Physicians often quote patient trust as crucial for optimized care delivery. But do patients really trust their providers? A 2013 Gallup poll shows people think the most honest and ethical professionals are nurses, followed by pharmacists and grade school teachers. Medical doctors ranked fourth, tied with military officers and outranking police officers easily.
The Robert Wood Johnson Foundation and National Institute of Mental Health supported a study to gather information on public trust in physicians and medical leaders over time, finding trust has waned considerably over the past 45 years. Findings published in a New England Journal of Medicine article this week show 73 percent of Americans had confidence in the leaders of the medical profession in 1966; in 2012 that number was down to 34 percent.
The article authors suggest "the decline in trust is probably attributable to broad cultural changes in the United States, as well as rising concerns about medical leaders' responses to major national problems affecting the U.S. healthcare system."
There are several factors playing into the public conception of medical professionals and leaders, including:
• Politicization of the healthcare system
• Access to quality healthcare
• Media coverage of negative events
• Failed surgeries and medical care
• "Bad actors" among physicians
Spine surgery has seen many of these issues over the past several years. Healthcare reform is changing the way patients access care, especially elective and specialty procedures. Some are worried a two-tiered system will develop to limit access for people without premium insurance or cash-pay; others foresee patients waiting in long lines just for the initial visit to their spine specialist.
Failed spine surgery has also been a key issue in the field. A 2011 study examining patients who underwent lumbar fusion for chronic low back pain from 1999 to 2001 showed 36 percent of the patients had complications and 27 percent had reoperations. Another 11 percent had permanent disability and 17 patients died before the study closed. There was continuing opioid use increase in 41 percent of the surgical patients and 76 percent reported still taking opioids after surgery.
Finally, more often than not, media coverage has focused on bad outcomes for spine patients. News outlets cover outlier spine surgeons with multiple lawsuits or those involved in potentially unethical physician-owned distributorships as a cautionary tale while often disregarding the good outcomes surgeons achieve every day.
Another unfortunate trend highlighted in the article shows that low-income individuals are less likely to trust their medical physicians and leaders than high-income individuals. With the income gap widening in the United States, this trend could be concerning for the future. They are also less satisfied with their outcome. Older adults — those 65 years old or more — are also more likely to trust their physicians than younger people, and men are more trusting than women, according to the NEJM article.
Are there remedies for these issues in healthcare, particularly in spine? How can spine surgeons buck this trend to gain their patients' trust?
Here's the good news: even while people reported trusting medical leaders less, they still felt their personal physician or surgeon was ethical. Similarly, many people feel Congress needs a change — we hear rallying cries from across the country to elect new representatives — but most will still say their personal representative is doing a good job. For physicians, this means most have good rapport with their patients and provide appropriate care, but people conceptualize other physicians as worse.
"Individual patients' satisfaction with the medical care they received during their most recent physician visit does not reflect the decline in overall trust," according to the NEJM article. "Rather, the United States ranks high on this measure of satisfaction."
When compared with other countries, the high rate of patient satisfaction with the individual's care coupled with a low overall trust in medical professionals is an odd combination. However, the difference in political environments and healthcare systems could contribute to this difference. In other countries, medical professionals share in the healthcare system management with government officials and are visible in their advocacy. Other countries have structures where physician leaders bargain and negotiate with the government, according to the NEJM article, over:
• Payment
• Professional autonomy
• Quality of care
We're starting to see this within the U.S. healthcare system — physicians are gaining a seat at the table for reimbursement discussions (including the CPT Panel's seat for International Society for the Advancement of Spine Surgery) and informal meetings between practicing medical professionals and their Congressional representatives. However, the medical societies and specialty organizations are still somewhat fragmented and advocate for opposing policies. Additionally, physicians are not mandatory for the Patient-Center Outcomes Research Institute, which makes recommendations on clinical coverage.
"We believe that the American public's trust in physicians as a group can be increased if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation's health and healthcare, even if doing so might be disadvantageous to some physicians," the NEJM article authors wrote.
Spine specialty societies are advocating on behalf of their patients and specialty, but outside of the spine specialist community those efforts are largely unrecognized. Patients don't see how physicians are working for them outside of the office, and they don't always understand why that's important.
There are several things spine surgeons can do to put their patients at ease and build trust at the individual level as well as national level, according to a Becker's Spine Review article:
• Set appropriate outcome expectations and discuss risks
• Select the appropriate treatment for each patient
• Be honest with the patients and upfront about outcomes and costs
• Communicate with patients as well as their other specialists
• Answer their questions as best as possible — about clinical as well as policy issues
• Host educational events at your practice/center/department for the community
• Participate in community outreach activities
Connecting with people outside of the office and operating room can help them see physicians in a different way and understand how medical leaders are standing up for them. There are a few campaigns to bridge this gap, including the Spine Research Foundation which hosts the "We've Got Your Back" race in several cities annually to support back pain research and education as well as those who have undergone back pain treatment; programs to provide charity care in the United States and abroad; and ISASS's International Advocates for Spine Patients which connects patient and physician advocates. Being seen as a public health advocate is a powerful tool for instilling trust.
There are some hospitals, device companies and community health groups that are also beginning to bring in patients as well as physicians board discussions on process and policy changes. This gives patients a behind-the-curtain look into healthcare delivery so they understand the different issues at hand and can participate in solutions.
Cost and price transparency is also allowing patients an inside look at their care, albeit limited for now. The data from Medicare is released — both on hospital and physician charges as well as financial relationships between physicians and device companies — but more context will be needed in the future for these numbers to truly make a difference.
So what should spine surgeons focus on to raise trust in their profession? Become visible though digital, print and in-person resources to show the local and national community what you and other spine surgeons are doing to improve healthcare overall. This could be a crucial step not only to improve patient care, but to avoid future healthcare policy debacles.
"If the medical profession and its leaders cannot raise the level of public trust, they're likely to find that many policy decisions affecting patient care will be made by others, without consideration of their perspective," concludes the NEJM article.