stage in the undergraduate and postgraduate educa-
tional training of young physicians. In recent years we have heard
many laments about the overspecialized technical orientation of phy-
sician training and the neglect of the interpersonal aspects of medical
care. Many medical schools are now working hard to correct these
problems, taking steps to develop patient-oriented interpersonal skills,
to improve physician sensitivity and empathy, to increase apprecia-
tion for diversity, to sensitize physicians to ethical dilemmas, and to
shed more light on the behavioral aspects of care (Marston and Jones
Health Care Initiatives and Public Trust
Developing Interpersonal Skills
The development of interpersonal skills is part of the required curricula
early in medical school as students initially come into contact with
patients. In many schools instruction continues in subsequent years and
is also common during residency training, particularly in general inter-
nal medicine, family practice, pediatrics, and psychiatry, or in programs
that combine these areas by drawing on faculty from more than one
department. Typically their focus is on interviewing skills and on rec-
ognizing and dealing with patients’ psychosocial concerns, but the top-
ics of patient diversity, communication of bad news, death and dying,
and ethics are increasingly often addressed as well.
Despite the recognition accorded to sensitive interviewing and effec-
tive patient communication, and amid much exhortation about their
importance, mastery of the required skills is not yet perceived as critical
to the main business of the medical endeavor. Beyond required courses,
usually during the first two years of medical school, and in some pri-
mary care residency programs, further training is highly self-selected.
However, health care plans that are sensitive to how their physicians
difficulties with interpersonal relations have elicited patient complaints
to enroll in programs that teach communication skills. They are also
developing their own educational materials for clinicians (Frankel and
Stein 1996). Nevertheless, no matter how good the training and mate-
rials, the structures and pressures of medical practice often stand in the
way of achieving the desired quality of communication, despite evi-
dence that strategies for establishing rapport with patients and giving
them a feeling of being understood need not take more time (Roter and
it involves improving the detection and treatment of psychosocial dis-
tress (Schade, Jones, and Wittlin 1998), increasing patient participation
in care (Wagner 1997), or upgrading communication skills. Doctors
who are trained in a primary care track or who are taught interviewing
skills have a more participatory decision-making style (Kaplan et al.
patient involvement, and better medical outcomes (Kaplan et al. 1996).
Intensive instruction in interpersonal skills is probably needed, al-
though even this strategy has produced little evidence of lasting effects.
As in many other areas of behavioral change, reinforcement should be
ongoing. One way to do this is to build reinforcement into organiza-
tional systems, clearly delineating incentives for the desired behaviors
(Scott et al. 1995). Other organizational arrangements remain impor-
tant, like the pace of patient care, as doctors with greater patient loads
are less likely to adopt a participatory decision-making style (Kaplan
et al. 1996).
Medical education has added a significant component to instruction
in the psychosocial and behavioral areas, through an emphasis on expe-
riential learning and on facilities to aid the process of self-learning
(Marston and Jones 1992). Through the use of role playing, simulated
patients, video recording, and other technologies, students receive im-
mediate feedback on their verbal and nonverbal communication and are
thereby helped to recognize and modify troublesome interactional hab-
its. Video feedback of interviews is one of the most effective ways of
improving communication skills (Goldberg and Huxley 1980). Such
feedback can be threatening and can lead to defensive behaviors, but
when students are properly prepared and are given appropriate support,
this kind of training is well received.
Most training in communication and psychosocial issues focuses on
the skills that can make a difference in effective communication. Its
success also depends on students’ attitudes and priorities and on orga-
nizational arrangements, which can either facilitate or impose barriers
to such training. The first factor depends on student selection and the
attitudes of important role models. Bright candidates are adept at con-
veying the outlooks they perceive as valued; a short interview thus does
not suffice as an effectively revealing screen. Most students, however, are
highly motivated to become good doctors, and they look to their pre-
ceptors and faculty for indications of what is important. It is no accident
that medical schools staffed with visible and highly regarded medical
faculty interested in the communication process typically have devel-
oped the most successful programs in this area.
The skills that are learned have to be adaptable to the realities of prac-
tice, to patient flow, and to financial and other incentives. Taking time
with the patient is central, but many factors get in the way of doing so.
Doctors face increasing expectations and obligations, often requiring
trade-offs and compromises between the ideal and the real. Shortcuts are
sistent with risks and benefits (Mechanic and Parson 1975).
