Original Research

Six months ago I embarked on a quest to develop a health care model that would truly serve our community. I had an epiphany that involving the community in the creation of the clinic would be integral to the success of the venture.

In neighborhoods and community centers throughout the region, I facilitated public forum discussions on the “Ideal Medical Clinic.” All participants were encouraged to express their wildest dreams and most creative visions in roundtable discussions that were remarkably lively, providing fertile material for the birth of our true community-based medical practice. Just 1 month later, 90% of the community input was incorporated into a fully functioning solo “Family and Community Medicine Clinic.”

Concurrent with my venture to create the ideal medical practice locally, the Future of Family Medicine (FFM) project has spearheaded a national campaign, a call to action for family physicians to create a new model of family medicine. After substantial research, the FFM project determined the characteristics of the “New Model” of family medicine:

• a personal medical home
• patient-centered care
• whole person orientation
• team approach
• elimination of barriers to access
• advanced information systems
• redesigned offices
• care provided within a community context
• emphasis on quality/safety
• enhanced practice finance
• provide family medicine’s basket of services.

It appeared we had inadvertently stumbled on this “new model” in our co-creation of the Family and Community Medicine Clinic, which successfully embodied all 11 characteristics.

A facility designed to reassure

The clinic is housed in a wellness center tucked into a wooded residential area within walking distance of my home. The center offers yoga, massage therapy, and counseling, and features a full size, solar-heated, wheelchair-accessible indoor pool/hot tub. A covered walkway connects the pool to the cozy medical office space, which feels more like a living room with its overstuffed chairs, pillows, and muted colors.

A partial wall separates the consultation area from the exam room. The exam area has a relaxing Caribbean decor with local commissioned artwork, fun flannel gowns, and an attached bathroom. A regional hospital with a full range of specialists is located just 2 miles from the clinic, and paramedics are next door in the fire station.

Gratifying physician-patient encounters

Patients enjoy 24/7 access to their family doctor, and hospital care if needed. After-hours calls are rare because appointments run 30 to 60 minutes and are comprehensive. Appointments are scheduled for weekday afternoons and evenings so patients never have to miss work. Same day and weekend visits are available for urgent needs.

I enjoy a leisurely bicycle ride to the office on scheduled afternoons, and I reward patients who walk, bicycle, or ride public transit to their visit with a selection of gifts (local handmade soaps, lotions). Other gifts such as massage or body work honor major behavior or lifestyle changes. Generic antibiotics are dispensed on site, free of charge, so ill patients do not have to wait at a pharmacy.

Patients active in care of selves and others

Novel voluntary programs were developed by the community and include healing circles and a quality improvement team composed of patients. Disease registries have made it possible to form chronic disease support groups.

For those in support groups, group medical visits are available and allow exchange of complex information in an informal nurturing environment. There are also a variety of volunteer opportunities for skilled patients to serve other patients with special needs.

Running the center with a little creativity

Our community medical practice operates without grants or outside financing aside from the small amount I contributed to buy furniture and supplies. Rented office space is $280/month, and with no staff I have extremely low overhead. My home business office is where I handle phone calls, billing, and charting on my Apple laptop computer. Malpractice insurance is inexpensive ($1200/first year); discounted 50%, as I work part-time. Insurance is accepted, and uninsured patients are given large discounts with barter options available. Oddly enough, I will likely exceed my prior full-time salary.

The rewards of embracing this new model

My colleagues were concerned I would serve the worried well in a wellness-centered “spa” setting. On the contrary, my first patient was an uninsured, whimsical, and thin 25-year-old man with a blood pressure of 220/120 mm Hg. I diagnosed renal artery stenosis due to fibromuscular dysplasia, and accompanied him to angioplasty.

Two weeks after his initial visit, I had his blood pressure down to 118/80 mm Hg without medication. The night after his angioplasty I brought the family and patient into the radiology department to recreate the amazing scene showing the catheters, wires, and film images, which they kept as souvenirs. We all stood there silently, in awe.

In this new practice model, I now have the luxury to stand in awe with my patients marveling at life itself. I also have the luxury of accompanying my patients through all facets of their treatment, including visits with specialists. It is an honor and a privilege to attend to patients with the curiosity and freedom (lack of time constraints) of a new medical student and with the wisdom of a seasoned family physician.

I am amazed at how simple and enjoyable it is to create a solo community medical practice that conforms to the national “New Model” of family medicine as supported by the FFM project. I look forward enthusiastically to exploring the new models that other family physicians develop in their communities, each with its own regional flavor, infused with the personalities of the creative physicians involved. May we all energize and inspire each other in our collective journey to renew our beloved profession.

CORRESPONDENCE:
Pamela L. Wible, MD, Family & Community Medicine, 3575 Donald St #220, Eugene, OR 97406. E-mail: [email protected]

Six months ago I embarked on a quest to develop a health care model that would truly serve our community. I had an epiphany that involving the community in the creation of the clinic would be integral to the success of the venture.

In neighborhoods and community centers throughout the region, I facilitated public forum discussions on the “Ideal Medical Clinic.” All participants were encouraged to express their wildest dreams and most creative visions in roundtable discussions that were remarkably lively, providing fertile material for the birth of our true community-based medical practice. Just 1 month later, 90% of the community input was incorporated into a fully functioning solo “Family and Community Medicine Clinic.”

Concurrent with my venture to create the ideal medical practice locally, the Future of Family Medicine (FFM) project has spearheaded a national campaign, a call to action for family physicians to create a new model of family medicine. After substantial research, the FFM project determined the characteristics of the “New Model” of family medicine:

• a personal medical home
• patient-centered care
• whole person orientation
• team approach
• elimination of barriers to access
• advanced information systems
• redesigned offices
• care provided within a community context
• emphasis on quality/safety
• enhanced practice finance
• provide family medicine’s basket of services.

It appeared we had inadvertently stumbled on this “new model” in our co-creation of the Family and Community Medicine Clinic, which successfully embodied all 11 characteristics.

A facility designed to reassure

The clinic is housed in a wellness center tucked into a wooded residential area within walking distance of my home. The center offers yoga, massage therapy, and counseling, and features a full size, solar-heated, wheelchair-accessible indoor pool/hot tub. A covered walkway connects the pool to the cozy medical office space, which feels more like a living room with its overstuffed chairs, pillows, and muted colors.

A partial wall separates the consultation area from the exam room. The exam area has a relaxing Caribbean decor with local commissioned artwork, fun flannel gowns, and an attached bathroom. A regional hospital with a full range of specialists is located just 2 miles from the clinic, and paramedics are next door in the fire station.

Gratifying physician-patient encounters

Patients enjoy 24/7 access to their family doctor, and hospital care if needed. After-hours calls are rare because appointments run 30 to 60 minutes and are comprehensive. Appointments are scheduled for weekday afternoons and evenings so patients never have to miss work. Same day and weekend visits are available for urgent needs.

I enjoy a leisurely bicycle ride to the office on scheduled afternoons, and I reward patients who walk, bicycle, or ride public transit to their visit with a selection of gifts (local handmade soaps, lotions). Other gifts such as massage or body work honor major behavior or lifestyle changes. Generic antibiotics are dispensed on site, free of charge, so ill patients do not have to wait at a pharmacy.

Patients active in care of selves and others

Novel voluntary programs were developed by the community and include healing circles and a quality improvement team composed of patients. Disease registries have made it possible to form chronic disease support groups.

For those in support groups, group medical visits are available and allow exchange of complex information in an informal nurturing environment. There are also a variety of volunteer opportunities for skilled patients to serve other patients with special needs.

Running the center with a little creativity

Our community medical practice operates without grants or outside financing aside from the small amount I contributed to buy furniture and supplies. Rented office space is $280/month, and with no staff I have extremely low overhead. My home business office is where I handle phone calls, billing, and charting on my Apple laptop computer. Malpractice insurance is inexpensive ($1200/first year); discounted 50%, as I work part-time. Insurance is accepted, and uninsured patients are given large discounts with barter options available. Oddly enough, I will likely exceed my prior full-time salary.

The rewards of embracing this new model

My colleagues were concerned I would serve the worried well in a wellness-centered “spa” setting. On the contrary, my first patient was an uninsured, whimsical, and thin 25-year-old man with a blood pressure of 220/120 mm Hg. I diagnosed renal artery stenosis due to fibromuscular dysplasia, and accompanied him to angioplasty.

Two weeks after his initial visit, I had his blood pressure down to 118/80 mm Hg without medication. The night after his angioplasty I brought the family and patient into the radiology department to recreate the amazing scene showing the catheters, wires, and film images, which they kept as souvenirs. We all stood there silently, in awe.

In this new practice model, I now have the luxury to stand in awe with my patients marveling at life itself. I also have the luxury of accompanying my patients through all facets of their treatment, including visits with specialists. It is an honor and a privilege to attend to patients with the curiosity and freedom (lack of time constraints) of a new medical student and with the wisdom of a seasoned family physician.

I am amazed at how simple and enjoyable it is to create a solo community medical practice that conforms to the national “New Model” of family medicine as supported by the FFM project. I look forward enthusiastically to exploring the new models that other family physicians develop in their communities, each with its own regional flavor, infused with the personalities of the creative physicians involved. May we all energize and inspire each other in our collective journey to renew our beloved profession.

CORRESPONDENCE:
Pamela L. Wible, MD, Family & Community Medicine, 3575 Donald St #220, Eugene, OR 97406. E-mail: [email protected]

Six months ago I embarked on a quest to develop a health care model that would truly serve our community. I had an epiphany that involving the community in the creation of the clinic would be integral to the success of the venture.

In neighborhoods and community centers throughout the region, I facilitated public forum discussions on the “Ideal Medical Clinic.” All participants were encouraged to express their wildest dreams and most creative visions in roundtable discussions that were remarkably lively, providing fertile material for the birth of our true community-based medical practice. Just 1 month later, 90% of the community input was incorporated into a fully functioning solo “Family and Community Medicine Clinic.”

Concurrent with my venture to create the ideal medical practice locally, the Future of Family Medicine (FFM) project has spearheaded a national campaign, a call to action for family physicians to create a new model of family medicine. After substantial research, the FFM project determined the characteristics of the “New Model” of family medicine:

• a personal medical home
• patient-centered care
• whole person orientation
• team approach
• elimination of barriers to access
• advanced information systems
• redesigned offices
• care provided within a community context
• emphasis on quality/safety
• enhanced practice finance
• provide family medicine’s basket of services.

It appeared we had inadvertently stumbled on this “new model” in our co-creation of the Family and Community Medicine Clinic, which successfully embodied all 11 characteristics.

A facility designed to reassure

The clinic is housed in a wellness center tucked into a wooded residential area within walking distance of my home. The center offers yoga, massage therapy, and counseling, and features a full size, solar-heated, wheelchair-accessible indoor pool/hot tub. A covered walkway connects the pool to the cozy medical office space, which feels more like a living room with its overstuffed chairs, pillows, and muted colors.

