David H. Thom, MD, PhD

The physician-patient relationship is recognized as having an essential role in the process of medical care, providing the context in which caring and healing can occur.^1-3 Patient trust in the physician has been proposed as a key feature of this relationship.^1,4-6 There are several potential benefits to patient trust, including increased satisfaction, adherence to treatment, and continuity of care.^6,7 Trust may also be associated with lower transaction costs,⁸ such as those incurred by a need to reassure patients (eg, ordering additional tests and referrals) or by inefficiencies due to incomplete disclosure of information by the patient.

Despite the apparent importance of patient trust, relatively little is known about what physician behaviors are most strongly associated with it. A previous study,¹ using patient focus groups, identified 7 categories of physician behaviors that increased patients’ trust: thoroughly evaluating problems, indicating an understanding of the patient’s experience, expressing care for the patient, providing appropriate and effective treatment, communicating clearly and completely, building partnership, and demonstrating honesty and respect. The qualitative nature of the focus group data does not allow for the assessment of the relative importance of specific types of physician behaviors in predicting subsequent patient trust. Ascertaining the association between physician behaviors and patient trust is important both on a theoretical level, for what it may reveal about the nature of patient trust, and on a practical level, for guiding interventions to improve trust through physician education and training.

The goal for our study was to assess the relative importance of physician behaviors on patient trust immediately following the visit, after 1 month, and after 6 months. The behaviors chosen for measurement had been previously identified as promoting trust in patients in focus groups.¹ The measurement of trust 3 times made it possible to ascertain if the physician behaviors most associated with trust immediately following a visit are those most associated with future trust. Also, the relative importance of physician behaviors for trust was explored in 3 patient subgroups: men and women patients, younger and older patients, and newer and more established patients.

Methods

Study Design and Subject Recruitment

This was a 6-month prospective study. Consecutive eligible patients were enrolled from the practices of 20 family physicians recruited by mail from a single geographic area based on their interest in practice-based research and physician-patient communication.^6,9 The patients were recruited by a research assistant who approached them in the waiting room after they had checked in and before they were brought to an examination room. Patients younger than 18 years, those unable to complete the questionnaire, and those in acute distress were excluded. In addition, patients with no previous visits to the study physician or who did not identify the study physician as their primary care physician were excluded. All patients signed an informed consent form at the time of enrollment.

Measures

Each physician provided demographic and practice characteristic data. Measures obtained from patients in the waiting room or examination room at the time of their enrollment (the previsit questionnaire) included: demographics, length of relationship with physician, number and type of chronic medical conditions, and health status (measured by the Medical Outcomes Study Short Form-³⁶).¹⁰ Following the office visit, patients completed a postvisit questionnaire concerning the physician’s interpersonal behavior during the visit, their trust in the physician, and their satisfaction with the visit (measured by a subset of 13 questions from the Consumer Satisfaction Survey).^6,11 Approximately 80% of the patients completed this form in the waiting room after the visit; the remaining 20% completed it within 24 hours and returned it by mail. The 18 items pertaining to physician interpersonal behavior Table W1* were chosen to assess the physician behaviors identified in the previous patient focus groups as affecting patient trust.¹ Fourteen items were taken from the 23-item version of the Humanistic Behaviors Questionnaire developed by the American Board of Internal Medicine.¹² This questionnaire was chosen because it had items pertaining to most of the behaviors identified in the focus groups as affecting patient trust, including receptive and expressive communication (listening and explaining), treating patients with warmth and respect, gentleness, honesty, partnership, and willingness to refer to a specialist. Four items were added to assess additional behaviors identified from the focus groups: finding out all the reasons for the visit, respecting opinions and feelings, caring and concern, and demonstrating competency to diagnose and treat. Patients rated physician performance of each behavior item on a 5-point Likert-type scale, from poor to excellent. The questionnaire was piloted for clarity and acceptability.

Patient trust was measured using a slightly modified version of the 11-item Trust in the Physician Scale developed from Anderson and Dedrick¹³ as previously described.⁶ At the time of the study, the Trust in Physician Scale was the only published measure of patient trust. One item, “My doctor is a real expert in taking care of medical problems like mine” was modified to read “My doctor is well qualified to manage (diagnose and treat or make an appropriate referral) medical problems like mine,” to be appropriate for the primary care setting. On the basis of a pilot study of the scale, response labels were changed from (1=strongly disagree; 2=disagree; 3=uncertain; 4=agree; 5=strongly agree) to (1=totally disagree; 2=disagree; 3=neutral; 4=agree; 5=totally agree).⁶ The scale was scored by transforming the mean response score (calculated after reverse coding the negative items) to a 0 to 100 scale. Patient trust was assessed again at 1 and 6 months after the enrollment visit by mail survey.

Statistical Analysis

The association between specific physician behaviors and level of trust was assessed using Pearson correlation coefficients. Behaviors were ranked on the basis of the relative strength of the correlations.

Results

Of 803 consecutive patients, 561 were eligible for enrollment. Of those, 414 (74%) enrolled and completed the previsit and postvisit questionnaires at the time of the index visit, 52 (9%) refused, 15 (3%) saw the physician and left before being approached by the research assistant, and 74 (13%) enrolled but failed to complete both questionnaires.

