Interventions for improving patients' trust in doctors and groups of doctors

Trust is a fundamental part of a patient-doctor relationship, and is associated with increased patient satisfaction, adherence to treatment, and continuity of care, although blind trust may on occasion facilitate poor care. We wished to know if there are effective ways of enhancing patient trust in doctors, by involving doctors (e.g. training) or patients (e.g. by providing information).

We searched a wide variety of databases on 18 March 2013 and identified 10 diverse studies, all randomised controlled clinical trials, with 11,063 participants, that met the review's inclusion criteria. Seven of the trials were new for this update. Overall, they did not provide sufficient evidence that a specific intervention affects trust. All were undertaken in the United States. Two were government funded, while seven were funded by charitable trusts and one by a Health Maintenance Organisation (HMO).

Interventions were of three main types; three employed additional physician training, four were education for patients and three provided additional information about doctors in terms of financial incentives or consulting style.

Two trialled physician training interventions to improve behaviours known to be associated with trust. The interventions showed no change in the patients' trust in their physician. The third trial showed that training oncologists in communication skills resulted in a small increase in trust.

Two trials examined group educational visits for uninsured diabetic patients. The first showed a small increase in trust, but the second showed no changes in trust. Another trial examined the effects of three types of educational introductory visits on new patients' trust in the doctors working for their health organisation. Trust in the doctors rose with one type of visit, in which patients were seen as a group. However, this was the least well taken up compared with individual visits with a physician, or a physician and health educator. A further trial explored helping patients decide about taking a statin by providing information and a chance to discuss options. This did not significantly increase trust.

Two trials explored disclosing to patients the incentives doctors are given for practising medicine in a cost-effective way via insurance plans. One trial led to no reduction and possibly an increase in trust. However, the plan information emphasised reducing unnecessary tests, rather than cost-cutting. The other trial showed no decrease in trust with disclosure. A final trial matched patients to doctors depending on their beliefs about care. Although some aspects of the doctor-patient relationship were improved, trust was not significantly affected. There was no evidence of harm from any of the studies.

The review was constrained by the lack of consistency between trust measurements, timeframes and populations. We have highlighted the types of further trials that are required to explore the impact of doctors' specific training or the use of a patient-centred or decision-sharing approach on patients' trust. Particularly, there is a need for international studies over longer follow-up periods in different healthcare systems.

Authors' conclusions: 

Overall, there remains insufficient evidence to conclude that any intervention may increase or decrease trust in doctors. This may be due in part to the sensitivity of trust instruments, and a ceiling effect, as trust in doctors is generally high. It may be that current measures of trust are insufficiently sensitive. Further trials are required to explore the impact of doctors' specific training or the use of a patient-centred or decision-sharing approach on patients' trust, especially in the areas of healthcare provider choice, and induction into healthcare organisation. International trials would be of particular benefit. The review was constrained by the lack of consistency between trust measurements, timeframes and populations.

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Background: 

Trust is a fundamental component of the patient-doctor relationship and is associated with increased satisfaction, adherence to treatment, and continuity of care. Our 2006 review found little evidence that interventions improve patients' trust in their doctor; therefore an updated search was required to find out if there is further evidence of the effects of interventions that may improve trust in doctors or groups of doctors.

Objectives: 

To update our earlier review assessing the effects of interventions intended to improve patients' trust in doctors or a group of doctors.

Search strategy: 

In 2003 we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, EMBASE, Health Star, PsycINFO, CINAHL, LILACS, African Trials Register, African Health Anthology, Dissertation Abstracts International and the bibliographies of studies selected for inclusion. We also contacted researchers active in the field. We updated and re-ran the searches on available original databases (Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 2, 2013), MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), CINAHL (Ebsco)) as well as Proquest Dissertations and Current Contents for the period 2003 to 18 March 2013.

Selection criteria: 

Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series of interventions (informative, educational, behavioural, organisational) directed at doctors or patients (or carers) where trust was assessed as a primary or secondary outcome.

Data collection and analysis: 

Two review authors independently extracted data and assessed the risk of bias of included studies. Where mentioned, we extracted data on adverse effects. We synthesised data narratively.

Main results: 

We included 10 randomised controlled trials (including 7 new trials) involving 11,063 patients. These studies were all undertaken in North America, and all but two involved primary care.  As expected, there was considerable heterogeneity between the studies.  Interventions were of three main types; three employed additional physician training, four were education for patients and three provided additional information about doctors in terms of financial incentives or consulting style. Additionally, several different measures of trust were employed.

The studies gave conflicting results. Trials showing a small but statistically-significant increase in trust included: a trial of physician disclosure of financial incentives; a trial of providing choice of physician based on concordance between patient and physician beliefs about care; a trial of group visits for new inductees into a Health Maintenance Organisation; a trial of training oncologists in communication skills; and a trial of group visits for diabetic patients. However, trust was not affected in a subsequent larger trial of group visits for uninsured people with diabetes, nor with a decision aid for helping choose statins, another trial of disclosure of financial incentives or specifically training doctors to increase trust or cultural competence. There was no evidence of harm from any of the studies.

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