A partial wall separates the consultation area from the exam room. The exam area has a relaxing Caribbean decor with local commissioned artwork, fun flannel gowns, and an attached bathroom. A regional hospital with a full range of specialists is located just 2 miles from the clinic, and paramedics are next door in the fire station.

Gratifying physician-patient encounters

Patients enjoy 24/7 access to their family doctor, and hospital care if needed. After-hours calls are rare because appointments run 30 to 60 minutes and are comprehensive. Appointments are scheduled for weekday afternoons and evenings so patients never have to miss work. Same day and weekend visits are available for urgent needs.

I enjoy a leisurely bicycle ride to the office on scheduled afternoons, and I reward patients who walk, bicycle, or ride public transit to their visit with a selection of gifts (local handmade soaps, lotions). Other gifts such as massage or body work honor major behavior or lifestyle changes. Generic antibiotics are dispensed on site, free of charge, so ill patients do not have to wait at a pharmacy.

Patients active in care of selves and others

Novel voluntary programs were developed by the community and include healing circles and a quality improvement team composed of patients. Disease registries have made it possible to form chronic disease support groups.

For those in support groups, group medical visits are available and allow exchange of complex information in an informal nurturing environment. There are also a variety of volunteer opportunities for skilled patients to serve other patients with special needs.

Running the center with a little creativity

Our community medical practice operates without grants or outside financing aside from the small amount I contributed to buy furniture and supplies. Rented office space is $280/month, and with no staff I have extremely low overhead. My home business office is where I handle phone calls, billing, and charting on my Apple laptop computer. Malpractice insurance is inexpensive ($1200/first year); discounted 50%, as I work part-time. Insurance is accepted, and uninsured patients are given large discounts with barter options available. Oddly enough, I will likely exceed my prior full-time salary.

The rewards of embracing this new model

My colleagues were concerned I would serve the worried well in a wellness-centered “spa” setting. On the contrary, my first patient was an uninsured, whimsical, and thin 25-year-old man with a blood pressure of 220/120 mm Hg. I diagnosed renal artery stenosis due to fibromuscular dysplasia, and accompanied him to angioplasty.

Two weeks after his initial visit, I had his blood pressure down to 118/80 mm Hg without medication. The night after his angioplasty I brought the family and patient into the radiology department to recreate the amazing scene showing the catheters, wires, and film images, which they kept as souvenirs. We all stood there silently, in awe.

In this new practice model, I now have the luxury to stand in awe with my patients marveling at life itself. I also have the luxury of accompanying my patients through all facets of their treatment, including visits with specialists. It is an honor and a privilege to attend to patients with the curiosity and freedom (lack of time constraints) of a new medical student and with the wisdom of a seasoned family physician.

I am amazed at how simple and enjoyable it is to create a solo community medical practice that conforms to the national “New Model” of family medicine as supported by the FFM project. I look forward enthusiastically to exploring the new models that other family physicians develop in their communities, each with its own regional flavor, infused with the personalities of the creative physicians involved. May we all energize and inspire each other in our collective journey to renew our beloved profession.

CORRESPONDENCE:
Pamela L. Wible, MD, Family & Community Medicine, 3575 Donald St #220, Eugene, OR 97406. E-mail: [email protected]

One day a residency program decided to put its evidence-based medicine (EBM) curriculum to good use. A group of faculty and residents conducted a thorough review of the evidence regarding liquid-based cytoloutilizegy vs conventional Pap smears. They identified the key national recommendations and reviewed the supporting evidence behind each recommendation, tracing back to the individual studies themselves.^1-3

Based on the review, the group concluded that there was insufficient evidence to recommend one method of screening over another, but that there were situations in which one method might be preferred. They presented the evidence and their conclusions to the majority of faculty and residents at grand rounds. Following the presentation, the larger group discussed the relative merits of each screening method and decided the elements of evidence that supported the liquid test were more relevant to the practice than the conventional Pap smear. As a result, a decision was made by the group to stop carrying supplies for the conventional Pap smear. While the decision seemed reasonable on the level of an individual practitioner, several faculty and residents were unhappy with the “evidence-based” decision.

KAP theory and EBM

KAP theory identifies Knowledge, Attitudes, and Practice beliefs as key elements that drive healthcare providers’ decisions about medical care. In a sense EBM represents knowledge.⁴ There is a collective body of medical knowledge in the form of research, which represents “the evidence.” And there is what the healthcare provider himself “knows.” A major purpose of healthcare recommendations, point of care information systems, and best practice guidelines is to help the healthcare provider’s individual medical knowledge reflect the collective body of evidence.

For the purposes of this example, evidence will be considered absolute, inadequate, conditional, or relative. Absolute evidence occurs when there is clearly a correct answer. For example, the net benefits of aspirin for the treatment of myocardial infarction are clear. However, for most topics the evidence is not absolute; rather, it is inconclusive.⁵ The evidence may be inconclusive because it is inadequate—eg, insufficient research, conflicting studies, or research on peripheral topics. As an example, studies have demonstrated that aspirin decreases colorectal polyps, which may or may not be peripheral to the question of whether aspirin prevents colorectal cancer.

The evidence can also be conditional, meaning that in some defined instances the net benefit is clear. However, extending this net benefit beyond these instances is less clear. For example, patients at high risk for cardiovascular disease have a clear net benefit in taking aspirin for myocardial infarction prevention. Finally, the evidence may be relative, with a balance of known benefits and known risks.⁶ Using the aspirin example for cardiovascular disease prevention, patients at moderate risk receive benefit from aspirin in preventing myocardial infarction but at a risk cost of increased bleeding.

When the evidence is inconclusive, the second and third aspects of KAP theory—attitudes and practice beliefs—become very important. Healthcare providers and patients may arrive at different conclusions based on different viewpoints. On an individual level, healthcare practitioners use tools such as shared decision-making and patient-centered care to reach decisions.^6,7 However, inconclusive evidence provides a unique challenge when trying to develop local, regional, or national standards.

Evidence heresy

EBM frequently has negative connotations. In a room full of healthcare providers, some will believe that EBM should revolutionize the practice of medicine,⁸ and some that EBM has limited utility.⁹ How does this happen? The above scenario serves as a useful example, highlighting 3 misuses of the term “evidence” that frequently give EBM a bad name.

First, inconclusive evidence should not be stated in absolute terms; rather, it is more helpful to explicitly state what we know and the limits of what we know. Shaughnessy and Slawson wrote, “Absolute certainty is absolutely impossible, and we do not have to wait for that, of course.”¹⁰ This reflects the paucity of topics with certain evidence and highlights the need for clinicians to act on the available information. Every clinician necessarily utilizes this skill on a daily basis. The clinician has to become an Information Master¹¹ and know not only the end result of what the evidence indicates but also the facts supporting the end results and how those facts apply to the care of an unique individual.¹² However, taking this a step further and stating that one answer or option is absolutely correct in all cases ventures into dangerous ground. During the residency’s discussion of cervical cancer screening tests, the group recognized the merits of both options verbally but, the act of removing all conventional Pap smear supplies implied the nonverbal judgment that liquid-based technology was an absolute correct answer.

Second, while attitudes and practice beliefs can be used to weigh elements of evidence to reach a final conclusion, the conclusion should not negate other perspectives. An important skill of an adept clinician is the ability to interweave the healthcare provider’s and the patient’s attitudes and practice beliefs into the body of existing evidence to determine the appropriate intervention.¹³ However, attitudes and practice beliefs vary from individual to individual and from community to community. When these factors play a critical role in defining the appropriate action based on the evidence, how attitudes and practice beliefs are used should be explicitly stated. In the Pap smear example, the pivotal issue of contention was the belief about whether individual practitioners should act as stewards of limited healthcare resources. Proponents of using solely the liquid-based Pap smear felt the cost problem was a national issue and that the actions of the individual clinician had little impact on global healthcare costs. Others felt their local actions affected insurance premiums, leading directly to decreased healthcare access.¹¹ For cervical cancer, the key impact on mortality is getting any form of screening.¹ Using the liquid-based method for low-risk women may increase cervical cancer mortality by increasing costs and decreasing healthcare access. Removing conventional Pap smears disempowered the latter group of clinicians from implementing their practice beliefs and attitudes.

Finally, a conclusion should not be labeled as “evidence-based” when it is really made on other grounds such as economics, law, ethics, convenience, social values, or policy. Certainly, reviewing medical evidence is an important step in making decisions. However, the process for making decisions on these factors should be held to the same standards as making medical evidence decisions. This includes defining the process and explicitly stating the basis by which final decision will be made. The US is very conflicted when it comes to dealing with these non-evidence issues. We have no national standard for incorporating costs into healthcare decisions.^14,15 With respect to healthcare delivery, we have a wide range of social values that are sometimes disproportionate to logical expectations.¹⁶ Few effective systems are in place to incorporate these elements in healthcare decisions and, as a result, “evidence” is often used as a code word to focus on other issues.

For the Pap smear example, the decision factors were really economics, law, and systems of care. Proponents of the liquid-based method cited the community standard of care, fear of malpractice, patient expectations of receiving the latest technology, and the ease of adopting one screening method for the entire office. Others felt these issues, although important, were secondary to the lack of evidence supporting a liquid-based system as a sole screening method. For lowrisk women, adopting the liquid-based method only makes economic sense if screening is done every 2 or 3 years.¹⁷ However, many low-risk women still favor performing a Pap smear annually.¹⁸ As a result a decision-making process other than the strict EBM method, focusing on other factors would be necessary to change the practice standard.

Conclusions: Recognize the limitations of EBM

Cervical cancer screening serves as a common example of a difficult decision healthcare providers are faced with on a daily basis—what to do when evidence, based on patient oriented outcomes, is inconclusive. Providers do not have the luxury of merely stating the evidence is inconclusive; they must act. Frequently decisions are based on attitudes and practice beliefs in a broader context of unique economic, legal, and practice environments.

EBM is one tool in the decision-making armamentarium. It is a very powerful tool and has had a very positive impact on healthcare. Its methods have been well defined and explicitly stated. However, failing to recognize its limitations and making a decision under the rubric of EBM, when other variables are clearly playing a role, perpetuates the perception of its limited utility. Advocates of EBM need to wield this instrument carefully and judiciously.

CORRESPONDENCE
Alex Krist, MD, 3825 Charles Stewart Drive, Fairfax VA 22033. E-mail: [email protected]

One day a residency program decided to put its evidence-based medicine (EBM) curriculum to good use. A group of faculty and residents conducted a thorough review of the evidence regarding liquid-based cytoloutilizegy vs conventional Pap smears. They identified the key national recommendations and reviewed the supporting evidence behind each recommendation, tracing back to the individual studies themselves.^1-3

Based on the review, the group concluded that there was insufficient evidence to recommend one method of screening over another, but that there were situations in which one method might be preferred. They presented the evidence and their conclusions to the majority of faculty and residents at grand rounds. Following the presentation, the larger group discussed the relative merits of each screening method and decided the elements of evidence that supported the liquid test were more relevant to the practice than the conventional Pap smear. As a result, a decision was made by the group to stop carrying supplies for the conventional Pap smear. While the decision seemed reasonable on the level of an individual practitioner, several faculty and residents were unhappy with the “evidence-based” decision.