Among the 414 enrolled patients, 334 (81%) completed the 1-month and 343 (83%) completed the 6-month follow-up questionnaires. Patients who did not complete the 1-month and 6-month questionnaires were compared with those who did with respect to age, length of the relationship with the physician, sex, race, education, and self-reported health status. Those who did complete the questionnaires at 6 months were virtually the same as those who did not at 1 month with respect to these characteristics. Those who did not complete the questionnaires at 6 months were slightly younger (45 vs 48 years), had been seeing their physician for a slightly shorter time at study enrollment (mean = 37 months vs 43 months), were more likely to be men (45% vs 36%), and were more likely to be nonwhite (41% vs 31%) than those who did complete the questionnaire, but they were virtually identical with respect to education and health status. None of these differences reached statistical significance.

The average age of the physicians was 47 years (range=34-73 years), with an average of 16 years in practice (range=8-44 years). Physicians were predominately men (85%) and white (70%), and most were in group practice (70%). Patients also had a mean age of 47 years and were predominately women (62%). Approximately two thirds (68%) of the patients were white, and 81% had graduated from high school. More than half (55%) reported at least one chronic medical condition, and almost half (45%) reported their health as being less than very good.

The correlation between physician behaviors during the visit, as rated by the patient, and trust immediately following the visit ranged from 0.46 to 0.64 Table 1. The 5 behaviors that were most strongly associated with trust immediately after the visit were: (1) being comforting and caring, (2) demonstrating competency, (3) encouraging and answering questions, (4) explaining what they were doing, and (5) referring to a specialist if needed. Behaviors least important for trust were: (1) gentleness during examination, (2) discussing options/asking opinions, (3) making eye contact, and (4) treating as an equal. Correlations between specific behaviors and trust decreased over time, with a range of 0.38 to 0.58 at 1 month and 0.27 to 0.46 at 6 months after the initial visit. The same pattern of the strength of associations between trust and specific behaviors remain essentially stable, with the exceptions of “being available when needed” and “working to adjust treatment.” Being available when needed was one of the behaviors least associated with trust at the index visit (ranked 16th out of 19) but moved up to be ranked 12th at 1 month and sixth at 6 months. Working to adjust treatment was also less important at the initial visit (ranked 14th out of 18), compared with 1 month (ranked 7th) and 6 months (ranked 8th).

The associations between specific behaviors and trust at the time of the enrollment visit were examined for the following subgroups of patients: men versus women, aged younger than 45 years versus 45 years and older, and length of relationship 2 years or less versus more than 2 years Table W2*. These subgroups were selected a priori for exploration and generation of hypotheses but without any particular hypothesis regarding the pattern of associations between behaviors and trust within each subgroup. As shown in Table 2, being comforting and caring, demonstrating competency in diagnosis and treatment, and expressive communication (encouraging and answering questions, explaining, and checking understanding) were among the behaviors most strongly associated with trust for all groups. Letting the whole story be told or finding out all the reasons for the visits (2 receptive communication behaviors) were strongly associated with trust in most of the groups. Referring to a specialist if needed was one of the behaviors most strongly associated with trust among women, younger patients, and established patients. Respecting feelings and opinions was among the most strongly associated behaviors only for younger patients, and checking progress was among the most strongly associated behaviors only for women.

Identical analyses were performed examining the association between specific physician behaviors and patient satisfaction following the enrollment visit. All physician behaviors were more highly correlated with patient satisfaction than with patient trust, ranging from 0.59 to 0.75 for satisfaction. In general, the pattern of correlation between behaviors and satisfaction was very similar to the pattern for trust. For the total sample, the 4 behaviors most strongly associated with trust were among the 5 behaviors most strongly associated with satisfaction. As with trust, there was relatively little variation in the associations with behaviors by patient subgroups.

Discussion

The strength of the association between key physician behaviors during the office visit on subsequent patient trust in the physician was assessed. The behaviors assessed were previously identified as affecting patient trust in a study using patient focus groups.¹ This study found that the behaviors assessed were predictive of patient trust up to 6 months after the initial visit, though the strength of the association decreased over time. There were relatively modest differences in the strength of the associations between behaviors and trust among the patient subgroups examined. Being comforting and caring, demonstrating competency, and explaining and listening were most strongly associated with trust in all, or virtually all, the subgroups. For women, referral to a specialist if needed and checking progress were also strongly associated with trust. The relative importance of referrals among women may reflect a concern for seeing a specialist for reproductive-related conditions. Referral was also more strongly associated with trust among more established patients, perhaps because these patients were more likely to have experienced a need for referral from their current physician at some time. For younger patients, willingness to refer and respect for feelings, opinions, and self-knowledge were among the most important behaviors, possibly reflecting differences in expectations for physician behaviors among younger versus older patients.

Interestingly, treating the patient as being on the same level and asking the patient’s opinion, while significantly associated with trust, were among the physician behaviors least associated with trust. This finding does not mean that equality and partnership are unimportant. The degree to which patients want to be involved in making decisions about their care varies,¹⁴ and patients may choose to stay with physicians whose practice style fits their preferences for involvement in their care. Bedside manners, such as gentleness during the examination, greeting warmly, and making eye contact, while significantly associated with trust, were also among the least strongly associated. These behaviors, while desirable, may be less important to establishing trust.

