Evidence-based recommendations for maintaining public trust
Key Takeaways
Patient trust in physicians has been linked to improved health outcomes, such as better shared decision-making and higher health-related quality of life.
Public trust in physicians and the medical profession has sharply declined over the past half-century.
Reversal of clinical guidelines plays a role in driving public mistrust of the medical profession.
Patient trust in physicians is essential for maintaining positive patient-physician relationships.
Studies have demonstrated that patients who display a strong degree of trust in a specific physician have a higher self-care ability, are more likely to adhere to treatments or screenings, and are able to maintain healthy lifestyles.[]
Higher patient trust in physicians is also correlated with positive long-term outcomes such as better glycemic control, higher health-related quality of life, patient satisfaction, fulfillment of medical needs, and better shared decision-making.
Public trust in the medical profession
Patient trust can be broken down into two categories: trust in a specific physician, and general trust in physicians and the medical profession.
The US healthcare system is shifting away from expanding healthcare coverage, and is instead focused on improving patient care. But for physicians to play an active role in shaping future policies that affect patients, there has to be a high level of public trust in the medical profession.
Unfortunately, data on public trust in physicians are not encouraging, and show a sharp decline since the 1960s. According to an article published in The New England Journal of Medicine, 73% of Americans said they had a lot of confidence in the leaders of the medical profession in 1966.[]
By 2012, that number decreased to 34%, and declined even more to 23% by 2014. US public trust in physicians ranks near the bottom among 29 industrialized countries.
In addition, the US differs from other industrialized nations in that adults from families with an income of less than $30,000 were significantly less trusting of physicians, and demonstrated less satisfaction with their medical care in comparison to adults not from low-income families.
However, while overall public trust of physicians is low in the US, trust in the integrity of physicians has remained high, with 69% of the public rating the honesty of physicians as “very high” or “high.”
Reasons for public mistrust
Important lessons can be drawn from the New England Journal of Medicine article’s international comparisons. The authors believe that public mistrust of physicians may stem from extensive media coverage of US political events that portray physician advocacy in a more controversial light than in other countries.
Another factor possibly fueling this mistrust is that physicians in the US must exert their influence on policy decisions outside of governmental institutions, enacting change through private medical organizations. This is in contrast to other countries where physicians partner with government officials to manage their healthcare systems.
Reversal of clinical guidelines can also contribute to public mistrust in physicians in general.
To retain public trust, the medical profession needs to ensure that guidelines are based on strong evidence. For example, medical organizations should not base their recommendations on a meta-analysis of inconclusive trials.[]
Aspirin for prevention of cardiovascular disease
As an example of the implications of clinical guideline reversal, consider the use of aspirin for the primary prevention of cardiovascular disease (CVD).[] Aspirin has been recommended for the secondary prevention of CVD and has been an integral component of antiplatelet therapy.
However, its utility in the primary prevention of CVD has been ambiguous. Meta-analyses of early primary prevention trials hinted that a low dose of aspirin offered some benefit in the prevention of a heart attack or stroke.
This came at the cost of excessive bleeding, however, and studies showed that the number of treated patients needed to prevent one cardiovascular event was similar to the number of patients harmed because of one major bleeding event. Still, early clinical guidelines recommended low-dose aspirin for patients with high CVD risk whenever the benefit for these individuals outweighed the risk.
Despite the evidence that aspirin was only marginally beneficial in preventing CVD, some institutions began extensive campaigns to increase aspirin uptake.
As an example, between 2015 and 2019, a massive campaign was implemented in Minnesota. It sought to spread awareness about aspirin use with advertisements on billboards and radio, newspaper articles, and the launch of an “Ask About Aspirin” website that had more than 1 million visitors. The program involved more than 1,000 primary care doctors and other clinicians in educational programs.
The result: Only 6% of the target population ever became aware of the campaign. In 2015, only about half of the patients who would be considered appropriate candidates for primary prevention aspirin were taking it. Its use dropped further when, by 2020, large trials had confirmed that low-dose aspirin had minimal clinical benefit, and that this benefit was outweighed by the risk of excess bleeding.
This highlights the importance of ensuring that clinical recommendations actually offer significant benefits to patients.
Physicians should offer advice deeply rooted in evidence, ensuring that campaigns based on inconclusive trials are avoided.
This will ensure that they can regain public trust and be involved in shaping policies that have a positive impact on patient care.
What this means for you
Patient trust is critical for maintaining favorable patient-physician relationships, and has been associated with positive outcomes for patients. However, the medical profession is currently facing a public mistrust crisis due in part to extensive media coverage and reversal of clinical guidelines. Physicians and other healthcare providers should be extremely cautious when making clinical recommendations that are not based on very strong evidence.