Health Care Initiatives and Public Trust
The viewpoints of doctor and patient may differ in several areas: First,
doctor and patient view health differently, with the doctor typically
focusing on a specific morbidity and the patient typically being more
concerned about his or her functioning and general sense of well-being
(Mechanic 1978). Although these concerns may overlap, they differ in
important ways. In moving expeditiously toward a differential diagno-
sis, physicians commonly inhibit patients’ expressions of their concerns
and close off opportunities for significant empathic or affirming re-
sponses (Suchman et al. 1977; Waitzkin 1991). They may also discour-
age the disclosure of concerns that are more important to the patient
than the presenting symptoms. This is particularly true of psychosocial
areas, where patients may feel inhibited about revealing stigmatizing
information unless the physician signals his or her interest and recep-
tivity (Ginsberg and Brown 1982). Physician interviewing skills are
critical to uncovering the sources of distress (Goldberg and Huxley
In an earlier article I identified seven types of initiatives that have been
launched by health institutions with the goal of eliciting trust either in
the institutions or in the providers of care (Mechanic 1996): solicitation
of consumer feedback; informational programs for patients and the pub-
lic; staff and professional education and sensitivity training; sponsorship
of support groups; patient empowerment programs; ethics consultation;
and programs to improve patient–professional relationships. I also iden-
tified a wide range of other initiatives with these aims: the encourage-
ment of community involvement and leadership; the transformation of
large and complex institutions from impersonal providers into user-
friendly, responsive, and helpful centers of care; and the improvement of
In a recent essay, Lawrence Weed (1997) argued that traditional med-
ical training rewards memorization to the exclusion of other skills,
leading to outdated and inefficient use of medical knowledge and poor
medical judgment. He maintained that new information technology
allows knowledge to be more reliably integrated into practice, thereby
improving the ability of clinicians to assess the diagnostic and treat-
ment options pertaining to each patient’s needs. These tools could be
used to help patients consider trade-offs and make choices that are
consistent with their own values and goals. “In this way information
tools would prevent the paternalism of providers that flourishes when
uninformed patients become passive objects in the medical care process”
(Weed 1997, 233).
Although new technologies are emphasized in medical care, their
ment in treatment has been overlooked. We tend to be intrigued by
innovative hardware, but technology refers as well to the application of
hardware, software, and organizational processes to the achievement of
desired goals. Even the process of caring itself can be viewed as a tech-
nology and thereby as subject to enhancement by effective organiza-
tional arrangements (Scott et al. 1995).
Approaches to a New Partnership
In building trust there is no substitute for competence and caring. I
have described some of the important efforts that are being made to
improve communication and to develop the technical skills of doctors.
However, health professionals must function in the larger economic and
institutional framework, and experience indicates that modifying the
interpersonal skills and behaviors of individual clinicians alone, without
appropriate institutional supports, has uncertain results (Scott et al.
1995). Medicine is no longer a simple activity between doctor and
patient. It inevitably involves many people and encompasses larger sys-
tems of care, all of which affect assumptions, expectations, and behavior.
There are thus multiple, intersecting levels of intervention, each hav-
ing an impact on what ultimately transpires between doctor and pa-
tient. In the broadest sense, the institutional structures of medicine,
health care entitlements, definitions of responsibilities, and social and
ethical norms define the context of care. The rapid changes taking place
in health care arrangements, modifications in coverage, and managed
care practices can affect the relations between doctor and patient. At a
lower level of organization, the manner in which medical care groups are
organized and governed, the pace of practice and the patient load, the
bureaucratic features that doctors and patients must deal with, incen-
Health Care Initiatives and Public Trust
factors—can significantly enhance or detract from effective care. Much
of the potential for innovation exists at this intermediate level of orga-
nization (Wagner 1997).