It was also found that to a large extent the same physician behaviors most associated with trust are also most associated with satisfaction, though the associations are stronger with satisfaction. A previous paper has reported data indicating that patient trust is somewhat separate from satisfaction, predicting continuity and self-reported adherence to treatment independently of satisfaction.6 One possible interpretation of this finding is that physician behaviors that lead to satisfaction in a single visit also help build trust, but trust is more dependent on factors in addition to physician behaviors during the office visit. No previous studies could be located that reported on the association of physician behaviors with patient trust. However studies of physician behaviors and patient satisfaction, have found that interpersonal competence (similar to comforting and caring in this study), communication, and technical competency were all significantly associated with satisfaction, a result confirmed in our study.^15-17

Limitations

Patients’ ratings of physician behaviors may reflect their overall positive feelings toward the physician. Thus it is not possible to conclude that differences in the specific physician behaviors cause differences in trust. However, identifying the behaviors most strongly associated with trust may help to focus future intervention studies on these behaviors.

Conclusions

The results suggest that caring and comfort are as important as technical competency in predicting patient trust. Also, expressive and receptive communication skills, which have been shown as strongly related to patient satisfaction, are also important predictors of trust. Although the relative importance of a few other behaviors differed between subgroups, these differences were relatively modest, suggesting that the listed behaviors are of general importance to patient trust. Further work is needed to test the hypothesis that changes in identified physician behaviors can modify levels of patient trust.

Acknowledgements

This study was supported in part by grants from the Picker/Commonwealth Fund (#94-130) and the Bayer Institute for Health Care Communication (#94-181). The author thanks Barbara Elspas, MPH, for her fine work as study coordinator. The participating Stanford Trust Study Physicians were: William G. Broad, MD, (Palo Alto, Calif); Lawrence J. Bruguera, MD, (Half Moon Bay, Calif); David R. Ehrenberger, MD, (Mountain View, Calif); Larry A. Freeman, MD, (Palo Alto, Calif); Robert J. Fuss, MD, (Milpitas, Calif); H. Wallace Greig, MD, (San Jose, Calif); Mary P. Hufty, MD, (Palo Alto, Calif); Carlos F. Inocencio, MD, (Los Altos, Calif); Steven R. Lane, MD, MPH, (Palo Alto, Calif), Jas P. Lockhart, MD, (Menlo Park, Calif); Jeffrey S. McClanahan, MD, (Cupertino, Calif); Catherine A. Owen, MD, (Half Moon Bay, Calif); William E. Page, MD, (Palo Alto, Calif); Kuljeet S. Rai, MD, (San Jose, Calif); Daljeet S. Rai, MD, (San Jose, Calif); Paulita R. Ramos, MD, (San Jose, Calif); William E. Straw, MD, (Los Altos, Calif); William S. Warshal, MD, (Campbell, Calif); Roger W. Washington, MD, (Mountain View, Calif); and Andrew W. White, MD, (Menlo Park, Calif).

Related resources

• Picker Institute—non-profit organization that offers products and services aimed at improving health care “through the eyes of the patient.”http://www.picker.org
• American Academy on Physician and Patient—professional society dedicated to research, education, and professional standards in doctor-patient communication.www.physicianpatient.org
• The Program in Communication and Medicine at Northwestern Universitywww.pcm.northwestern.edu

The physician-patient relationship is recognized as having an essential role in the process of medical care, providing the context in which caring and healing can occur.^1-3 Patient trust in the physician has been proposed as a key feature of this relationship.^1,4-6 There are several potential benefits to patient trust, including increased satisfaction, adherence to treatment, and continuity of care.^6,7 Trust may also be associated with lower transaction costs,⁸ such as those incurred by a need to reassure patients (eg, ordering additional tests and referrals) or by inefficiencies due to incomplete disclosure of information by the patient.

Despite the apparent importance of patient trust, relatively little is known about what physician behaviors are most strongly associated with it. A previous study,¹ using patient focus groups, identified 7 categories of physician behaviors that increased patients’ trust: thoroughly evaluating problems, indicating an understanding of the patient’s experience, expressing care for the patient, providing appropriate and effective treatment, communicating clearly and completely, building partnership, and demonstrating honesty and respect. The qualitative nature of the focus group data does not allow for the assessment of the relative importance of specific types of physician behaviors in predicting subsequent patient trust. Ascertaining the association between physician behaviors and patient trust is important both on a theoretical level, for what it may reveal about the nature of patient trust, and on a practical level, for guiding interventions to improve trust through physician education and training.

The goal for our study was to assess the relative importance of physician behaviors on patient trust immediately following the visit, after 1 month, and after 6 months. The behaviors chosen for measurement had been previously identified as promoting trust in patients in focus groups.¹ The measurement of trust 3 times made it possible to ascertain if the physician behaviors most associated with trust immediately following a visit are those most associated with future trust. Also, the relative importance of physician behaviors for trust was explored in 3 patient subgroups: men and women patients, younger and older patients, and newer and more established patients.