KAP theory and EBM

KAP theory identifies Knowledge, Attitudes, and Practice beliefs as key elements that drive healthcare providers’ decisions about medical care. In a sense EBM represents knowledge.⁴ There is a collective body of medical knowledge in the form of research, which represents “the evidence.” And there is what the healthcare provider himself “knows.” A major purpose of healthcare recommendations, point of care information systems, and best practice guidelines is to help the healthcare provider’s individual medical knowledge reflect the collective body of evidence.

For the purposes of this example, evidence will be considered absolute, inadequate, conditional, or relative. Absolute evidence occurs when there is clearly a correct answer. For example, the net benefits of aspirin for the treatment of myocardial infarction are clear. However, for most topics the evidence is not absolute; rather, it is inconclusive.⁵ The evidence may be inconclusive because it is inadequate—eg, insufficient research, conflicting studies, or research on peripheral topics. As an example, studies have demonstrated that aspirin decreases colorectal polyps, which may or may not be peripheral to the question of whether aspirin prevents colorectal cancer.

The evidence can also be conditional, meaning that in some defined instances the net benefit is clear. However, extending this net benefit beyond these instances is less clear. For example, patients at high risk for cardiovascular disease have a clear net benefit in taking aspirin for myocardial infarction prevention. Finally, the evidence may be relative, with a balance of known benefits and known risks.⁶ Using the aspirin example for cardiovascular disease prevention, patients at moderate risk receive benefit from aspirin in preventing myocardial infarction but at a risk cost of increased bleeding.

When the evidence is inconclusive, the second and third aspects of KAP theory—attitudes and practice beliefs—become very important. Healthcare providers and patients may arrive at different conclusions based on different viewpoints. On an individual level, healthcare practitioners use tools such as shared decision-making and patient-centered care to reach decisions.^6,7 However, inconclusive evidence provides a unique challenge when trying to develop local, regional, or national standards.

Evidence heresy

EBM frequently has negative connotations. In a room full of healthcare providers, some will believe that EBM should revolutionize the practice of medicine,⁸ and some that EBM has limited utility.⁹ How does this happen? The above scenario serves as a useful example, highlighting 3 misuses of the term “evidence” that frequently give EBM a bad name.

First, inconclusive evidence should not be stated in absolute terms; rather, it is more helpful to explicitly state what we know and the limits of what we know. Shaughnessy and Slawson wrote, “Absolute certainty is absolutely impossible, and we do not have to wait for that, of course.”¹⁰ This reflects the paucity of topics with certain evidence and highlights the need for clinicians to act on the available information. Every clinician necessarily utilizes this skill on a daily basis. The clinician has to become an Information Master¹¹ and know not only the end result of what the evidence indicates but also the facts supporting the end results and how those facts apply to the care of an unique individual.¹² However, taking this a step further and stating that one answer or option is absolutely correct in all cases ventures into dangerous ground. During the residency’s discussion of cervical cancer screening tests, the group recognized the merits of both options verbally but, the act of removing all conventional Pap smear supplies implied the nonverbal judgment that liquid-based technology was an absolute correct answer.

Second, while attitudes and practice beliefs can be used to weigh elements of evidence to reach a final conclusion, the conclusion should not negate other perspectives. An important skill of an adept clinician is the ability to interweave the healthcare provider’s and the patient’s attitudes and practice beliefs into the body of existing evidence to determine the appropriate intervention.¹³ However, attitudes and practice beliefs vary from individual to individual and from community to community. When these factors play a critical role in defining the appropriate action based on the evidence, how attitudes and practice beliefs are used should be explicitly stated. In the Pap smear example, the pivotal issue of contention was the belief about whether individual practitioners should act as stewards of limited healthcare resources. Proponents of using solely the liquid-based Pap smear felt the cost problem was a national issue and that the actions of the individual clinician had little impact on global healthcare costs. Others felt their local actions affected insurance premiums, leading directly to decreased healthcare access.¹¹ For cervical cancer, the key impact on mortality is getting any form of screening.¹ Using the liquid-based method for low-risk women may increase cervical cancer mortality by increasing costs and decreasing healthcare access. Removing conventional Pap smears disempowered the latter group of clinicians from implementing their practice beliefs and attitudes.

Finally, a conclusion should not be labeled as “evidence-based” when it is really made on other grounds such as economics, law, ethics, convenience, social values, or policy. Certainly, reviewing medical evidence is an important step in making decisions. However, the process for making decisions on these factors should be held to the same standards as making medical evidence decisions. This includes defining the process and explicitly stating the basis by which final decision will be made. The US is very conflicted when it comes to dealing with these non-evidence issues. We have no national standard for incorporating costs into healthcare decisions.^14,15 With respect to healthcare delivery, we have a wide range of social values that are sometimes disproportionate to logical expectations.¹⁶ Few effective systems are in place to incorporate these elements in healthcare decisions and, as a result, “evidence” is often used as a code word to focus on other issues.

For the Pap smear example, the decision factors were really economics, law, and systems of care. Proponents of the liquid-based method cited the community standard of care, fear of malpractice, patient expectations of receiving the latest technology, and the ease of adopting one screening method for the entire office. Others felt these issues, although important, were secondary to the lack of evidence supporting a liquid-based system as a sole screening method. For lowrisk women, adopting the liquid-based method only makes economic sense if screening is done every 2 or 3 years.¹⁷ However, many low-risk women still favor performing a Pap smear annually.¹⁸ As a result a decision-making process other than the strict EBM method, focusing on other factors would be necessary to change the practice standard.

Conclusions: Recognize the limitations of EBM

Cervical cancer screening serves as a common example of a difficult decision healthcare providers are faced with on a daily basis—what to do when evidence, based on patient oriented outcomes, is inconclusive. Providers do not have the luxury of merely stating the evidence is inconclusive; they must act. Frequently decisions are based on attitudes and practice beliefs in a broader context of unique economic, legal, and practice environments.

EBM is one tool in the decision-making armamentarium. It is a very powerful tool and has had a very positive impact on healthcare. Its methods have been well defined and explicitly stated. However, failing to recognize its limitations and making a decision under the rubric of EBM, when other variables are clearly playing a role, perpetuates the perception of its limited utility. Advocates of EBM need to wield this instrument carefully and judiciously.

CORRESPONDENCE
Alex Krist, MD, 3825 Charles Stewart Drive, Fairfax VA 22033. E-mail: [email protected]

One day a residency program decided to put its evidence-based medicine (EBM) curriculum to good use. A group of faculty and residents conducted a thorough review of the evidence regarding liquid-based cytoloutilizegy vs conventional Pap smears. They identified the key national recommendations and reviewed the supporting evidence behind each recommendation, tracing back to the individual studies themselves.^1-3

Based on the review, the group concluded that there was insufficient evidence to recommend one method of screening over another, but that there were situations in which one method might be preferred. They presented the evidence and their conclusions to the majority of faculty and residents at grand rounds. Following the presentation, the larger group discussed the relative merits of each screening method and decided the elements of evidence that supported the liquid test were more relevant to the practice than the conventional Pap smear. As a result, a decision was made by the group to stop carrying supplies for the conventional Pap smear. While the decision seemed reasonable on the level of an individual practitioner, several faculty and residents were unhappy with the “evidence-based” decision.

KAP theory and EBM

KAP theory identifies Knowledge, Attitudes, and Practice beliefs as key elements that drive healthcare providers’ decisions about medical care. In a sense EBM represents knowledge.⁴ There is a collective body of medical knowledge in the form of research, which represents “the evidence.” And there is what the healthcare provider himself “knows.” A major purpose of healthcare recommendations, point of care information systems, and best practice guidelines is to help the healthcare provider’s individual medical knowledge reflect the collective body of evidence.

For the purposes of this example, evidence will be considered absolute, inadequate, conditional, or relative. Absolute evidence occurs when there is clearly a correct answer. For example, the net benefits of aspirin for the treatment of myocardial infarction are clear. However, for most topics the evidence is not absolute; rather, it is inconclusive.⁵ The evidence may be inconclusive because it is inadequate—eg, insufficient research, conflicting studies, or research on peripheral topics. As an example, studies have demonstrated that aspirin decreases colorectal polyps, which may or may not be peripheral to the question of whether aspirin prevents colorectal cancer.

The evidence can also be conditional, meaning that in some defined instances the net benefit is clear. However, extending this net benefit beyond these instances is less clear. For example, patients at high risk for cardiovascular disease have a clear net benefit in taking aspirin for myocardial infarction prevention. Finally, the evidence may be relative, with a balance of known benefits and known risks.⁶ Using the aspirin example for cardiovascular disease prevention, patients at moderate risk receive benefit from aspirin in preventing myocardial infarction but at a risk cost of increased bleeding.

When the evidence is inconclusive, the second and third aspects of KAP theory—attitudes and practice beliefs—become very important. Healthcare providers and patients may arrive at different conclusions based on different viewpoints. On an individual level, healthcare practitioners use tools such as shared decision-making and patient-centered care to reach decisions.^6,7 However, inconclusive evidence provides a unique challenge when trying to develop local, regional, or national standards.

Evidence heresy

EBM frequently has negative connotations. In a room full of healthcare providers, some will believe that EBM should revolutionize the practice of medicine,⁸ and some that EBM has limited utility.⁹ How does this happen? The above scenario serves as a useful example, highlighting 3 misuses of the term “evidence” that frequently give EBM a bad name.

First, inconclusive evidence should not be stated in absolute terms; rather, it is more helpful to explicitly state what we know and the limits of what we know. Shaughnessy and Slawson wrote, “Absolute certainty is absolutely impossible, and we do not have to wait for that, of course.”¹⁰ This reflects the paucity of topics with certain evidence and highlights the need for clinicians to act on the available information. Every clinician necessarily utilizes this skill on a daily basis. The clinician has to become an Information Master¹¹ and know not only the end result of what the evidence indicates but also the facts supporting the end results and how those facts apply to the care of an unique individual.¹² However, taking this a step further and stating that one answer or option is absolutely correct in all cases ventures into dangerous ground. During the residency’s discussion of cervical cancer screening tests, the group recognized the merits of both options verbally but, the act of removing all conventional Pap smear supplies implied the nonverbal judgment that liquid-based technology was an absolute correct answer.