As part of a larger project on trust, I attempted to catalog the range
of activities initiated by physician groups, medical plans, and health
care organizations with the goal of improving communication, creating
a sense of security for patients and their families, and finding new ways
to involve patients in their own care. I have constructed this catalog
through a short survey that sampled members of the Institute of Med-
icine, medical school deans, and members of the American Academy on
Physician and Patient. I asked each respondent to nominate programs
that contributed to a sense of trust. Because of the size and diversity of
the health sector, characterizing innovations is no easy task. There are
many initiatives. A few, like patient satisfaction surveys and various
types of focus and support groups, are now used almost universally. The
majority of innovations, however, are local, are initiated by persons who
believe strongly in them, involve relatively small populations, and re-
main unevaluated. Many represent efforts to build structures and ap-
proaches that are consistent with new ways of relating to patients and
communities in a changing health care environment. Respondents de-
scribe these initiatives as efforts to build patient and public trust, but
very few of them have been seriously evaluated, and almost none has
been explicitly demonstrated to increase trust. Yet they reflect the di-
versity of our health care system and the dedication and inventiveness of
many health professionals and institutions.
In surveying this range of activities, I see no useful analytic scheme
for classifying them. In contrast, it seems more helpful to describe
individual initiatives that I find intriguing and that may have wider
applicability than others that are tied to specific local settings. I do this
with full appreciation of the enormous difficulty of achieving the wide-
spread adoption of any social innovation. Much creative energy has been
channeled into programs devised to make patients active participants in
their care, into self-management programs, into developing practice
guidelines, and into many other aspects of the caring process, but these
have not had a serious impact on organized health systems (Gold et al.
1995; Wagner 1997). In the examples below, I seek to convey the
various ways that patients and their families could become more actively
involved in partnerships with health organizations and health profes-
sionals. Such involvement has been shown to result in better informed
patients and improved disease outcomes (Greenfield, Kaplan, and Ware
1985; Roter and Hall 1993).
The Uses of the Internet
The impact of the Internet on our lives has often been exaggerated, and
there are those who remain skeptical of its potential. The fact, however,
is that the Internet has become a significant informational resource on
health for millions of people. Books, articles, and other aids on how to
access online health sources are now available (Ferguson 1996), and
articles on the use of the Internet for medical professionals now com-
monly appear in medical journals (Millman, Lee, and Kealy 1995; Pe-
ters and Sikorski 1997). It is apparent that the Internet offers enormous
resources, although the sheer quantity of information and its variable
quality and accuracy can be bewildering and counterproductive. The
Internet, however, offers easy access to general information, discussion
groups, support groups, and often opportunities to ask questions and
receive feedback from qualified professionals. Some organizations that
provide medical information report the names and credentials of experts
who have reviewed the data for accuracy. Expert reviews, accreditation,
and other ways of differentiating good from poor information is very
much needed (Silberg, Lundberg, and Musacchio 1997).
One innovative use of the Internet is the Comprehensive Health
Enhancement Support System (CHESS) that was developed by the Cen-
ter for Health Systems Research and Analysis at the University of
Wisconsin–Madison. CHESS is an educational/supportive technology
with modules for AIDS, breast cancer, and other serious health problems
that are accessed through personal computers placed in the homes of
patients or family members (those, for example, who are caretakers of
patients with Alzheimer’s disease or partners of alcoholics) (Gustafson et
al. 1993, 1994). CHESS offers eleven services: answers to frequently
asked questions; a library of articles and other informational resources;
access to relevant discussion groups; the ability to direct questions to an
expert; decision aids; and personal accounts of people with similar prob-
lems, to name a few.
CHESS has undergone randomized studies, which have revealed it to
have high acceptability and use, to be accessible to persons with little
education and minority status, and to improve patients’ participation in
Health Care Initiatives and Public Trust
treatment and their quality of life (McTavish et al. 1994; Boberg,
Gustafson, and Hawkins 1995; Pingree et al. 1996; Gustafson et al.
1997). CHESS and related approaches are still in the early stages, and
much remains to be developed. Experience with CHESS, however,
illustrates the potential contribution to patient awareness and involve-
ment of carefully screened information and decision aids and of access
to support groups.
The Uses of Videotapes
Videotapes have long been an obvious but unexploited technology for
patient education. Patients often wait for hours in clinics and hospitals
or have long periods of time with little to do. There are thus many
opportunities to use video technology to inform patients about their
illness conditions, self-care, and other pertinent aspects of their treat-
ment and health. Because many people now have video players at home,
and the technology is inexpensive, videotapes can be either distributed
to patients at low cost or provided on loan.