Methods

Study Design and Subject Recruitment

This was a 6-month prospective study. Consecutive eligible patients were enrolled from the practices of 20 family physicians recruited by mail from a single geographic area based on their interest in practice-based research and physician-patient communication.^6,9 The patients were recruited by a research assistant who approached them in the waiting room after they had checked in and before they were brought to an examination room. Patients younger than 18 years, those unable to complete the questionnaire, and those in acute distress were excluded. In addition, patients with no previous visits to the study physician or who did not identify the study physician as their primary care physician were excluded. All patients signed an informed consent form at the time of enrollment.

Measures

Each physician provided demographic and practice characteristic data. Measures obtained from patients in the waiting room or examination room at the time of their enrollment (the previsit questionnaire) included: demographics, length of relationship with physician, number and type of chronic medical conditions, and health status (measured by the Medical Outcomes Study Short Form-³⁶).¹⁰ Following the office visit, patients completed a postvisit questionnaire concerning the physician’s interpersonal behavior during the visit, their trust in the physician, and their satisfaction with the visit (measured by a subset of 13 questions from the Consumer Satisfaction Survey).^6,11 Approximately 80% of the patients completed this form in the waiting room after the visit; the remaining 20% completed it within 24 hours and returned it by mail. The 18 items pertaining to physician interpersonal behavior Table W1* were chosen to assess the physician behaviors identified in the previous patient focus groups as affecting patient trust.¹ Fourteen items were taken from the 23-item version of the Humanistic Behaviors Questionnaire developed by the American Board of Internal Medicine.¹² This questionnaire was chosen because it had items pertaining to most of the behaviors identified in the focus groups as affecting patient trust, including receptive and expressive communication (listening and explaining), treating patients with warmth and respect, gentleness, honesty, partnership, and willingness to refer to a specialist. Four items were added to assess additional behaviors identified from the focus groups: finding out all the reasons for the visit, respecting opinions and feelings, caring and concern, and demonstrating competency to diagnose and treat. Patients rated physician performance of each behavior item on a 5-point Likert-type scale, from poor to excellent. The questionnaire was piloted for clarity and acceptability.

Patient trust was measured using a slightly modified version of the 11-item Trust in the Physician Scale developed from Anderson and Dedrick¹³ as previously described.⁶ At the time of the study, the Trust in Physician Scale was the only published measure of patient trust. One item, “My doctor is a real expert in taking care of medical problems like mine” was modified to read “My doctor is well qualified to manage (diagnose and treat or make an appropriate referral) medical problems like mine,” to be appropriate for the primary care setting. On the basis of a pilot study of the scale, response labels were changed from (1=strongly disagree; 2=disagree; 3=uncertain; 4=agree; 5=strongly agree) to (1=totally disagree; 2=disagree; 3=neutral; 4=agree; 5=totally agree).⁶ The scale was scored by transforming the mean response score (calculated after reverse coding the negative items) to a 0 to 100 scale. Patient trust was assessed again at 1 and 6 months after the enrollment visit by mail survey.

Statistical Analysis

The association between specific physician behaviors and level of trust was assessed using Pearson correlation coefficients. Behaviors were ranked on the basis of the relative strength of the correlations.

Results

Of 803 consecutive patients, 561 were eligible for enrollment. Of those, 414 (74%) enrolled and completed the previsit and postvisit questionnaires at the time of the index visit, 52 (9%) refused, 15 (3%) saw the physician and left before being approached by the research assistant, and 74 (13%) enrolled but failed to complete both questionnaires.

Among the 414 enrolled patients, 334 (81%) completed the 1-month and 343 (83%) completed the 6-month follow-up questionnaires. Patients who did not complete the 1-month and 6-month questionnaires were compared with those who did with respect to age, length of the relationship with the physician, sex, race, education, and self-reported health status. Those who did complete the questionnaires at 6 months were virtually the same as those who did not at 1 month with respect to these characteristics. Those who did not complete the questionnaires at 6 months were slightly younger (45 vs 48 years), had been seeing their physician for a slightly shorter time at study enrollment (mean = 37 months vs 43 months), were more likely to be men (45% vs 36%), and were more likely to be nonwhite (41% vs 31%) than those who did complete the questionnaire, but they were virtually identical with respect to education and health status. None of these differences reached statistical significance.

The average age of the physicians was 47 years (range=34-73 years), with an average of 16 years in practice (range=8-44 years). Physicians were predominately men (85%) and white (70%), and most were in group practice (70%). Patients also had a mean age of 47 years and were predominately women (62%). Approximately two thirds (68%) of the patients were white, and 81% had graduated from high school. More than half (55%) reported at least one chronic medical condition, and almost half (45%) reported their health as being less than very good.

