Changing Medical Organization and the Erosion of Trust

Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ 08903, USA.
Milbank Quarterly (Impact Factor: 3.38). 02/1996; 74(2):171-89. DOI: 10.2307/3350245
Source: PubMed


Trust in medicine contributes to effective communication, cooperation in treatment, and the ability to cope with uncertainties. Social trust in medicine reflects public attitudes and is shaped by media and current events. Interpersonal trust depends on the degree to which patients see their doctors as competent, responsible, and caring. The commercialization of medical care, conflicts of interest, media attention to medical uncertainty and error, and the growth of managed care all challenge trust. Trust is encouraged by patient choice, continuity of care, and encounter time that allows, opportunities for feedback, patient instruction, and patient participation in decisions. An informal inquiry of medical leaders indicates that most believe trust is eroding. Institutions are taking measures to help restore trust: eliciting patient feedback; providing more information for patients are the public; improving staff education and sensitivity training; paying attention to clinicians' interpersonal skills; sponsoring support groups; instituting patient empowerment projects; and focusing on ethics issues.

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    • "Some recent studies have also suggested that trust is associated with improved self-reported health status (Wang et al. 2009). Empirical research from highincome settings has tended to focus on patient–provider trust, investigating , among other areas, 'cues' of trustworthiness (Anderson and Dedrick 1990;Mechanic 1996;Thom and Campbell 1997), and the role of institutions and structures such as ethical codes, training standards and regulatory mechanisms for improving patient– provider trust (Campbell 1996;Rothstein 1998;Straten et al. 2002). A more limited body of work has explored the concept of distrust.Mascarenhas et al. (2006)argue that 'distrust is a qualified[or]conditional trust in doctors and/or the health care delivery system on the part of the patient' arising from a range of factors including cost, the difficulty of navigating the health system, pre-existing anxiety and previous negative encounters within the health system. "
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    ABSTRACT: Background: Human decisions, actions and relationships that invoke trust are at the core of functional and productive health systems. Although widely studied in high-income settings, comparatively few studies have explored the influence of trust on health system performance in low- and middle-income countries. This study examines how workplace and inter-personal trust impact service quality and responsiveness in primary health services in Zambia. Methods: This multi-case study included four health centres selected for urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (two weeks/centre) and key informant interviews (14) that were recorded and transcribed verbatim. Case-based thematic analysis incorporated inductive and deductive coding. Results: Findings demonstrated that providers had weak workplace trust influenced by a combination of poor working conditions, perceptions of low pay and experiences of inequitable or inefficient health centre management. Weak trust in health centre managers’ organizational capacity and fairness contributed to resentment amongst many providers and promoted a culture of blame-shifting and one-upmanship that undermined teamwork and enabled disrespectful treatment of patients. Although patients expressed a high degree of trust in health workers’ clinical capacity, repeated experiences of disrespectful or unresponsive care undermined patients’ trust in health workers’ service values and professionalism. Lack of patient–provider trust prompted some patients to circumvent clinic systems in an attempt to secure better or more timely care. Conclusion: Lack of resourcing and poor leadership were key factors leading to providers’ weak workplace trust and contributed to often-poor quality services, driving a perverse cycle of negative patient–provider relations across the four sites. Findings highlight the importance of investing in both structural factors and organizational management to strengthen providers’ trust in their employer(s) and colleagues, as an entry-point for developing both the capacity and a work culture oriented towards respectful and patient-centred care.
    No preview · Article · May 2015 · Health Policy and Planning
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    • "This also applies to modern medicine where public attitudes frequently alternate between reverence and disillusionment (Calnan and Williams 1992). Given that public trust in health care systems has declined in recent decades (Mechanic 1996, Gilson 2003), trust is often related to what experts do – patients seek it and professionals have to earn it. This is certainly the case in genetic counselling where feelings of trust and mistrust can have a bearing on whether women take up prenatal testing or whether communication is effective (Rapp 1999). "

    Full-text · Chapter · Jan 2015
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    • "The evidence presented indicates that bureaucratic targets, monitoring and regulation also coexist uneasily with the devolution of power to the users of services and with a market, which, if anything, requires more rather than less trust in order to function well (Brown 2008). A vicious cycle may also be set in motion whenever providers are prompted to adopt harsh and uncaring attitudes towards categories of patients who do not fit the targets or incentives set by government or insurers, as evidenced in the managed care arrangements in the USA (Feldman et al. 1998, Mechanic 1996, 1998). Clinicians often feel vulnerable in such environments and may adopt defensive and inappropriate practices, with negative consequences for individual patients' trust in their physician (Pilgrim et al. 2011). "
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    ABSTRACT: Trust has long been regarded as a vitally important aspect of the relationship between health service providers and patients. Recently, consumer choice has been increasingly advocated as a means of improving the quality and effectiveness of health service provision. However, it is uncertain how the increase of information necessary to allow users of health services to exercise choice, and the simultaneous introduction of markets in public health systems, will affect various dimensions of trust, and how changing relations of trust will impact upon patients and services. This article employs a theory-driven approach to investigate conceptual and material links between choice, trust and markets in health care in the context of the National Health Service in England. It also examines the implications of patient choice on systemic, organisational and interpersonal trust. The article is divided into two parts. The first argues that the shift to marketisation in public health services might lead to an over-reliance on rational-calculative aspects of trust at the expense of embodied, relational and social attributes. The second develops an alternative psychosocial conception of trust: it focuses on the central role of affect and accounts for the material and symbolic links between choice, trust and markets in health care.
    Full-text · Article · Dec 2014 · Sociology of Health & Illness
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