John Wennberg (1990) and his colleagues brought the possibilities of
this technology to a wide audience with their patient decision-making
aids. Using videotape presentations to enhance patient decision-making
in the treatment of benign hypertrophy of the prostate and other con-
ditions, they have shown that patients’ treatment preferences are often
more conservative than those of their physicians and have revealed the
importance of taking such preferences into account. Patient education
videotapes are used at individual institutions in some departments but
are not widely disseminated or shared. Among the more common uses
are preparing and instructing patients for certain procedures and treat-
improving the informed consent process, acting as aids to inform pa-
tients about their condition at the time of diagnosis, and instructing
patients in self-care.
Such instructional technologies can either enhance the quality of care
and clinician–patient interaction or depersonalize it. They should be
used in conjunction with personal follow-up to answer patients’ con-
cerns and questions and to provide the necessary link between generic
educational material and patients’ unique situations. When used in this
fashion, good materials can add depth to clinician–patient interaction,
help patients to formulate their questions and concerns more clearly,
and aid clinicians in formulating more appropriate and responsive
Innovative materials are being prepared at individual institutions,
but there is no adequate mechanism for cataloging, sharing materials
and experience across institutions, or easily availing them to patients or
patient organizations. Many video presentations are customized for in-
should reflect their specific treatment pathways. Nevertheless, it should
be possible to create clearinghouses so that programs and organizations
can learn from one another, to exchange and share educational modules,
and to facilitate the adaptation of available materials to various clinical
settings. With the growth of managed care, such educational programs
may receive increased attention.
“Customer” Service Programs
Many health plans, hospitals, and other health institutions, faced with
growing competition for patients and increased public expectations,
have initiated programs to improve customer services. Typically these
are directed to nonprofessional staff, but some are tailored to physicians
and nurses. Some are superficial while others employ sophisticated strat-
egies to make use of patient participation and feedback.
“Patients and Families First” is such a program that was developed
for professional and support staff at the cancer and geriatrics centers at
the University of Michigan Hospitals. It is a one-day course for staff
with streamlined, two-hour modules for nurses and physicians. The
course has been endorsed by physician and nurse leaders in the institu-
tion. Among its themes are basic guest relations, patient evaluations of
quality of service, steps to provide excellent service, effective commu-
nication, nonverbal communication, active listening, telephone com-
munication skills, and complaint resolution. Patients participate in the
program by sharing their experiences at the hospital with staff. The
course also uses small group exercises and other interactive activities.
More than 200 physicians, patients, and support staff have taken part.
Such programs, however well organized, need to be formally evalu-
ated. A single intervention is unlikely to have much effect unless it is
reinforced in various ways. There is still much to learn about how to
gram at the University of Michigan Hospitals, adopted from a program
Health Care Initiatives and Public Trust
at the MD Anderson Cancer Center, is the M Greeter Service. Hospital
employees and other volunteers greet and assist visitors to the medical
center, make them feel welcome, and direct or escort them to their
destinations. The intent of this modest effort is to make a complex,
confusing, and sometimes intimidating medical center more user-
Critical Pathways for Patients
Substantial research suggests that preparing patients for what lies ahead
helps them to cope with their illnesses and improves outcomes (Ben-
yamini and Leventhal 1997). Such research, however, has typically fo-
cused on specific diagnostic or surgical procedures in contrast to more
complex courses of treatment. In recent years, critical pathway guide-
lines have become common, primarily for the treatment of high-volume
diagnoses in hospitals. These guidelines provide systematic directions,
defining goals and outlining the necessary sequences for achieving them
evidence-based decisions, to monitor the progress of care, and to ensure
that treatment proceeds in an appropriate and timely way.
Critical pathways are now commonly used, but there are many un-
certainties about their variety, validity, implementation, and cost-
effectiveness (Pearson, Goulart-Fisher, and Lee 1995). Nevertheless,
patient pathways are being developed that are based on the same ma-
terials used by the staff; these allow patients to monitor the course of
their own care. In one study, patients undergoing cardiac bypass graft
surgery were given a compendium and were then compared with pa-
tients who did not receive these materials (Shulkin and Ferniany 1996).