The correlation between physician behaviors during the visit, as rated by the patient, and trust immediately following the visit ranged from 0.46 to 0.64 Table 1. The 5 behaviors that were most strongly associated with trust immediately after the visit were: (1) being comforting and caring, (2) demonstrating competency, (3) encouraging and answering questions, (4) explaining what they were doing, and (5) referring to a specialist if needed. Behaviors least important for trust were: (1) gentleness during examination, (2) discussing options/asking opinions, (3) making eye contact, and (4) treating as an equal. Correlations between specific behaviors and trust decreased over time, with a range of 0.38 to 0.58 at 1 month and 0.27 to 0.46 at 6 months after the initial visit. The same pattern of the strength of associations between trust and specific behaviors remain essentially stable, with the exceptions of “being available when needed” and “working to adjust treatment.” Being available when needed was one of the behaviors least associated with trust at the index visit (ranked 16th out of 19) but moved up to be ranked 12th at 1 month and sixth at 6 months. Working to adjust treatment was also less important at the initial visit (ranked 14th out of 18), compared with 1 month (ranked 7th) and 6 months (ranked 8th).

The associations between specific behaviors and trust at the time of the enrollment visit were examined for the following subgroups of patients: men versus women, aged younger than 45 years versus 45 years and older, and length of relationship 2 years or less versus more than 2 years Table W2*. These subgroups were selected a priori for exploration and generation of hypotheses but without any particular hypothesis regarding the pattern of associations between behaviors and trust within each subgroup. As shown in Table 2, being comforting and caring, demonstrating competency in diagnosis and treatment, and expressive communication (encouraging and answering questions, explaining, and checking understanding) were among the behaviors most strongly associated with trust for all groups. Letting the whole story be told or finding out all the reasons for the visits (2 receptive communication behaviors) were strongly associated with trust in most of the groups. Referring to a specialist if needed was one of the behaviors most strongly associated with trust among women, younger patients, and established patients. Respecting feelings and opinions was among the most strongly associated behaviors only for younger patients, and checking progress was among the most strongly associated behaviors only for women.

Identical analyses were performed examining the association between specific physician behaviors and patient satisfaction following the enrollment visit. All physician behaviors were more highly correlated with patient satisfaction than with patient trust, ranging from 0.59 to 0.75 for satisfaction. In general, the pattern of correlation between behaviors and satisfaction was very similar to the pattern for trust. For the total sample, the 4 behaviors most strongly associated with trust were among the 5 behaviors most strongly associated with satisfaction. As with trust, there was relatively little variation in the associations with behaviors by patient subgroups.

Discussion

The strength of the association between key physician behaviors during the office visit on subsequent patient trust in the physician was assessed. The behaviors assessed were previously identified as affecting patient trust in a study using patient focus groups.¹ This study found that the behaviors assessed were predictive of patient trust up to 6 months after the initial visit, though the strength of the association decreased over time. There were relatively modest differences in the strength of the associations between behaviors and trust among the patient subgroups examined. Being comforting and caring, demonstrating competency, and explaining and listening were most strongly associated with trust in all, or virtually all, the subgroups. For women, referral to a specialist if needed and checking progress were also strongly associated with trust. The relative importance of referrals among women may reflect a concern for seeing a specialist for reproductive-related conditions. Referral was also more strongly associated with trust among more established patients, perhaps because these patients were more likely to have experienced a need for referral from their current physician at some time. For younger patients, willingness to refer and respect for feelings, opinions, and self-knowledge were among the most important behaviors, possibly reflecting differences in expectations for physician behaviors among younger versus older patients.

Interestingly, treating the patient as being on the same level and asking the patient’s opinion, while significantly associated with trust, were among the physician behaviors least associated with trust. This finding does not mean that equality and partnership are unimportant. The degree to which patients want to be involved in making decisions about their care varies,¹⁴ and patients may choose to stay with physicians whose practice style fits their preferences for involvement in their care. Bedside manners, such as gentleness during the examination, greeting warmly, and making eye contact, while significantly associated with trust, were also among the least strongly associated. These behaviors, while desirable, may be less important to establishing trust.

It was also found that to a large extent the same physician behaviors most associated with trust are also most associated with satisfaction, though the associations are stronger with satisfaction. A previous paper has reported data indicating that patient trust is somewhat separate from satisfaction, predicting continuity and self-reported adherence to treatment independently of satisfaction.6 One possible interpretation of this finding is that physician behaviors that lead to satisfaction in a single visit also help build trust, but trust is more dependent on factors in addition to physician behaviors during the office visit. No previous studies could be located that reported on the association of physician behaviors with patient trust. However studies of physician behaviors and patient satisfaction, have found that interpersonal competence (similar to comforting and caring in this study), communication, and technical competency were all significantly associated with satisfaction, a result confirmed in our study.^15-17

Limitations

Patients’ ratings of physician behaviors may reflect their overall positive feelings toward the physician. Thus it is not possible to conclude that differences in the specific physician behaviors cause differences in trust. However, identifying the behaviors most strongly associated with trust may help to focus future intervention studies on these behaviors.

Conclusions

The results suggest that caring and comfort are as important as technical competency in predicting patient trust. Also, expressive and receptive communication skills, which have been shown as strongly related to patient satisfaction, are also important predictors of trust. Although the relative importance of a few other behaviors differed between subgroups, these differences were relatively modest, suggesting that the listed behaviors are of general importance to patient trust. Further work is needed to test the hypothesis that changes in identified physician behaviors can modify levels of patient trust.