Second, while attitudes and practice beliefs can be used to weigh elements of evidence to reach a final conclusion, the conclusion should not negate other perspectives. An important skill of an adept clinician is the ability to interweave the healthcare provider’s and the patient’s attitudes and practice beliefs into the body of existing evidence to determine the appropriate intervention.¹³ However, attitudes and practice beliefs vary from individual to individual and from community to community. When these factors play a critical role in defining the appropriate action based on the evidence, how attitudes and practice beliefs are used should be explicitly stated. In the Pap smear example, the pivotal issue of contention was the belief about whether individual practitioners should act as stewards of limited healthcare resources. Proponents of using solely the liquid-based Pap smear felt the cost problem was a national issue and that the actions of the individual clinician had little impact on global healthcare costs. Others felt their local actions affected insurance premiums, leading directly to decreased healthcare access.¹¹ For cervical cancer, the key impact on mortality is getting any form of screening.¹ Using the liquid-based method for low-risk women may increase cervical cancer mortality by increasing costs and decreasing healthcare access. Removing conventional Pap smears disempowered the latter group of clinicians from implementing their practice beliefs and attitudes.

Finally, a conclusion should not be labeled as “evidence-based” when it is really made on other grounds such as economics, law, ethics, convenience, social values, or policy. Certainly, reviewing medical evidence is an important step in making decisions. However, the process for making decisions on these factors should be held to the same standards as making medical evidence decisions. This includes defining the process and explicitly stating the basis by which final decision will be made. The US is very conflicted when it comes to dealing with these non-evidence issues. We have no national standard for incorporating costs into healthcare decisions.^14,15 With respect to healthcare delivery, we have a wide range of social values that are sometimes disproportionate to logical expectations.¹⁶ Few effective systems are in place to incorporate these elements in healthcare decisions and, as a result, “evidence” is often used as a code word to focus on other issues.

For the Pap smear example, the decision factors were really economics, law, and systems of care. Proponents of the liquid-based method cited the community standard of care, fear of malpractice, patient expectations of receiving the latest technology, and the ease of adopting one screening method for the entire office. Others felt these issues, although important, were secondary to the lack of evidence supporting a liquid-based system as a sole screening method. For lowrisk women, adopting the liquid-based method only makes economic sense if screening is done every 2 or 3 years.¹⁷ However, many low-risk women still favor performing a Pap smear annually.¹⁸ As a result a decision-making process other than the strict EBM method, focusing on other factors would be necessary to change the practice standard.

Conclusions: Recognize the limitations of EBM

Cervical cancer screening serves as a common example of a difficult decision healthcare providers are faced with on a daily basis—what to do when evidence, based on patient oriented outcomes, is inconclusive. Providers do not have the luxury of merely stating the evidence is inconclusive; they must act. Frequently decisions are based on attitudes and practice beliefs in a broader context of unique economic, legal, and practice environments.

EBM is one tool in the decision-making armamentarium. It is a very powerful tool and has had a very positive impact on healthcare. Its methods have been well defined and explicitly stated. However, failing to recognize its limitations and making a decision under the rubric of EBM, when other variables are clearly playing a role, perpetuates the perception of its limited utility. Advocates of EBM need to wield this instrument carefully and judiciously.

CORRESPONDENCE
Alex Krist, MD, 3825 Charles Stewart Drive, Fairfax VA 22033. E-mail: [email protected]

Evidence-based medicine (EBM) involves decision-making based on the systematic identification and critical appraisal of research evidence in combination with clinical expertise and patient values.¹ Two important EBM tools are systematic reviews and an activity known as systematic literature surveillance.

Surveillance complements commonly used resources. Systematic reviews answer a precisely defined question using explicit methods to search for, select, evaluate, and synthesize available evidence. Though extremely valuable, new systematic reviews cannot be produced at a rate that keeps pace with new research information.²

Systematic literature surveillance, by contrast, starts with the evidence and uses explicit, protocol-based methods to select, evaluate, and synthesize new research information. It is an efficient way to find answers to numerous clinical questions, and thus complements systematic reviews for supporting point-of-care clinical references. Both tools should be an indispensable part of supporting clinical practice.

It can dramatically change knowledge. Imagine being faced with a patient who has a clinically significant head injury and not having immediate specialty backup. Steroid administration has been promoted to reduce cerebral edema. You search the Cochrane Library and find a systematic review of 19 randomized trials with 2295 patients. The review concludes that evidence is insufficient to rule out moderate benefits or moderate harms.³ A source complementing systematic reviews with systematic literature surveillance would include a more recent randomized trial with 10,008 patients showing that steroids significantly increase mortality at 2 weeks.⁴

And it’s efficient. Because each article can be identified and evaluated “once”—rather than repeatedly for separate questions posed in systematic reviews—systematic literature surveillance is a more efficient means for answering a large number of questions. It may be used for clinician alerting/newsletter services^5,6 or for updating knowledge syntheses in a clinical reference.⁷

To find the best available evidence during clinical practice, the evidence-based clinician should use references that synthesize the results of systematic literature surveillance and systematic reviews.

CORRESPONDENCE
Brian S. Alper, MD, MSPH, DynaMed, 3610 Buttonwood Drive, Suite 200, Columbia, MO 65201. E-mail: [email protected]

Evidence-based medicine (EBM) involves decision-making based on the systematic identification and critical appraisal of research evidence in combination with clinical expertise and patient values.¹ Two important EBM tools are systematic reviews and an activity known as systematic literature surveillance.

Surveillance complements commonly used resources. Systematic reviews answer a precisely defined question using explicit methods to search for, select, evaluate, and synthesize available evidence. Though extremely valuable, new systematic reviews cannot be produced at a rate that keeps pace with new research information.²

Systematic literature surveillance, by contrast, starts with the evidence and uses explicit, protocol-based methods to select, evaluate, and synthesize new research information. It is an efficient way to find answers to numerous clinical questions, and thus complements systematic reviews for supporting point-of-care clinical references. Both tools should be an indispensable part of supporting clinical practice.

It can dramatically change knowledge. Imagine being faced with a patient who has a clinically significant head injury and not having immediate specialty backup. Steroid administration has been promoted to reduce cerebral edema. You search the Cochrane Library and find a systematic review of 19 randomized trials with 2295 patients. The review concludes that evidence is insufficient to rule out moderate benefits or moderate harms.³ A source complementing systematic reviews with systematic literature surveillance would include a more recent randomized trial with 10,008 patients showing that steroids significantly increase mortality at 2 weeks.⁴

And it’s efficient. Because each article can be identified and evaluated “once”—rather than repeatedly for separate questions posed in systematic reviews—systematic literature surveillance is a more efficient means for answering a large number of questions. It may be used for clinician alerting/newsletter services^5,6 or for updating knowledge syntheses in a clinical reference.⁷

To find the best available evidence during clinical practice, the evidence-based clinician should use references that synthesize the results of systematic literature surveillance and systematic reviews.

CORRESPONDENCE
Brian S. Alper, MD, MSPH, DynaMed, 3610 Buttonwood Drive, Suite 200, Columbia, MO 65201. E-mail: [email protected]

Evidence-based medicine (EBM) involves decision-making based on the systematic identification and critical appraisal of research evidence in combination with clinical expertise and patient values.¹ Two important EBM tools are systematic reviews and an activity known as systematic literature surveillance.

Surveillance complements commonly used resources. Systematic reviews answer a precisely defined question using explicit methods to search for, select, evaluate, and synthesize available evidence. Though extremely valuable, new systematic reviews cannot be produced at a rate that keeps pace with new research information.²

Systematic literature surveillance, by contrast, starts with the evidence and uses explicit, protocol-based methods to select, evaluate, and synthesize new research information. It is an efficient way to find answers to numerous clinical questions, and thus complements systematic reviews for supporting point-of-care clinical references. Both tools should be an indispensable part of supporting clinical practice.

It can dramatically change knowledge. Imagine being faced with a patient who has a clinically significant head injury and not having immediate specialty backup. Steroid administration has been promoted to reduce cerebral edema. You search the Cochrane Library and find a systematic review of 19 randomized trials with 2295 patients. The review concludes that evidence is insufficient to rule out moderate benefits or moderate harms.³ A source complementing systematic reviews with systematic literature surveillance would include a more recent randomized trial with 10,008 patients showing that steroids significantly increase mortality at 2 weeks.⁴

And it’s efficient. Because each article can be identified and evaluated “once”—rather than repeatedly for separate questions posed in systematic reviews—systematic literature surveillance is a more efficient means for answering a large number of questions. It may be used for clinician alerting/newsletter services^5,6 or for updating knowledge syntheses in a clinical reference.⁷

To find the best available evidence during clinical practice, the evidence-based clinician should use references that synthesize the results of systematic literature surveillance and systematic reviews.

CORRESPONDENCE
Brian S. Alper, MD, MSPH, DynaMed, 3610 Buttonwood Drive, Suite 200, Columbia, MO 65201. E-mail: [email protected]

Levels of evidence are assigned to studies based on the quality of their design, validity, and applicability to patient care. The Agency for Health Care Quality and Research (AHRQ) has proposed that any system assigning levels of evidence should incorporate quality, quantity, and consistency of the evidence.

Leading family medicine journals have adopted a uniform grading system known as the Strength of Recommendation Taxonomy¹ (SORT), which includes these key elements and 3 levels of evidence. SORT is one among several different methods of grading levels of evidence that make use of similar principles. SORT’s primary advantage is its simplicity.

The randomized controlled trial (RCT) is the most rigorous study design. According to SORT, RCTs that deal with patient-oriented outcomes and include concealment, double-blinding, intention-to-treat analysis, and complete follow-up (and meta-analyses or systematic reviews of such randomized trials) provide Level 1 evidence. Observational studies, such as cohort and case-control studies (and systematic reviews that include them), are less rigorous in their design. They are assigned a Level of Evidence of 2. Level 3 evidence, the lowest level, is assigned to consensus guidelines, expert opinion, usual practice, and so forth, or to studies that look at intermediate or disease-ori-ented outcomes.

How it applies to recent findings

Although the Nurses Health Study,² a large cohort trial involving nearly 88,000 women, and other observational studies (SORT LOE: 2) suggested a cardiovascular benefit from vitamin E; the Finnish Alpha-Tocopherol, Beta-Carotene Cancer Prevention study,³ a well-designed RCT (LOE: 1), proved the opposite. A recently published Italian study⁴ provided Level 3 evidence, demonstrating that vitamin E prevented an oxidation-induced reduction in coronary blood flow. Therefore, based on the highest level of evidence available, vitamin E to prevent cardiovascular disease is not recommended.

Levels of evidence can make it easier for busy physicians to apply the results of clinical research to their practice and to incorporate evidence-based medicine into patient care.

Levels of evidence are assigned to studies based on the quality of their design, validity, and applicability to patient care. The Agency for Health Care Quality and Research (AHRQ) has proposed that any system assigning levels of evidence should incorporate quality, quantity, and consistency of the evidence.

