Sheena Sharma is a GP and Trainer at Bartlemas Surgery, Oxford, and an Associate GP Dean for Health Education England in Thames Valley. She is on Twitter: @Sheena1Sharma
My first appointment on Monday morning a patient had called to talk to me about his unexplained neutropenia. He answered ‘I am well and strong’ to my usual opening question ‘how are you?’ We talked only about his fascinating job and plans to follow his wife to Dublin for her career. At the end of the conversation, he took me aback with ‘I feel better and so reassured by you. I trust you’.
Clearly trust is a crucial part of the doctor–patient relationship. Common sense tells us this, so does research — a study in 2014 showed lower levels of trust led to more emotional distress and more physical limitations at 3, 9, and 15 months after diagnosis.1
It also encourages appropriate use of services, facilitates disclosure of important medical information, and by helping patients choose continuity it can indirectly improve health outcomes.2 I have therefore been thinking about how trust can be formed, nurtured, and broken, especially in the new more remote world of doctoring.
We put a lot of emphasis on the development of communication skills when we teach our trainee GPs. While good communication skills help patients feel satisfied with their consultations, this is perhaps not the only building block of trust.
… he took me aback with ‘I feel better and so reassured by you. I trust you’.
Certainly, I remember my own obstetrician, many years ago now, who helped me through a stressful high-risk pregnancy. His communication skills certainly did not tick any of primary care consultation models tasks and he barely made eye contact, however, I trusted him.
What did he have? He was confident, calm, and had a good reputation for providing excellent care. He found my situation medically curious, and I perhaps mistook an interest in science for an interest in me. Nevertheless, it was enough.
I expect times have changed and people no longer assume a high standard of care will be provided — they need evidence. This evidence may be provided on a consultation level (explanations to patients showing that we are using evidence-based medicine for our decisions) and on an institutional level (Care Quality Commission gradings/satisfaction survey results).
Patients also need to believe we care and will work hard for their individual best interests. The joy of our job as GPs comes from doing this and achieving trust will feed our natural desire for reward. We can search for features we can identify within the most characteristically different patient, rather than just employing sympathy, and use our non-judgement to always think deeply about where ‘negative’ behaviours are born. In other words, identify with patients even in the most unlikely scenario.
Honesty plays a part in this too. A memorable quote from a patient on the internet:
‘Doctor (after more thought): “I don’t know, but I can find out, if you’d like.”’3
Patients need to believe we care and will work hard for their individual best interests. The joy of our job as GPs comes from doing this …
And those were the words that made me realize I could trust him — ‘I don’t know’. I’d never known a doctor to say them before, and frankly I was surprised. By admitting ignorance, he put whatever else he told me into clearer perspective. I knew now I could trust anything else he said. I later found that he never pretended to know something when he didn’t, and that he was always willing to qualify his judgements when it was appropriate.
Unfortunately, not all facets of trust are all under our control. Late cancer diagnosis, for example, is sadly an area that is shown to cause breakdown in GP–patient relationships at times. This is irrespective of whether we provided competent care.
Media coverage of medical errors, high demand with under-resourcing, and doctor shaming around the inappropriate use of WhatsApp groups add to the difficulties. There is also no doubt that the remote consulting we have been forced to employ and are indeed being encouraged to continue to use has done little to foster patient trust on top of ‘tick box medicine’.
Diminished trust may be an important cause of the increased workload we are seeing in primary care so we certainly have reason to think hard about it. Not ignoring the fact that trust makes for a much more fulfilling relationship and can reduce burn out.
For me, the pronoun ‘I’ personalises care and my decision making: ‘I think that you have … I would like to … I am wondering if … ’ rather than ‘we tend to refer when … ‘. Otherwise, it comes down to, never assume, keep your heart on your sleeve, involve patients in your thought processes and take responsibility for them, and be competent! Hopefully trust can be rebuilt.
1. Hinnen C, Pool G, Holwerda N, et al. Lower levels of trust in one’s physician is associated with more distress over time in more anxiously attached individuals with cancer. Gen Hosp Psychiatry 2014; 36(4): 382–387.
2. Safran DG, Taira DA, Rodgers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract 1998; 47(3): 213–220.
3. Silveira J. Three honest words: “I don’t know”. Backwoods Home Magazine 2000; http://www.backwoodshome.com/articles/silveira63.html (accessed 20 Apr 2021).