Acknowledgements

This study was supported in part by grants from the Picker/Commonwealth Fund (#94-130) and the Bayer Institute for Health Care Communication (#94-181). The author thanks Barbara Elspas, MPH, for her fine work as study coordinator. The participating Stanford Trust Study Physicians were: William G. Broad, MD, (Palo Alto, Calif); Lawrence J. Bruguera, MD, (Half Moon Bay, Calif); David R. Ehrenberger, MD, (Mountain View, Calif); Larry A. Freeman, MD, (Palo Alto, Calif); Robert J. Fuss, MD, (Milpitas, Calif); H. Wallace Greig, MD, (San Jose, Calif); Mary P. Hufty, MD, (Palo Alto, Calif); Carlos F. Inocencio, MD, (Los Altos, Calif); Steven R. Lane, MD, MPH, (Palo Alto, Calif), Jas P. Lockhart, MD, (Menlo Park, Calif); Jeffrey S. McClanahan, MD, (Cupertino, Calif); Catherine A. Owen, MD, (Half Moon Bay, Calif); William E. Page, MD, (Palo Alto, Calif); Kuljeet S. Rai, MD, (San Jose, Calif); Daljeet S. Rai, MD, (San Jose, Calif); Paulita R. Ramos, MD, (San Jose, Calif); William E. Straw, MD, (Los Altos, Calif); William S. Warshal, MD, (Campbell, Calif); Roger W. Washington, MD, (Mountain View, Calif); and Andrew W. White, MD, (Menlo Park, Calif).

Related resources

• Picker Institute—non-profit organization that offers products and services aimed at improving health care “through the eyes of the patient.”http://www.picker.org
• American Academy on Physician and Patient—professional society dedicated to research, education, and professional standards in doctor-patient communication.www.physicianpatient.org
• The Program in Communication and Medicine at Northwestern Universitywww.pcm.northwestern.edu

The physician-patient relationship is recognized as having an essential role in the process of medical care, providing the context in which caring and healing can occur.^1-3 Patient trust in the physician has been proposed as a key feature of this relationship.^1,4-6 There are several potential benefits to patient trust, including increased satisfaction, adherence to treatment, and continuity of care.^6,7 Trust may also be associated with lower transaction costs,⁸ such as those incurred by a need to reassure patients (eg, ordering additional tests and referrals) or by inefficiencies due to incomplete disclosure of information by the patient.

Despite the apparent importance of patient trust, relatively little is known about what physician behaviors are most strongly associated with it. A previous study,¹ using patient focus groups, identified 7 categories of physician behaviors that increased patients’ trust: thoroughly evaluating problems, indicating an understanding of the patient’s experience, expressing care for the patient, providing appropriate and effective treatment, communicating clearly and completely, building partnership, and demonstrating honesty and respect. The qualitative nature of the focus group data does not allow for the assessment of the relative importance of specific types of physician behaviors in predicting subsequent patient trust. Ascertaining the association between physician behaviors and patient trust is important both on a theoretical level, for what it may reveal about the nature of patient trust, and on a practical level, for guiding interventions to improve trust through physician education and training.

The goal for our study was to assess the relative importance of physician behaviors on patient trust immediately following the visit, after 1 month, and after 6 months. The behaviors chosen for measurement had been previously identified as promoting trust in patients in focus groups.¹ The measurement of trust 3 times made it possible to ascertain if the physician behaviors most associated with trust immediately following a visit are those most associated with future trust. Also, the relative importance of physician behaviors for trust was explored in 3 patient subgroups: men and women patients, younger and older patients, and newer and more established patients.

Methods

Study Design and Subject Recruitment

This was a 6-month prospective study. Consecutive eligible patients were enrolled from the practices of 20 family physicians recruited by mail from a single geographic area based on their interest in practice-based research and physician-patient communication.^6,9 The patients were recruited by a research assistant who approached them in the waiting room after they had checked in and before they were brought to an examination room. Patients younger than 18 years, those unable to complete the questionnaire, and those in acute distress were excluded. In addition, patients with no previous visits to the study physician or who did not identify the study physician as their primary care physician were excluded. All patients signed an informed consent form at the time of enrollment.

Measures

Each physician provided demographic and practice characteristic data. Measures obtained from patients in the waiting room or examination room at the time of their enrollment (the previsit questionnaire) included: demographics, length of relationship with physician, number and type of chronic medical conditions, and health status (measured by the Medical Outcomes Study Short Form-³⁶).¹⁰ Following the office visit, patients completed a postvisit questionnaire concerning the physician’s interpersonal behavior during the visit, their trust in the physician, and their satisfaction with the visit (measured by a subset of 13 questions from the Consumer Satisfaction Survey).^6,11 Approximately 80% of the patients completed this form in the waiting room after the visit; the remaining 20% completed it within 24 hours and returned it by mail. The 18 items pertaining to physician interpersonal behavior Table W1* were chosen to assess the physician behaviors identified in the previous patient focus groups as affecting patient trust.¹ Fourteen items were taken from the 23-item version of the Humanistic Behaviors Questionnaire developed by the American Board of Internal Medicine.¹² This questionnaire was chosen because it had items pertaining to most of the behaviors identified in the focus groups as affecting patient trust, including receptive and expressive communication (listening and explaining), treating patients with warmth and respect, gentleness, honesty, partnership, and willingness to refer to a specialist. Four items were added to assess additional behaviors identified from the focus groups: finding out all the reasons for the visit, respecting opinions and feelings, caring and concern, and demonstrating competency to diagnose and treat. Patients rated physician performance of each behavior item on a 5-point Likert-type scale, from poor to excellent. The questionnaire was piloted for clarity and acceptability.

