The Simple Reasons Trust in Physicians is Crumbling

It’s no secret that trust in the medical profession has cratered since the COVID-19 pandemic. Doctors, specifically, seem to have borne the brunt of this trust deficit, with other health professionals, like nurses, maintaining high levels of trust. If we’re looking to avoid going the way of the reputation of lawyers and politicians, it’s clear that something needs to change, fast.

There are many supposed reasons for this change. People know their doctors less than they used to. Appointments have gotten shorter, and opportunities for interactions with a physician in primary care, versus an advanced practice practitioner or nurse, have dwindled as demand has increased. The COVID pandemic itself is a frequent source of blame, and the rise of social media and other influences outside the traditional medical system also are felt to play a role.

While all those factors are certainly important, I’m going to go more basic than all that. The formula for trust I’d propose is quite simple. Building trust comes down to two things:

1. Have adequate time to develop a relationship with someone
2. Exhibiting the ability to listen to a patient and provide actionable, personalized advice based on their problem

Let’s break that down a bit further.

What does it mean to have a relationship with someone? Well, in medicine, we talk about the doctor-patient relationship. There’s obviously the time in the exam room. There are also the million “micro” interactions with the system that add to or diminish trust: the interactions that occur on the patient portal, the phone, the waiting room, and even in the follow-up survey. Every touch with the “system” is an opportunity to build or erode trust.

We fail often at this first crucial juncture in medicine. The system is designed predominantly to restrict access to physicians, not for patients to develop a relationship with them. Office visits are short, and face time with the physician is shorter. Responses to portal messages, if they come at all, are often perfunctory and characterless. The call system for most practices is designed around AVOIDING having to talk to the doctor, not enabling it. While these processes are designed to maximize efficiency, unless there’s alignment at every level of the organization, these barriers to access can erode trust, not build it.

One would hope that listening and providing actionable advice are areas we don’t struggle with as physicians, but that’s not always the case. Many patients leave appointments confused about next steps in their care, or how doing x, y, or z is actually going to help them with their problem. As a primary care doctor, I can’t even begin to tell you just how much of my job is simply explaining to someone the relationship between their habits, medications, and disease processes. This is quite a challenging skill for physicians to master in giving good, evidence-based advice. It is much easier if you’re not so concerned about providing good advice or don’t know what good advice is.

Considering these two basic factors makes it easy to see where problems arise, opportunities for improvement, and why people trust non-physicians more than physicians in health matters. I’ll illustrate with an example:

Joe starts to have shortness of breath. Being a “good” patient, Joe does the “right” thing and calls his doctor’s office. The receptionist tells him he needs to go to the ER because the doctor cannot see him today, and shortness of breath is on her list of “trigger words” to tell someone to seek emergency care. Joe goes to the ER, is diagnosed with bronchitis, and is sent home and told to follow up with his PCP. He calls back his primary care doctor’s office the next day, upset that he didn’t get an antibiotic, which he has had in the past for bronchitis. The receptionist tells him the earliest he can be fit in is next week, since this isn’t an emergency (keep in mind, he was told this was an emergency yesterday). Fed up, Joe goes to urgent care, gets his z-pak, and makes a mental note that it’s not worth it to bother with his PCP in the future.

Is it any wonder that, in Joe’s case, his trust in his doctors has been eroded? Keep in mind he hasn’t even gotten a bill yet for his ER visit – if you think things are bad now, wait until he sees that charge! Let’s re-imagine a high-trust version of the same scenario, based on the principles we’ve already outlined.

Joe starts to have shortness of breath. Being a “good” patient, Joe does the “right” thing and calls his doctor’s office. The receptionist, seeing that “shortness of breath” is on a list of “trigger words” to tell someone to seek emergency care, transfers Joe to the clinic’s triage RN since the doctor is busy seeing patients. She asks Joe a few questions, quickly determines that he is not currently experiencing an emergency, and gives a few suggestions for self-care at home. She sets an appointment for next week with his PCP and offers to place him on a cancellation list if anything comes available for him sooner. Joe asks if he needs an antibiotic, and the nurse explains why this might not be necessary currently, but assures Joe that she will run it by the doctor, since he’s needed one for this to clear up in the past.

Now, there are many reasons our primary care system looks like scenario 1, not scenario 2, but that’s a topic for another day. My aim with this post is to posit that if there is a crisis of trust in medicine, it might be one of our own doing, and it’s possible to break ourselves out of it with relatively simple systems redesign and a focus on fundamental principles of trust-building rather than efficiency.

In the next post in this series, I’ll talk more about the second part of the equation – the art of listening, why online influencers have so much sway over medical topics, and how physicians can reclaim trust by personalizing care and improving patient accessibility.