Physician Behaviors that Predict Patient Trust

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.