Leading family medicine journals have adopted a uniform grading system known as the Strength of Recommendation Taxonomy¹ (SORT), which includes these key elements and 3 levels of evidence. SORT is one among several different methods of grading levels of evidence that make use of similar principles. SORT’s primary advantage is its simplicity.

The randomized controlled trial (RCT) is the most rigorous study design. According to SORT, RCTs that deal with patient-oriented outcomes and include concealment, double-blinding, intention-to-treat analysis, and complete follow-up (and meta-analyses or systematic reviews of such randomized trials) provide Level 1 evidence. Observational studies, such as cohort and case-control studies (and systematic reviews that include them), are less rigorous in their design. They are assigned a Level of Evidence of 2. Level 3 evidence, the lowest level, is assigned to consensus guidelines, expert opinion, usual practice, and so forth, or to studies that look at intermediate or disease-ori-ented outcomes.

How it applies to recent findings

Although the Nurses Health Study,² a large cohort trial involving nearly 88,000 women, and other observational studies (SORT LOE: 2) suggested a cardiovascular benefit from vitamin E; the Finnish Alpha-Tocopherol, Beta-Carotene Cancer Prevention study,³ a well-designed RCT (LOE: 1), proved the opposite. A recently published Italian study⁴ provided Level 3 evidence, demonstrating that vitamin E prevented an oxidation-induced reduction in coronary blood flow. Therefore, based on the highest level of evidence available, vitamin E to prevent cardiovascular disease is not recommended.

Levels of evidence can make it easier for busy physicians to apply the results of clinical research to their practice and to incorporate evidence-based medicine into patient care.

Levels of evidence are assigned to studies based on the quality of their design, validity, and applicability to patient care. The Agency for Health Care Quality and Research (AHRQ) has proposed that any system assigning levels of evidence should incorporate quality, quantity, and consistency of the evidence.

Leading family medicine journals have adopted a uniform grading system known as the Strength of Recommendation Taxonomy¹ (SORT), which includes these key elements and 3 levels of evidence. SORT is one among several different methods of grading levels of evidence that make use of similar principles. SORT’s primary advantage is its simplicity.

The randomized controlled trial (RCT) is the most rigorous study design. According to SORT, RCTs that deal with patient-oriented outcomes and include concealment, double-blinding, intention-to-treat analysis, and complete follow-up (and meta-analyses or systematic reviews of such randomized trials) provide Level 1 evidence. Observational studies, such as cohort and case-control studies (and systematic reviews that include them), are less rigorous in their design. They are assigned a Level of Evidence of 2. Level 3 evidence, the lowest level, is assigned to consensus guidelines, expert opinion, usual practice, and so forth, or to studies that look at intermediate or disease-ori-ented outcomes.

How it applies to recent findings

Although the Nurses Health Study,² a large cohort trial involving nearly 88,000 women, and other observational studies (SORT LOE: 2) suggested a cardiovascular benefit from vitamin E; the Finnish Alpha-Tocopherol, Beta-Carotene Cancer Prevention study,³ a well-designed RCT (LOE: 1), proved the opposite. A recently published Italian study⁴ provided Level 3 evidence, demonstrating that vitamin E prevented an oxidation-induced reduction in coronary blood flow. Therefore, based on the highest level of evidence available, vitamin E to prevent cardiovascular disease is not recommended.

Levels of evidence can make it easier for busy physicians to apply the results of clinical research to their practice and to incorporate evidence-based medicine into patient care.

It is widely perceived and documented that both of the following are valuable attributes of treatment relationships: 1) patients’ trust in physicians and in the medical profession,¹ and 2) patients’ active involvement in treatment seeking, decision making, and adherence.^2-8 Both patient trust and active patient involvement are desirable in their own right and because they are associated with improved health outcomes. Paradoxically, however, it might be thought that these 2 attributes are in sharp conflict.

Patient trust might be more consistent with a deferential style of patient-physician interaction in which patients are passive, in contrast to assertive patient questioning or limitation of physician authority which might be indicative of patient distrust. If so, then pursuing active patient involvement might lead to lower trust, or promoting trust might lead to more passive patients, either of which might compromise optimal treatment relationships and health outcomes. At a minimum, it is a conceptual puzzle how these 2 views of desirable attributes of medical relationships can coexist without each taking account of the other view. There certainly are skeptics of patient trust who warn that, contrary to conventional wisdom, too much trust might be negative and that patients, for their own good, should be encouraged to trust less to avoid the dangers of paternalistic medicine,⁹ especially in managed care settings. ^10,11

Numerous studies examine either patient trust or patients’ roles in seeking care, level of participation in medical decisions, and adherence to treatment. However, few studies examine both halves of these 2 sets of attitudes and behaviors, and none examine the full cluster. None of the leading studies of patients’ attitudes toward seeking care or participating in medical decisions include measures of trust. A few studies of care-seeking also examine attitudes similar to or overlapping with trust, such as confidentiality or competency,^12,13 but none of these use the trust concept itself or any of the validated instruments that measure trust. Among studies of trust, some have explored trust’s connections with adherence,¹⁴ preferred role in decision making,¹⁵ patients’ requests for specific services,¹⁶ or willingness to seek care,^17,18 but few studies simultaneously explore these measures,^17,18 and only 1 study examines how they relate to trust in the medical profession, rather than trust in a specific physician.¹⁸ In general, these studies report that trust in a specific physician is associated with greater adherence to treatment recommendations, more willingness to seek care, and giving physicians more control over medical decisions.

Absent in this literature is any concurrent examination of how different types of trust relate to various aspects of patients’ views about their involvement in medical care. To advance understanding of these important connections, this study was designed to investigate whether patients’ trust in their primary physician and in the medical profession are related to their attitudes toward seeking care, preferred roles in medical decision making, and reported adherence to treatment recommendations.

Methods

How the sample was collected

A random national sample of 2637 households was selected in 1999 from a proprietary database of working residential telephone exchanges in the continental United States. A minimum of 15 attempts was made to reach those numbers that were not answered. Respondent selection within eligible households was done using the next birthday method.¹⁹

Inclusion criteria for the study included being at least 21 years of age and the ability to speak and understand English. Because this survey was part of a larger study of recent experiences with physicians and health insurers,^20-22 respondents were further screened to select only those with some type of public or private health care coverage and those who had been to a physician or other health professional at least twice during the past 2 years. Health care coverage broadly includes any type of public or private insurance, or access to other type of government or indigent care program or facility.

Contacts with 2172 potentially eligible individuals resulted in the following dispositions: 1117 (51.4%) were interviewed; 571 (26.3%) refused; 484 (22.3%) were unable to participate (not home, ill, non-English-speaking). To reduce respondent burden, the sample was randomly divided and only half (N=553) were asked the battery of questions about trust in the medical profession and following physicians’ recommendations. (The other half were asked other questions unrelated to this analysis. There were no statistically significant differences between the 2 halves on age, race, gender, health status, education, or income.)

Due to the particular selection criteria and survey method, this random sample is not fully representative of national norms. There is a somewhat greater representation of whites (84.3%) and females (68.9%) because they are more likely to have insurance and have gone to a physician recently. Otherwise, the majority of our sample was between 30 to 60 years old (58%) and college educated (58%), with a median income of about $40,000. Thus, the sample composition is sufficient to analyze most major demographic and socioeconomic groups.

Telephone interviews lasted approximately 25 minutes and were conducted by trained interviewers at the Survey Research Center of the University of South Carolina using computer assisted telephone interviewing. Verbal informed consent was obtained at the start of the telephone interviews and the study protocols were reviewed and approved by Wake Forest University Medical Center’s Institutional Review Board.

Measures

Attitudes toward and preferred roles in medical care were measured by the 5 questions listed in TABLE 1 . Data were also collected on a range of topics, including demographic characteristics, trust in the subject’s regular physician and the medical profession, satisfaction with care, and physical and mental health. Trust in the specific physician and in the medical profession were measured by 5-item scales, whose validation and properties are reported elsewhere (Cronbach’s alpha ≥0.77 for all).²³ Satisfaction with medical care was measured with a previously validated 12-item scale asking about health care received from all sources over the past few years.²⁴

TABLE 1
Items assessing patients’ roles in medical relationships

Statistical analysis

To assess patients’ involvement in medical care, frequencies of response categories were calculated for the general study population, as well as key subgroups— men, African Americans, and the elderly (age ≥65 years). Chi-square tests were used to determine whether views varied by sex, race, and the elderly. Spearman correlation was used to assess the relationship of the 5 views to each other, as well as to test whether views varied by trust in the physician and the medical profession, satisfaction with care, age, education, income, physical and mental health, number of visits and years with physician, and past dispute with a physician. Finally, multivariate regressions were performed to determine the most significant predictors of involvement in medical care. In all analyses, a P-value of .05 was considered statistically significant. However, in recognition of the multiple testing environment, consistency over the 5 items was considered as well.

Results

TABLE 2 summarizes the response frequencies for the 5 questions and TABLE 3 shows the correlations of the 5 items with each other. All items are significantly correlated at level 0.005 or below. As one might expect, the questions on relying on physicians’ judgment and seeking professional help are most correlated, as are physician/patient control and roles.

TABLE 2
Views of the general population and subgroups about involvement in medical care

TABLE 3
Correlation between views on involvement in medical care

Trust and satisfaction

As shown in TABLE 4 , trust in a specific physician is associated only with always following recommendations. Trust in the medical profession and satisfaction with care are both highly associated with all 5 views towards involvement in medical care. More trust in the medical profession, and greater satisfaction with care, are associated with following recommendations, relying on the judgment of physicians, seeking professional medical help, and granting increased control and decision making to the physician.

TABLE 4
Correlation between trust and satisfaction and medical views

Patient demographics

A number of patient demographic characteristics are significantly associated with patients’ involvement in medical care. Women are less likely to want to rely on the judgment of physicians and are more likely to want to share control and make joint decisions. There is also an extremely strong effect of age. The elderly (age ≥65 years) are more compliant, deferential, and passive under each of our measures. Interestingly, race has no significant effects on these measures of involvement.

Patients with less education are more likely to want to follow physicians’ recommendations, rely on their physician’s judgment, and seek professional medical help (P=.0015, <0.001, 0.027, respectively). They are also more likely to give the physician more control and authority to make decisions for them (P<.001 for both). People with less income (on a 9-point scale) are also more likely to want to follow physicians’ recommendations, rely on their judgment, and give the physician more control and authority (P<.007 for all). Patients in worse physical health (on a 5-point scale) are more likely to want to rely on the judgment of physicians and to seek professional medical help (correlation=0.11; P=.014, .017). There is no significant association between mental health and any of these views.

Patients’ relationship with physicians

Several aspects of the patient/physician relationship were significantly associated with patients’ involvement in medical care. Not surprisingly, willingness to seek professional medical help increases with number of visits to the physician (P=.039), and granting increased control and decision making to the physician increases with continuity of care, as measured by number of years with the physician (P=.001, .037). Additionally, having had a past dispute with a physician was significantly related to patients’ involvement in medical care. Patients with a past dispute were less likely to always follow physicians’ recommendations, rely on the judgment of physicians, or seek professional medical help. They were also more likely to take control and make medical decisions themselves.