Patient trust was measured using a slightly modified version of the 11-item Trust in the Physician Scale developed from Anderson and Dedrick¹³ as previously described.⁶ At the time of the study, the Trust in Physician Scale was the only published measure of patient trust. One item, “My doctor is a real expert in taking care of medical problems like mine” was modified to read “My doctor is well qualified to manage (diagnose and treat or make an appropriate referral) medical problems like mine,” to be appropriate for the primary care setting. On the basis of a pilot study of the scale, response labels were changed from (1=strongly disagree; 2=disagree; 3=uncertain; 4=agree; 5=strongly agree) to (1=totally disagree; 2=disagree; 3=neutral; 4=agree; 5=totally agree).⁶ The scale was scored by transforming the mean response score (calculated after reverse coding the negative items) to a 0 to 100 scale. Patient trust was assessed again at 1 and 6 months after the enrollment visit by mail survey.

Statistical Analysis

The association between specific physician behaviors and level of trust was assessed using Pearson correlation coefficients. Behaviors were ranked on the basis of the relative strength of the correlations.

Results

Of 803 consecutive patients, 561 were eligible for enrollment. Of those, 414 (74%) enrolled and completed the previsit and postvisit questionnaires at the time of the index visit, 52 (9%) refused, 15 (3%) saw the physician and left before being approached by the research assistant, and 74 (13%) enrolled but failed to complete both questionnaires.

Among the 414 enrolled patients, 334 (81%) completed the 1-month and 343 (83%) completed the 6-month follow-up questionnaires. Patients who did not complete the 1-month and 6-month questionnaires were compared with those who did with respect to age, length of the relationship with the physician, sex, race, education, and self-reported health status. Those who did complete the questionnaires at 6 months were virtually the same as those who did not at 1 month with respect to these characteristics. Those who did not complete the questionnaires at 6 months were slightly younger (45 vs 48 years), had been seeing their physician for a slightly shorter time at study enrollment (mean = 37 months vs 43 months), were more likely to be men (45% vs 36%), and were more likely to be nonwhite (41% vs 31%) than those who did complete the questionnaire, but they were virtually identical with respect to education and health status. None of these differences reached statistical significance.

The average age of the physicians was 47 years (range=34-73 years), with an average of 16 years in practice (range=8-44 years). Physicians were predominately men (85%) and white (70%), and most were in group practice (70%). Patients also had a mean age of 47 years and were predominately women (62%). Approximately two thirds (68%) of the patients were white, and 81% had graduated from high school. More than half (55%) reported at least one chronic medical condition, and almost half (45%) reported their health as being less than very good.

The correlation between physician behaviors during the visit, as rated by the patient, and trust immediately following the visit ranged from 0.46 to 0.64 Table 1. The 5 behaviors that were most strongly associated with trust immediately after the visit were: (1) being comforting and caring, (2) demonstrating competency, (3) encouraging and answering questions, (4) explaining what they were doing, and (5) referring to a specialist if needed. Behaviors least important for trust were: (1) gentleness during examination, (2) discussing options/asking opinions, (3) making eye contact, and (4) treating as an equal. Correlations between specific behaviors and trust decreased over time, with a range of 0.38 to 0.58 at 1 month and 0.27 to 0.46 at 6 months after the initial visit. The same pattern of the strength of associations between trust and specific behaviors remain essentially stable, with the exceptions of “being available when needed” and “working to adjust treatment.” Being available when needed was one of the behaviors least associated with trust at the index visit (ranked 16th out of 19) but moved up to be ranked 12th at 1 month and sixth at 6 months. Working to adjust treatment was also less important at the initial visit (ranked 14th out of 18), compared with 1 month (ranked 7th) and 6 months (ranked 8th).

The associations between specific behaviors and trust at the time of the enrollment visit were examined for the following subgroups of patients: men versus women, aged younger than 45 years versus 45 years and older, and length of relationship 2 years or less versus more than 2 years Table W2*. These subgroups were selected a priori for exploration and generation of hypotheses but without any particular hypothesis regarding the pattern of associations between behaviors and trust within each subgroup. As shown in Table 2, being comforting and caring, demonstrating competency in diagnosis and treatment, and expressive communication (encouraging and answering questions, explaining, and checking understanding) were among the behaviors most strongly associated with trust for all groups. Letting the whole story be told or finding out all the reasons for the visits (2 receptive communication behaviors) were strongly associated with trust in most of the groups. Referring to a specialist if needed was one of the behaviors most strongly associated with trust among women, younger patients, and established patients. Respecting feelings and opinions was among the most strongly associated behaviors only for younger patients, and checking progress was among the most strongly associated behaviors only for women.