Although the researcher found no statistically significant differences in
satisfaction between patients who received the guidelines and those who
Both theory and the existing research literature (Benyamini and
Leventhal 1997) offer reasons to anticipate that well-executed patient
pathways should improve important patient outcomes, but practice
settings offer little evidence to support this belief. Patient pathways
are now being developed that are written in clear, nontechnical lan-
guage and sometimes illustrated with pictures. Problems have arisen
when expected staff procedures are not carried out as specified by the
pathways, and some guidelines are now being redefined according to
phases, rather than being charted in days or hours, in order to avoid
upsetting patients when treatment does not progress according to
specified time lines. Many uncertainties about how best to develop
and implement patient versions of guidelines still remain, but their
potential for improving communication and understanding is consid-
erable. Patients who can anticipate the course of their future care,
who have their questions answered, and and who can prepare them-
selves adequately for most eventualities are more likely to be better
partners in their own care.
Many educational aids are now available for training health profession-
als, support staff, patients, and concerned family members. These aids
may use actors to simulate patients so that clinicians can improve com-
munication skills, or they may rely on computers to assist in mapping
out the best course of treatment through treatment simulations. The
technologies may be as simple as clearly labeled pill boxes for patients
who must follow complex medication regimens or as complex as the
elaborate equipment for self-care that has been constructed for persons
with significant disabilities and chronic diseases.
age that includes an audiotaped simulation for health professionals,
students, and family members of schizophrenics to help them under-
stand the experience of hearing hallucinatory voices (Deegan 1996).
Participants tackle a series of interactive and cognitive tasks while lis-
tening to a specially designed audiotape. The simulation helps the par-
ticipants appreciate the impact of such an experience and to examine
their assumptions and practices in dealing with persons who live with
Physicians have repeatedly noted in their memoirs how their own
formed their views of medical care (Heymann 1995; Stetten 1981). It is
probably more than coincidence that many medical leaders in their later
years, particularly when facing inevitable infirmities, demonstrate in-
creased interest in broader issues of functioning and psychosocial con-
cerns. The young more typically feel invulnerable and find it more
difficult to understand fully the pain and frustrations associated with
decrements in function. It is believed that physicians who have suffered
Health Care Initiatives and Public Trust
a serious illness in their youth often are more empathetic and under-
standing (Geiger 1975).
A survey of the medical care environment uncovers impressive and
innovative programs for teaching communication skills to clinicians, for
developing empathy and leadership in patient-oriented care, and for
helping patients become better-informed and more effective partici-
pants in their treatment. A striking number of these innovations are
local, fueled by the energies of a small group of dedicated clinicians and
researchers. More often than not, these innovations are neither known
nor recognized by other divisions of the parent institution or by the
health services field.
A number of organizations seek to focus on communication issues
and to modify how medicine is practiced, but their efforts are modest
relative to the size and complexity of the health care sector. The Amer-
ican Academy of Physician and Patient, comprising some 600 health
care professionals who are involved in patient-centered research and
education, promotes a professional network, work groups, and courses
Bayer Institute for Health Care Communication organizes courses and
workshops around the country that are now commonly used by large
HMOs like Kaiser–Permanente. Other foundation-sponsored organiza-
tions, like the Picker/Commonwealth Program for Patient-Centered
and the C. Everett Koop Institute at Dartmouth University, are iden-
tifying patient concerns and developing strategies and educational ap-
proaches to increase the responsiveness of care. The Program for
educational program in effective communication and humane care and
offers excellent interdisciplinary training experiences for medical stu-
dents and primary care clinicians.
Much greater efforts are still needed to identify innovative ap-
proaches, to facilitate new health care partnerships, to evaluate alterna-
tive strategies and programs, and to disseminate ideas on the best forms
of practice. Most innovators remain invisible, isolated in their efforts,
with few career rewards in this difficult and underfunded area. Those
who pursue it enter an uncertain and precarious trajectory in academic
settings. Whatever the barriers, the reality is that patient trust depends
on the capacity of clinicians and health organizations to communicate
effectively and to involve patients in new partnerships. The failure to
develop effective approaches will contribute to the continuing erosion of
public esteem for medicine and doctors.
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Acknowledgment: This work was supported by a Robert Wood Johnson Investi-
gator Award in Health Policy Research.
Address correspondence to: David Mechanic, PhD, Institute for Health, Health
Care Policy and Aging Research, Rutgers University, 30 College Avenue, New
Brunswick, NJ 08903 (e-mail: firstname.lastname@example.org).