Multivariate regression models

Multivariate regression models were used to determine the most significant predictors of patients’ involvement in medical care. Multivariate linear regression was used for the outcomes of following physicians’ recommendations and physician/patient control and roles. Logistic regression was used for the binary outcome variables— rely on physician’s judgment and seek professional help.

The predictor variables used in the model were sex, age, education, physical health, number of physician visits, number of years with physician, past dispute, trust, and satisfaction with care. Income and elderly were not used as they are correlated with education and age, respectively, which were more predictive of patient involvement. Significant predictors are shown in TABLE 5 . Notably, the patient’s trust in their specific physician did not predict any of these views, and satisfaction with care predicted only following physicians’ recommendations. Demographic, health status, and other variables were also nonsignificant in many or most regressions. Only trust in the medical profession predicted all 5 views.

TABLE 5
P-values for significant predictors in the multivariate analysis

Discussion

What predicts involvement in medical care?

Trust a key predictor. Trust in the medical profession is a key predictor of people’s involvement in medical care. It is a significant predictor of self reports of: 1) following physicians’ treatment recommendations, willingness to 2) seek care and to 3) rely on physicians’ judgment, and wanting to 4) give physicians more control and 5) let them make decisions for patients. Most other relationship factors (trust in a specific physician, length and continuity of treatment relationship, past dispute with physician) predict fewer of these variables and are no longer significant in multivariate analyses. In bivariate analyses, satisfaction with care is also a consistent predictor of all 5 measures of involvement in medical care, but it usually no longer remains significant in regression analyses once trust in the medical profession is added to the models.

Demographics not significant. Similarly, demographic characteristics such as age, sex, or education often are no longer significant in regression models that control for trust in the medical profession, suggesting that, in some instances, these factors may influence views about involvement through their effect on trust in the medical profession.

Patient roles and control of medical care.

In general, increased trust in the medical profession is associated with a more deferential patient role in medical relationships. Higher trust is associated with greater willingness to give control to physicians and allow them to make decisions for the patient. However, other aspects of patient involvement are not as easily classified as deferential in the sense of the term that connotes a passive patient role. Trust in the medical profession is also associated with greater willingness to seek care and to comply with treatment recommendations.

To the extent that trust is associated with deferential or passive patient roles, it is notable that this association exists primarily only with the measures that refer to the medical system as a whole (including satisfaction with care generally), and not with the measures that are specific to particular physicians. The latter include trust in the patient’s personal physician, past disputes with that physician, number of visits with that physician, and length of relationship with that physician. Each of these is much less predictive of patients’ involvement in medical care than is trust in the medical profession or satisfaction with care generally.

What does this say about patient relationships in general?

This suggests, consistent with prior research,^18,22 that patients’ views about particular physicians are substantially (but not entirely) independent from their views about the medical system in general. This finding is also consistent with prior explanations that the nature of interpersonal physician trust evolves over the course of an ongoing treatment relationship to accommodate both more active and more passive patient roles.²⁵ In fact, in our sample, trust in the specific physician was generally quite high regardless of preferred involvement in medical care.

Throughout all of these associations, the direction of possible causality is not established by this study. A person’s attitudes about involvement in medical care may be determined by their trust in the medical profession, or their trust may be determined by the types of involvement they have had in medical care. Most likely, there is a cyclical relationship between the 2.³⁵

These findings provide reassurance that promoting trust will not likely cause a reversion to excessively paternalistic medical relationships. Trust in specific physicians is only weakly related to patients’ views about active vs passive roles. Trust in the medical profession is much more pertinent to these views, but that type of trust is distinct from trust in specific physicians. Moreover, trust in the medical profession is consistent with some desirable forms of patient involvement.

These findings also suggest that trust is able to form in relationships where patients are either active or passive. Assertive patient involvement should not be seen as indicative of distrust. Instead, other studies suggest that trust is promoted by communicating effectively with patients such as by listening carefully, answering questions clearly, giving them as much information as they want, and involving them in medical decisions.^26,27

Attitudes towards involvement in medical care. Apart from the relationship to trust, these findings shed important light on general attitudes toward involvement in medical care. Overall, the majority of people report following their physicians’ recommendations and think that it is better to rely on the expert judgment of physicians and seek professional help. Most people think the physician and patient should share control equally and make decisions together. More patients give control to their physicians than to themselves. These findings are consistent with previous studies.^8,28-36

Also, consistent with prior studies, we found that younger and more educated patients prefer more assertive roles, as do women. We found no racial differences, but this may be due to the under representation of minorities in our sample. Finally, the small amount of variability explained in our models indicates that while we have identified predictive factors, many other factors affect people’s views towards medical care. Physicians need to be aware that patient desires for participation vary, and communication about such desires is necessary during visits.

Limitations of this study

Several study limitations should be noted. First, our measures of involvement in medical care are self-reported and do not necessarily reflect patients’ actual behaviors. However, most measures have been previously validated to some extent. Second, the selection criteria for the study do not allow for generalization to populations that less routinely seek care or are uninsured. Lastly, this is an exploratory study that was not driven by specific hypotheses derived from prior studies or firm theory. The empirical study of trust and its connection with other attitudes and relationship characteristics is still in its infancy,³⁷ which calls for more exploratory approaches that identify areas of focus for future research. The connection between trust and patients’ involvement in medical care is one such area deserving further study.

Acknowledgments

Research supported by the Robert Wood Johnson Foundation, the National Eye Institute (EY012443-02), and the National Institute on Aging (AG015248-03).

CORRESPONDING AUTHOR
Felicia Trachtenberg, PhD, New England Research Institutes, 9 Galen Street, Watertown, MA 02472. E-mail: [email protected]

It is widely perceived and documented that both of the following are valuable attributes of treatment relationships: 1) patients’ trust in physicians and in the medical profession,¹ and 2) patients’ active involvement in treatment seeking, decision making, and adherence.^2-8 Both patient trust and active patient involvement are desirable in their own right and because they are associated with improved health outcomes. Paradoxically, however, it might be thought that these 2 attributes are in sharp conflict.

Patient trust might be more consistent with a deferential style of patient-physician interaction in which patients are passive, in contrast to assertive patient questioning or limitation of physician authority which might be indicative of patient distrust. If so, then pursuing active patient involvement might lead to lower trust, or promoting trust might lead to more passive patients, either of which might compromise optimal treatment relationships and health outcomes. At a minimum, it is a conceptual puzzle how these 2 views of desirable attributes of medical relationships can coexist without each taking account of the other view. There certainly are skeptics of patient trust who warn that, contrary to conventional wisdom, too much trust might be negative and that patients, for their own good, should be encouraged to trust less to avoid the dangers of paternalistic medicine,⁹ especially in managed care settings. ^10,11

Numerous studies examine either patient trust or patients’ roles in seeking care, level of participation in medical decisions, and adherence to treatment. However, few studies examine both halves of these 2 sets of attitudes and behaviors, and none examine the full cluster. None of the leading studies of patients’ attitudes toward seeking care or participating in medical decisions include measures of trust. A few studies of care-seeking also examine attitudes similar to or overlapping with trust, such as confidentiality or competency,^12,13 but none of these use the trust concept itself or any of the validated instruments that measure trust. Among studies of trust, some have explored trust’s connections with adherence,¹⁴ preferred role in decision making,¹⁵ patients’ requests for specific services,¹⁶ or willingness to seek care,^17,18 but few studies simultaneously explore these measures,^17,18 and only 1 study examines how they relate to trust in the medical profession, rather than trust in a specific physician.¹⁸ In general, these studies report that trust in a specific physician is associated with greater adherence to treatment recommendations, more willingness to seek care, and giving physicians more control over medical decisions.

Absent in this literature is any concurrent examination of how different types of trust relate to various aspects of patients’ views about their involvement in medical care. To advance understanding of these important connections, this study was designed to investigate whether patients’ trust in their primary physician and in the medical profession are related to their attitudes toward seeking care, preferred roles in medical decision making, and reported adherence to treatment recommendations.

Methods

How the sample was collected

A random national sample of 2637 households was selected in 1999 from a proprietary database of working residential telephone exchanges in the continental United States. A minimum of 15 attempts was made to reach those numbers that were not answered. Respondent selection within eligible households was done using the next birthday method.¹⁹

Inclusion criteria for the study included being at least 21 years of age and the ability to speak and understand English. Because this survey was part of a larger study of recent experiences with physicians and health insurers,^20-22 respondents were further screened to select only those with some type of public or private health care coverage and those who had been to a physician or other health professional at least twice during the past 2 years. Health care coverage broadly includes any type of public or private insurance, or access to other type of government or indigent care program or facility.

Contacts with 2172 potentially eligible individuals resulted in the following dispositions: 1117 (51.4%) were interviewed; 571 (26.3%) refused; 484 (22.3%) were unable to participate (not home, ill, non-English-speaking). To reduce respondent burden, the sample was randomly divided and only half (N=553) were asked the battery of questions about trust in the medical profession and following physicians’ recommendations. (The other half were asked other questions unrelated to this analysis. There were no statistically significant differences between the 2 halves on age, race, gender, health status, education, or income.)

Due to the particular selection criteria and survey method, this random sample is not fully representative of national norms. There is a somewhat greater representation of whites (84.3%) and females (68.9%) because they are more likely to have insurance and have gone to a physician recently. Otherwise, the majority of our sample was between 30 to 60 years old (58%) and college educated (58%), with a median income of about $40,000. Thus, the sample composition is sufficient to analyze most major demographic and socioeconomic groups.

Telephone interviews lasted approximately 25 minutes and were conducted by trained interviewers at the Survey Research Center of the University of South Carolina using computer assisted telephone interviewing. Verbal informed consent was obtained at the start of the telephone interviews and the study protocols were reviewed and approved by Wake Forest University Medical Center’s Institutional Review Board.

Measures

Attitudes toward and preferred roles in medical care were measured by the 5 questions listed in TABLE 1 . Data were also collected on a range of topics, including demographic characteristics, trust in the subject’s regular physician and the medical profession, satisfaction with care, and physical and mental health. Trust in the specific physician and in the medical profession were measured by 5-item scales, whose validation and properties are reported elsewhere (Cronbach’s alpha ≥0.77 for all).²³ Satisfaction with medical care was measured with a previously validated 12-item scale asking about health care received from all sources over the past few years.²⁴

TABLE 1
Items assessing patients’ roles in medical relationships

Statistical analysis

To assess patients’ involvement in medical care, frequencies of response categories were calculated for the general study population, as well as key subgroups— men, African Americans, and the elderly (age ≥65 years). Chi-square tests were used to determine whether views varied by sex, race, and the elderly. Spearman correlation was used to assess the relationship of the 5 views to each other, as well as to test whether views varied by trust in the physician and the medical profession, satisfaction with care, age, education, income, physical and mental health, number of visits and years with physician, and past dispute with a physician. Finally, multivariate regressions were performed to determine the most significant predictors of involvement in medical care. In all analyses, a P-value of .05 was considered statistically significant. However, in recognition of the multiple testing environment, consistency over the 5 items was considered as well.