Identical analyses were performed examining the association between specific physician behaviors and patient satisfaction following the enrollment visit. All physician behaviors were more highly correlated with patient satisfaction than with patient trust, ranging from 0.59 to 0.75 for satisfaction. In general, the pattern of correlation between behaviors and satisfaction was very similar to the pattern for trust. For the total sample, the 4 behaviors most strongly associated with trust were among the 5 behaviors most strongly associated with satisfaction. As with trust, there was relatively little variation in the associations with behaviors by patient subgroups.

Discussion

The strength of the association between key physician behaviors during the office visit on subsequent patient trust in the physician was assessed. The behaviors assessed were previously identified as affecting patient trust in a study using patient focus groups.¹ This study found that the behaviors assessed were predictive of patient trust up to 6 months after the initial visit, though the strength of the association decreased over time. There were relatively modest differences in the strength of the associations between behaviors and trust among the patient subgroups examined. Being comforting and caring, demonstrating competency, and explaining and listening were most strongly associated with trust in all, or virtually all, the subgroups. For women, referral to a specialist if needed and checking progress were also strongly associated with trust. The relative importance of referrals among women may reflect a concern for seeing a specialist for reproductive-related conditions. Referral was also more strongly associated with trust among more established patients, perhaps because these patients were more likely to have experienced a need for referral from their current physician at some time. For younger patients, willingness to refer and respect for feelings, opinions, and self-knowledge were among the most important behaviors, possibly reflecting differences in expectations for physician behaviors among younger versus older patients.

Interestingly, treating the patient as being on the same level and asking the patient’s opinion, while significantly associated with trust, were among the physician behaviors least associated with trust. This finding does not mean that equality and partnership are unimportant. The degree to which patients want to be involved in making decisions about their care varies,¹⁴ and patients may choose to stay with physicians whose practice style fits their preferences for involvement in their care. Bedside manners, such as gentleness during the examination, greeting warmly, and making eye contact, while significantly associated with trust, were also among the least strongly associated. These behaviors, while desirable, may be less important to establishing trust.

It was also found that to a large extent the same physician behaviors most associated with trust are also most associated with satisfaction, though the associations are stronger with satisfaction. A previous paper has reported data indicating that patient trust is somewhat separate from satisfaction, predicting continuity and self-reported adherence to treatment independently of satisfaction.6 One possible interpretation of this finding is that physician behaviors that lead to satisfaction in a single visit also help build trust, but trust is more dependent on factors in addition to physician behaviors during the office visit. No previous studies could be located that reported on the association of physician behaviors with patient trust. However studies of physician behaviors and patient satisfaction, have found that interpersonal competence (similar to comforting and caring in this study), communication, and technical competency were all significantly associated with satisfaction, a result confirmed in our study.^15-17

Limitations

Patients’ ratings of physician behaviors may reflect their overall positive feelings toward the physician. Thus it is not possible to conclude that differences in the specific physician behaviors cause differences in trust. However, identifying the behaviors most strongly associated with trust may help to focus future intervention studies on these behaviors.

Conclusions

The results suggest that caring and comfort are as important as technical competency in predicting patient trust. Also, expressive and receptive communication skills, which have been shown as strongly related to patient satisfaction, are also important predictors of trust. Although the relative importance of a few other behaviors differed between subgroups, these differences were relatively modest, suggesting that the listed behaviors are of general importance to patient trust. Further work is needed to test the hypothesis that changes in identified physician behaviors can modify levels of patient trust.

Acknowledgements

This study was supported in part by grants from the Picker/Commonwealth Fund (#94-130) and the Bayer Institute for Health Care Communication (#94-181). The author thanks Barbara Elspas, MPH, for her fine work as study coordinator. The participating Stanford Trust Study Physicians were: William G. Broad, MD, (Palo Alto, Calif); Lawrence J. Bruguera, MD, (Half Moon Bay, Calif); David R. Ehrenberger, MD, (Mountain View, Calif); Larry A. Freeman, MD, (Palo Alto, Calif); Robert J. Fuss, MD, (Milpitas, Calif); H. Wallace Greig, MD, (San Jose, Calif); Mary P. Hufty, MD, (Palo Alto, Calif); Carlos F. Inocencio, MD, (Los Altos, Calif); Steven R. Lane, MD, MPH, (Palo Alto, Calif), Jas P. Lockhart, MD, (Menlo Park, Calif); Jeffrey S. McClanahan, MD, (Cupertino, Calif); Catherine A. Owen, MD, (Half Moon Bay, Calif); William E. Page, MD, (Palo Alto, Calif); Kuljeet S. Rai, MD, (San Jose, Calif); Daljeet S. Rai, MD, (San Jose, Calif); Paulita R. Ramos, MD, (San Jose, Calif); William E. Straw, MD, (Los Altos, Calif); William S. Warshal, MD, (Campbell, Calif); Roger W. Washington, MD, (Mountain View, Calif); and Andrew W. White, MD, (Menlo Park, Calif).

Related resources

• Picker Institute—non-profit organization that offers products and services aimed at improving health care “through the eyes of the patient.”http://www.picker.org
• American Academy on Physician and Patient—professional society dedicated to research, education, and professional standards in doctor-patient communication.www.physicianpatient.org
• The Program in Communication and Medicine at Northwestern Universitywww.pcm.northwestern.edu