U.S. Physician Leaders Suffer Loss of Public Trust
But patients still like their own doctors.
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Physicians in the U.S. enjoy a lower level of public trust than physicians in any of the countries that the U.S. healthcare system is normally compared against.
Only 58% of U.S. adults agree with the statement, "All things considered, doctors in [your country] can be trusted." That puts the U.S. at 24th among the 29 industrialized countries where this survey was carried out, above only Chile, Bulgaria, Russia, and Poland, and tied with Croatia.
In other countries -- Turkey, France, Finland, Britain, the Netherlands, Denmark and Switzerland -- more than 75% of adults agreed that doctors could be trusted.
This lack of trust may diminish the influence of physicians in decision-making around the next stages of health system reform, according to an article by Robert J. Blendon,John M. Benson, and Joachim O. Hero published in the New England Journal of Medicine. The authors are affiliated with the Harvard School of Public Health and the Harvard University Program in Health Policy.
Their article examines both the declining standing of U.S. physician leaders in the public eye since the 1960s and the low trust in physicians in the U.S. compared with those in other developed countries.
Public trust in the leaders of the medical profession has declined sharply. In 1966 75% of Americans surveyed had great confidence in them. By 2012 only 34% shared this outlook.
At the same time, the public still trusts in the integrity and professionalism of individual doctors. About 69% say the honesty and ethical standards of physicians are "very high" or "high," according to a 2013 Gallup survey. On the other hand, only 23% of the public have a lot of confidence in the healthcare system, another Gallup survey found this year.
But Americans have confidence in their own doctors. The percent expressing satisfaction with the treatment they received when they last saw their doctor was 56%, higher than all but three countries in a poll conducted by the International Social Survey Programme. Only Switzerland (64%) and Denmark (61%) ranked higher.
"The U.S. is the only country where so many people were satisfied with the care they get, but they have this low level of trust," Blendon told MedPage Today in an interview. In other countries it appears that the dissatisfaction may be related to "a system of service that isn't working for many people very well. Here, for many people, the service system is working well." Thus doctors in the U.S. "have a strong basis to build on. It suggests you can do something about this."
The low level of public trust in physician leadership in the U.S. portends certain risks for the profession, Blendon said. The extensive literature on trust in public institutions suggests that groups that aren't trusted "are more susceptible to having the public process pay not much attention to them." As issues emerge that affect a profession or industry, they will progressively lose the ability to shape the future. When bankers, for example, are seen as self-seeking and indifferent to the public's needs, there is a rising call for regulating the banking industry, such as happened after the financial crisis.
The decline in trust is most likely attributable to "broad cultural changes in the U.S., as well as rising concerns about medical leaders' responses to major national problems affecting the U.S. healthcare system," the article said.
As implementation of the Affordable Care Act evolves, there will be many policy proposals on which physicians as a class would like to be heard. They would probably have more influence "if they were seen as more broadly concerned with the public interest issues," Blendon said, instead of issues of payment and professional authority.
The results of the survey derive from the larger problem that "physicians don't seem to be involved with improving the health system," said Robert A. Berenson, MD, a fellow at the Urban Institute in Washington. "I think it's pretty clear that physicians have a significant role to play in improving health delivery. But many doctors think they are this beleaguered class of people who are being picked on. They think the responsibility for the problem lies elsewhere."
When doctors are surveyed on the sources of high healthcare costs, they report that "every other party is responsible but not them," Berenson said in an interview withMedPage Today. "It's medical liability, insurers, patients who don't adhere to medications." Doctors refuse to take responsibility for their own role in the dysfunctionality of the system, he said. If physicians would be willing to be visibly associated with health system changes and at the same time acknowledge their own role in contributing to problems in the health system, "that would go a long way to change these responses," he added.
Trust by Americans in their institutions has declined broadly over the past 40 years, Berenson noted. The baseline of 1966 was before the disillusionment of the Vietnam War and the Watergate scandal. The U.S. public is more generally negative than it used to be. That may or may not be the case in other countries.
Physicians were very well trusted as leaders through the early 1970s, Blendon said. Even though all professional groups and institutions have suffered losses in confidence, the decline of physicians has been steeper, because they started out from a higher place.
"I believe it has to do with the sense they are not involved with broad public positions," Blendon said. "In other countries physicians speak out on broad public issues, they have an organized voice regarding health and medicine in the country. That gets them to a level of trust." Their opinions are sought on a broad range of issues, "not just the Medicare sustainable growth rate or malpractice. That, we believe, is probably why they rank higher."
Berenson agreed that physicians have not put their best foot forward. "There has been example after example of avaricious behavior of physicians more interested in revenue than in patients. We know from the Medicare Part B data that there is overt fraud, there is indefensible behavior by physicians. That has to have an impact."
Direct patient experience is also coloring public opinion. The series of articles in The New York Times about excessive expenses in medical care has highlighted how practitioners have exploited the system for private gain. "These are not rare, aberrant cases," Berenson said. "I think people's experiences are that. There is merit in that skepticism. Medical professionals are willing to bilk people and commit fraud. And the profession itself doesn't seem to be doing anything about it."
Organized medicine at the margin has been a positive force. Berenson cited the American Medical Association's endorsement of the Affordable Care Act as a constructive engagement despite the qualms of many individual physicians. But, he added, physicians have not been willing to acknowledge that they themselves "have contributed to these problems" and need to "do a better job of solving them. That would help their image with the public."
It is striking that organized medicine has been reduced to the role of a bit player on the larger topic of health reform, he added. In part this may be due to the fact that organized medicine has shrunk; only some 20% of doctors are members of the AMA, and the specialty societies tend to focus on narrow issues of interest to their membership.
The absence of vehicles for physicians to get involved in these overarching questions of the shape of the healthcare system may be contributing to the absence of physician leadership. As the recent Ebola scare has demonstrated, there are no longer any doctors in the public eye enjoying wide respect to comfort and guide the public. There is no surgeon general. The authority of a personage like C. Everett Koop 25 years ago has vanished. "Nobody is looked to as exemplifying the best aspects of the medical profession," Berenson said.
In other countries the profession's viewpoint would be actively sought out, Berenson said. That may be related to the fact that the prevailing private system of medical finance and delivery in the U.S. creates many diverse stakeholders with conflicting or nonaligned perspectives.
The Harvard study also showed that poor people in the U.S. have a substantially lower level of trust in the entire healthcare system. Adults from families earning less than $30,000 "are significantly less trusting of physicians and less satisfied with their own medical care than adults not from low-income families," the article said. Less than half (47%) of low-income Americans reported that they trusted their doctors, compared with 63% of non-low-income people. They were also significantly less satisfied with their last visit to the doctor's office (48% versus 59%).
"Low-income people feel they face a lot of problems and inequities, and physicians don't speak about it," Blendon said. "How many physicians are speaking on TV about Medicaid cutbacks, how that affects low-income communities, or making Medicare more available? Do they think American physicians are speaking about their problems? They don't feel the medical community has a strong set of positions on things that might affect their lives."
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