Results

TABLE 2 summarizes the response frequencies for the 5 questions and TABLE 3 shows the correlations of the 5 items with each other. All items are significantly correlated at level 0.005 or below. As one might expect, the questions on relying on physicians’ judgment and seeking professional help are most correlated, as are physician/patient control and roles.

TABLE 2
Views of the general population and subgroups about involvement in medical care

TABLE 3
Correlation between views on involvement in medical care

Trust and satisfaction

As shown in TABLE 4 , trust in a specific physician is associated only with always following recommendations. Trust in the medical profession and satisfaction with care are both highly associated with all 5 views towards involvement in medical care. More trust in the medical profession, and greater satisfaction with care, are associated with following recommendations, relying on the judgment of physicians, seeking professional medical help, and granting increased control and decision making to the physician.

TABLE 4
Correlation between trust and satisfaction and medical views

Patient demographics

A number of patient demographic characteristics are significantly associated with patients’ involvement in medical care. Women are less likely to want to rely on the judgment of physicians and are more likely to want to share control and make joint decisions. There is also an extremely strong effect of age. The elderly (age ≥65 years) are more compliant, deferential, and passive under each of our measures. Interestingly, race has no significant effects on these measures of involvement.

Patients with less education are more likely to want to follow physicians’ recommendations, rely on their physician’s judgment, and seek professional medical help (P=.0015, <0.001, 0.027, respectively). They are also more likely to give the physician more control and authority to make decisions for them (P<.001 for both). People with less income (on a 9-point scale) are also more likely to want to follow physicians’ recommendations, rely on their judgment, and give the physician more control and authority (P<.007 for all). Patients in worse physical health (on a 5-point scale) are more likely to want to rely on the judgment of physicians and to seek professional medical help (correlation=0.11; P=.014, .017). There is no significant association between mental health and any of these views.

Patients’ relationship with physicians

Several aspects of the patient/physician relationship were significantly associated with patients’ involvement in medical care. Not surprisingly, willingness to seek professional medical help increases with number of visits to the physician (P=.039), and granting increased control and decision making to the physician increases with continuity of care, as measured by number of years with the physician (P=.001, .037). Additionally, having had a past dispute with a physician was significantly related to patients’ involvement in medical care. Patients with a past dispute were less likely to always follow physicians’ recommendations, rely on the judgment of physicians, or seek professional medical help. They were also more likely to take control and make medical decisions themselves.

Multivariate regression models

Multivariate regression models were used to determine the most significant predictors of patients’ involvement in medical care. Multivariate linear regression was used for the outcomes of following physicians’ recommendations and physician/patient control and roles. Logistic regression was used for the binary outcome variables— rely on physician’s judgment and seek professional help.

The predictor variables used in the model were sex, age, education, physical health, number of physician visits, number of years with physician, past dispute, trust, and satisfaction with care. Income and elderly were not used as they are correlated with education and age, respectively, which were more predictive of patient involvement. Significant predictors are shown in TABLE 5 . Notably, the patient’s trust in their specific physician did not predict any of these views, and satisfaction with care predicted only following physicians’ recommendations. Demographic, health status, and other variables were also nonsignificant in many or most regressions. Only trust in the medical profession predicted all 5 views.

TABLE 5
P-values for significant predictors in the multivariate analysis

Discussion

What predicts involvement in medical care?

Trust a key predictor. Trust in the medical profession is a key predictor of people’s involvement in medical care. It is a significant predictor of self reports of: 1) following physicians’ treatment recommendations, willingness to 2) seek care and to 3) rely on physicians’ judgment, and wanting to 4) give physicians more control and 5) let them make decisions for patients. Most other relationship factors (trust in a specific physician, length and continuity of treatment relationship, past dispute with physician) predict fewer of these variables and are no longer significant in multivariate analyses. In bivariate analyses, satisfaction with care is also a consistent predictor of all 5 measures of involvement in medical care, but it usually no longer remains significant in regression analyses once trust in the medical profession is added to the models.

Demographics not significant. Similarly, demographic characteristics such as age, sex, or education often are no longer significant in regression models that control for trust in the medical profession, suggesting that, in some instances, these factors may influence views about involvement through their effect on trust in the medical profession.

Patient roles and control of medical care.

In general, increased trust in the medical profession is associated with a more deferential patient role in medical relationships. Higher trust is associated with greater willingness to give control to physicians and allow them to make decisions for the patient. However, other aspects of patient involvement are not as easily classified as deferential in the sense of the term that connotes a passive patient role. Trust in the medical profession is also associated with greater willingness to seek care and to comply with treatment recommendations.

To the extent that trust is associated with deferential or passive patient roles, it is notable that this association exists primarily only with the measures that refer to the medical system as a whole (including satisfaction with care generally), and not with the measures that are specific to particular physicians. The latter include trust in the patient’s personal physician, past disputes with that physician, number of visits with that physician, and length of relationship with that physician. Each of these is much less predictive of patients’ involvement in medical care than is trust in the medical profession or satisfaction with care generally.

What does this say about patient relationships in general?

This suggests, consistent with prior research,^18,22 that patients’ views about particular physicians are substantially (but not entirely) independent from their views about the medical system in general. This finding is also consistent with prior explanations that the nature of interpersonal physician trust evolves over the course of an ongoing treatment relationship to accommodate both more active and more passive patient roles.²⁵ In fact, in our sample, trust in the specific physician was generally quite high regardless of preferred involvement in medical care.

Throughout all of these associations, the direction of possible causality is not established by this study. A person’s attitudes about involvement in medical care may be determined by their trust in the medical profession, or their trust may be determined by the types of involvement they have had in medical care. Most likely, there is a cyclical relationship between the 2.³⁵

These findings provide reassurance that promoting trust will not likely cause a reversion to excessively paternalistic medical relationships. Trust in specific physicians is only weakly related to patients’ views about active vs passive roles. Trust in the medical profession is much more pertinent to these views, but that type of trust is distinct from trust in specific physicians. Moreover, trust in the medical profession is consistent with some desirable forms of patient involvement.

These findings also suggest that trust is able to form in relationships where patients are either active or passive. Assertive patient involvement should not be seen as indicative of distrust. Instead, other studies suggest that trust is promoted by communicating effectively with patients such as by listening carefully, answering questions clearly, giving them as much information as they want, and involving them in medical decisions.^26,27

Attitudes towards involvement in medical care. Apart from the relationship to trust, these findings shed important light on general attitudes toward involvement in medical care. Overall, the majority of people report following their physicians’ recommendations and think that it is better to rely on the expert judgment of physicians and seek professional help. Most people think the physician and patient should share control equally and make decisions together. More patients give control to their physicians than to themselves. These findings are consistent with previous studies.^8,28-36

Also, consistent with prior studies, we found that younger and more educated patients prefer more assertive roles, as do women. We found no racial differences, but this may be due to the under representation of minorities in our sample. Finally, the small amount of variability explained in our models indicates that while we have identified predictive factors, many other factors affect people’s views towards medical care. Physicians need to be aware that patient desires for participation vary, and communication about such desires is necessary during visits.

Limitations of this study

Several study limitations should be noted. First, our measures of involvement in medical care are self-reported and do not necessarily reflect patients’ actual behaviors. However, most measures have been previously validated to some extent. Second, the selection criteria for the study do not allow for generalization to populations that less routinely seek care or are uninsured. Lastly, this is an exploratory study that was not driven by specific hypotheses derived from prior studies or firm theory. The empirical study of trust and its connection with other attitudes and relationship characteristics is still in its infancy,³⁷ which calls for more exploratory approaches that identify areas of focus for future research. The connection between trust and patients’ involvement in medical care is one such area deserving further study.

Acknowledgments

Research supported by the Robert Wood Johnson Foundation, the National Eye Institute (EY012443-02), and the National Institute on Aging (AG015248-03).

CORRESPONDING AUTHOR
Felicia Trachtenberg, PhD, New England Research Institutes, 9 Galen Street, Watertown, MA 02472. E-mail: [email protected]

It is widely perceived and documented that both of the following are valuable attributes of treatment relationships: 1) patients’ trust in physicians and in the medical profession,¹ and 2) patients’ active involvement in treatment seeking, decision making, and adherence.^2-8 Both patient trust and active patient involvement are desirable in their own right and because they are associated with improved health outcomes. Paradoxically, however, it might be thought that these 2 attributes are in sharp conflict.

Patient trust might be more consistent with a deferential style of patient-physician interaction in which patients are passive, in contrast to assertive patient questioning or limitation of physician authority which might be indicative of patient distrust. If so, then pursuing active patient involvement might lead to lower trust, or promoting trust might lead to more passive patients, either of which might compromise optimal treatment relationships and health outcomes. At a minimum, it is a conceptual puzzle how these 2 views of desirable attributes of medical relationships can coexist without each taking account of the other view. There certainly are skeptics of patient trust who warn that, contrary to conventional wisdom, too much trust might be negative and that patients, for their own good, should be encouraged to trust less to avoid the dangers of paternalistic medicine,⁹ especially in managed care settings. ^10,11

Numerous studies examine either patient trust or patients’ roles in seeking care, level of participation in medical decisions, and adherence to treatment. However, few studies examine both halves of these 2 sets of attitudes and behaviors, and none examine the full cluster. None of the leading studies of patients’ attitudes toward seeking care or participating in medical decisions include measures of trust. A few studies of care-seeking also examine attitudes similar to or overlapping with trust, such as confidentiality or competency,^12,13 but none of these use the trust concept itself or any of the validated instruments that measure trust. Among studies of trust, some have explored trust’s connections with adherence,¹⁴ preferred role in decision making,¹⁵ patients’ requests for specific services,¹⁶ or willingness to seek care,^17,18 but few studies simultaneously explore these measures,^17,18 and only 1 study examines how they relate to trust in the medical profession, rather than trust in a specific physician.¹⁸ In general, these studies report that trust in a specific physician is associated with greater adherence to treatment recommendations, more willingness to seek care, and giving physicians more control over medical decisions.

Absent in this literature is any concurrent examination of how different types of trust relate to various aspects of patients’ views about their involvement in medical care. To advance understanding of these important connections, this study was designed to investigate whether patients’ trust in their primary physician and in the medical profession are related to their attitudes toward seeking care, preferred roles in medical decision making, and reported adherence to treatment recommendations.

Methods

How the sample was collected

A random national sample of 2637 households was selected in 1999 from a proprietary database of working residential telephone exchanges in the continental United States. A minimum of 15 attempts was made to reach those numbers that were not answered. Respondent selection within eligible households was done using the next birthday method.¹⁹

Inclusion criteria for the study included being at least 21 years of age and the ability to speak and understand English. Because this survey was part of a larger study of recent experiences with physicians and health insurers,^20-22 respondents were further screened to select only those with some type of public or private health care coverage and those who had been to a physician or other health professional at least twice during the past 2 years. Health care coverage broadly includes any type of public or private insurance, or access to other type of government or indigent care program or facility.

Contacts with 2172 potentially eligible individuals resulted in the following dispositions: 1117 (51.4%) were interviewed; 571 (26.3%) refused; 484 (22.3%) were unable to participate (not home, ill, non-English-speaking). To reduce respondent burden, the sample was randomly divided and only half (N=553) were asked the battery of questions about trust in the medical profession and following physicians’ recommendations. (The other half were asked other questions unrelated to this analysis. There were no statistically significant differences between the 2 halves on age, race, gender, health status, education, or income.)

Due to the particular selection criteria and survey method, this random sample is not fully representative of national norms. There is a somewhat greater representation of whites (84.3%) and females (68.9%) because they are more likely to have insurance and have gone to a physician recently. Otherwise, the majority of our sample was between 30 to 60 years old (58%) and college educated (58%), with a median income of about $40,000. Thus, the sample composition is sufficient to analyze most major demographic and socioeconomic groups.

Telephone interviews lasted approximately 25 minutes and were conducted by trained interviewers at the Survey Research Center of the University of South Carolina using computer assisted telephone interviewing. Verbal informed consent was obtained at the start of the telephone interviews and the study protocols were reviewed and approved by Wake Forest University Medical Center’s Institutional Review Board.

Measures

Attitudes toward and preferred roles in medical care were measured by the 5 questions listed in TABLE 1 . Data were also collected on a range of topics, including demographic characteristics, trust in the subject’s regular physician and the medical profession, satisfaction with care, and physical and mental health. Trust in the specific physician and in the medical profession were measured by 5-item scales, whose validation and properties are reported elsewhere (Cronbach’s alpha ≥0.77 for all).²³ Satisfaction with medical care was measured with a previously validated 12-item scale asking about health care received from all sources over the past few years.²⁴

TABLE 1
Items assessing patients’ roles in medical relationships

Statistical analysis

To assess patients’ involvement in medical care, frequencies of response categories were calculated for the general study population, as well as key subgroups— men, African Americans, and the elderly (age ≥65 years). Chi-square tests were used to determine whether views varied by sex, race, and the elderly. Spearman correlation was used to assess the relationship of the 5 views to each other, as well as to test whether views varied by trust in the physician and the medical profession, satisfaction with care, age, education, income, physical and mental health, number of visits and years with physician, and past dispute with a physician. Finally, multivariate regressions were performed to determine the most significant predictors of involvement in medical care. In all analyses, a P-value of .05 was considered statistically significant. However, in recognition of the multiple testing environment, consistency over the 5 items was considered as well.

Results

TABLE 2 summarizes the response frequencies for the 5 questions and TABLE 3 shows the correlations of the 5 items with each other. All items are significantly correlated at level 0.005 or below. As one might expect, the questions on relying on physicians’ judgment and seeking professional help are most correlated, as are physician/patient control and roles.

TABLE 2
Views of the general population and subgroups about involvement in medical care

TABLE 3
Correlation between views on involvement in medical care

Trust and satisfaction

As shown in TABLE 4 , trust in a specific physician is associated only with always following recommendations. Trust in the medical profession and satisfaction with care are both highly associated with all 5 views towards involvement in medical care. More trust in the medical profession, and greater satisfaction with care, are associated with following recommendations, relying on the judgment of physicians, seeking professional medical help, and granting increased control and decision making to the physician.

TABLE 4
Correlation between trust and satisfaction and medical views

Patient demographics

A number of patient demographic characteristics are significantly associated with patients’ involvement in medical care. Women are less likely to want to rely on the judgment of physicians and are more likely to want to share control and make joint decisions. There is also an extremely strong effect of age. The elderly (age ≥65 years) are more compliant, deferential, and passive under each of our measures. Interestingly, race has no significant effects on these measures of involvement.

Patients with less education are more likely to want to follow physicians’ recommendations, rely on their physician’s judgment, and seek professional medical help (P=.0015, <0.001, 0.027, respectively). They are also more likely to give the physician more control and authority to make decisions for them (P<.001 for both). People with less income (on a 9-point scale) are also more likely to want to follow physicians’ recommendations, rely on their judgment, and give the physician more control and authority (P<.007 for all). Patients in worse physical health (on a 5-point scale) are more likely to want to rely on the judgment of physicians and to seek professional medical help (correlation=0.11; P=.014, .017). There is no significant association between mental health and any of these views.

Patients’ relationship with physicians

Several aspects of the patient/physician relationship were significantly associated with patients’ involvement in medical care. Not surprisingly, willingness to seek professional medical help increases with number of visits to the physician (P=.039), and granting increased control and decision making to the physician increases with continuity of care, as measured by number of years with the physician (P=.001, .037). Additionally, having had a past dispute with a physician was significantly related to patients’ involvement in medical care. Patients with a past dispute were less likely to always follow physicians’ recommendations, rely on the judgment of physicians, or seek professional medical help. They were also more likely to take control and make medical decisions themselves.

Multivariate regression models

Multivariate regression models were used to determine the most significant predictors of patients’ involvement in medical care. Multivariate linear regression was used for the outcomes of following physicians’ recommendations and physician/patient control and roles. Logistic regression was used for the binary outcome variables— rely on physician’s judgment and seek professional help.

The predictor variables used in the model were sex, age, education, physical health, number of physician visits, number of years with physician, past dispute, trust, and satisfaction with care. Income and elderly were not used as they are correlated with education and age, respectively, which were more predictive of patient involvement. Significant predictors are shown in TABLE 5 . Notably, the patient’s trust in their specific physician did not predict any of these views, and satisfaction with care predicted only following physicians’ recommendations. Demographic, health status, and other variables were also nonsignificant in many or most regressions. Only trust in the medical profession predicted all 5 views.

TABLE 5
P-values for significant predictors in the multivariate analysis

Discussion

What predicts involvement in medical care?

Trust a key predictor. Trust in the medical profession is a key predictor of people’s involvement in medical care. It is a significant predictor of self reports of: 1) following physicians’ treatment recommendations, willingness to 2) seek care and to 3) rely on physicians’ judgment, and wanting to 4) give physicians more control and 5) let them make decisions for patients. Most other relationship factors (trust in a specific physician, length and continuity of treatment relationship, past dispute with physician) predict fewer of these variables and are no longer significant in multivariate analyses. In bivariate analyses, satisfaction with care is also a consistent predictor of all 5 measures of involvement in medical care, but it usually no longer remains significant in regression analyses once trust in the medical profession is added to the models.

Demographics not significant. Similarly, demographic characteristics such as age, sex, or education often are no longer significant in regression models that control for trust in the medical profession, suggesting that, in some instances, these factors may influence views about involvement through their effect on trust in the medical profession.

Patient roles and control of medical care.

In general, increased trust in the medical profession is associated with a more deferential patient role in medical relationships. Higher trust is associated with greater willingness to give control to physicians and allow them to make decisions for the patient. However, other aspects of patient involvement are not as easily classified as deferential in the sense of the term that connotes a passive patient role. Trust in the medical profession is also associated with greater willingness to seek care and to comply with treatment recommendations.

To the extent that trust is associated with deferential or passive patient roles, it is notable that this association exists primarily only with the measures that refer to the medical system as a whole (including satisfaction with care generally), and not with the measures that are specific to particular physicians. The latter include trust in the patient’s personal physician, past disputes with that physician, number of visits with that physician, and length of relationship with that physician. Each of these is much less predictive of patients’ involvement in medical care than is trust in the medical profession or satisfaction with care generally.

What does this say about patient relationships in general?

This suggests, consistent with prior research,^18,22 that patients’ views about particular physicians are substantially (but not entirely) independent from their views about the medical system in general. This finding is also consistent with prior explanations that the nature of interpersonal physician trust evolves over the course of an ongoing treatment relationship to accommodate both more active and more passive patient roles.²⁵ In fact, in our sample, trust in the specific physician was generally quite high regardless of preferred involvement in medical care.

Throughout all of these associations, the direction of possible causality is not established by this study. A person’s attitudes about involvement in medical care may be determined by their trust in the medical profession, or their trust may be determined by the types of involvement they have had in medical care. Most likely, there is a cyclical relationship between the 2.³⁵

These findings provide reassurance that promoting trust will not likely cause a reversion to excessively paternalistic medical relationships. Trust in specific physicians is only weakly related to patients’ views about active vs passive roles. Trust in the medical profession is much more pertinent to these views, but that type of trust is distinct from trust in specific physicians. Moreover, trust in the medical profession is consistent with some desirable forms of patient involvement.

These findings also suggest that trust is able to form in relationships where patients are either active or passive. Assertive patient involvement should not be seen as indicative of distrust. Instead, other studies suggest that trust is promoted by communicating effectively with patients such as by listening carefully, answering questions clearly, giving them as much information as they want, and involving them in medical decisions.^26,27

Attitudes towards involvement in medical care. Apart from the relationship to trust, these findings shed important light on general attitudes toward involvement in medical care. Overall, the majority of people report following their physicians’ recommendations and think that it is better to rely on the expert judgment of physicians and seek professional help. Most people think the physician and patient should share control equally and make decisions together. More patients give control to their physicians than to themselves. These findings are consistent with previous studies.^8,28-36

Also, consistent with prior studies, we found that younger and more educated patients prefer more assertive roles, as do women. We found no racial differences, but this may be due to the under representation of minorities in our sample. Finally, the small amount of variability explained in our models indicates that while we have identified predictive factors, many other factors affect people’s views towards medical care. Physicians need to be aware that patient desires for participation vary, and communication about such desires is necessary during visits.

Limitations of this study

Several study limitations should be noted. First, our measures of involvement in medical care are self-reported and do not necessarily reflect patients’ actual behaviors. However, most measures have been previously validated to some extent. Second, the selection criteria for the study do not allow for generalization to populations that less routinely seek care or are uninsured. Lastly, this is an exploratory study that was not driven by specific hypotheses derived from prior studies or firm theory. The empirical study of trust and its connection with other attitudes and relationship characteristics is still in its infancy,³⁷ which calls for more exploratory approaches that identify areas of focus for future research. The connection between trust and patients’ involvement in medical care is one such area deserving further study.

Acknowledgments

Research supported by the Robert Wood Johnson Foundation, the National Eye Institute (EY012443-02), and the National Institute on Aging (AG015248-03).

CORRESPONDING AUTHOR
Felicia Trachtenberg, PhD, New England Research Institutes, 9 Galen Street, Watertown, MA 02472. E-mail: [email protected]