August 2006

Can we avert a crisis of confidence?

by Robert H. Blanks, PhD, President, RCS

The Harvard School of Public Health (HSPH) recently initiated a new course entitled, "Crisis of Confidence." The developer of the "Trust Initiative," David Shore, makes the bold claim that "if the HSPH crash course can help rebuild trust in the health care industry, the results could be as powerful as any medicine available today".

Health care experts agree that trust (i.e., a firm belief that a person or thing can be relied on) between a patient and caregiver is a key factor in promoting improved quality of life, compliance with the care plan, and better health outcomes. Without trust, the patient‑caregiver relationship may not be firmly established, thus hindering the caregiver's ability to deliver optimal care.

In medicine, the issue of trust in the patient‑doctor relationship has come under increasing scrutiny over the past 50 years, beginning with the shift after World War II from primary care (the "family doctor") to medical sub‑specialization and, more recently, with the advent of managed care.

The current challenges to the patient‑doctor relationship are many and are driven by technology, concerns about cost containment, environmental health issues, poor patient compliance, problems of financial barriers to adequate health care and others.

Mistrust of the chiropractic profession in general is increasingly being generated from well‑organized and funded groups that disseminate anti‑chiropractic rhetoric through websites and other public forums.

Recently, a new campaign was launched on a billboard reading, "Injured by a Chiropractor?" Similar signs then started appearing on public buses and in print ads in the Northeast.

These groups persist in linking chiropractic and upper cervical adjustment to strokes despite extensive evidence ‑‑ and considerable literature available about the safety of chiropractic ‑‑ to the contrary.

The result is an eroding of the trust the public has come to have in chiropractic.

"Trust is the glue that binds patient to physician," wrote noted author and Vanderbilt University Professor of Obstetrics and Gynecology Frank Boehm, MD, in reference to the crisis of trust in medicine. "With physicians leaving the operating room for a trip to the ATM, medical instruments showing up in a patient's post‑op body, wrong organs or appendage removed... no wonder the legendary doctor/patient trust relationship has become an endangered species," said Boehm. [1]

Friedenberg [2] expresses a growing concern among providers that "the scientific aspects of care need to be delivered in the context of a personal relationship, the patient‑doctor relationship,which is based on a healing bond of trust between a patient and a physician and serves the needs of both." [emphasis added]

"Managed care," he says, "has damaged this relationship, and both physicians and patients must insist on its restoration."

Illingworth [3] echoes this contention that the level of trust patients have in their doctors and in the institution of medicine itself has been impaired by managed care. He believes that "trust is a form of social capital and should not be left in the hands of organizations that are concerned primarily with meeting their fiduciary duty to their stockholders."

Kenagy et al. [4] make the analogy that most patients judge health care in the way they would an airline flight. They assume the airlines are reliable and run by competent people. They judge the airline by personal criteria such as friendly personnel, on‑time schedules and comfort. If there is any truth in this analogy, then how do chiropractic patients view their chiropractor and the profession in general?

Although patient satisfaction is very high among chiropractic patients, [5, 6] the market penetration is low. Only about seven percent of the US population has seen a chiropractor in the past 12 months. [7] A focus on rebuilding trust might be one way to increase the number of patients seeking chiropractic care.

Balancing trust and belief

For many, a better sense of balance can be achieved when there is a shared belief and value system between the patient and caregiver.

Herbert Benson [8] from the Harvard Medical School Mind‑Body Medicine group describes three essential components of what he terms the ideal patient‑caregiver relationship: Belief and expectancy on the part of the patient; belief and expectancy on the part of the caregiver; and belief and expectancies generated by a relationship between the patient and the caregiver.

We need to understand those factors that strengthen professionalism and the doctor/patient bond, and reject efforts that conflict with these professional ideals. Clearly, anti‑chiropractic websites, public billboards and print ads undermine the public trust in chiropractic and thereby interfere with the sanctity of the patient‑doctor relationship. These issues must be dealt with if the profession is to reach its full potential.

The strength of the relationship between patient and practitioner is also being eroded by internal professional bickering. We must weigh very carefully the controversy within the profession about political alliances, coalitions, and even attitudes towards evidence‑based chiropractic.

Better external and internal communication are necessary to improve both the patient‑chiropractor relationship and general patient trust in the health, wellness and quality‑of‑life benefits of chiropractic care.

David Shore is passionate about the importance of trust and tells health professionals to "[a]rticulate the importance of trust in your every endeavor." He says, "think of trust as a brand in the way safety is Volvo's brand." The ideal is therefore to develop a "Trust Mission." Furthermore, Shore argues: "Organizations must ensure the trustworthiness and consistency of their every action."

Trust is difficult to earn, and easy to lose. Chiropractic needs to earn back any trust that's been lost and then do everything in its power to keep it.

References

1. Boehm F. "Building Patient/Doctor Trust." Frank Boehm publisher, 2005.

2. Friedenberg RM. "Patient‑Doctor Relationships." Radiology 2003; 226: 306‑308.

3. Illingworth T. "Trust: the scarcest of medical resources." J Med Philos 2002;27:36‑46.

4. Kenagy JW, Berwick DM, Shore MF. "Service quality in health care." JAMA 1999;281:661‑65.

5. Cherkin DC, MacCornack FA. "Patient evaluations of low back pain care from family physicians and chiropractors." West J Med. 1989;150:351‑5.

6. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. "The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons." The North Carolina Back Pain Project. N Engl J Med. 1995;333:913‑7.

7. National Center for Complementary and Alternative Medicine http://nccam.nih.gov/research/

8. Benson H. "Timeless Healing: The Power and Biology of Belief." Simon and Schuster Canada, 1997.

(RCS co‑founder and President Dr. Robert Blanks is Professor in the Department of Biomedical Sciences at Florida Atlantic University and a past Professor of Anatomy and Neurobiology at the University of California, Irvine. Prior to this he spent two years at the Max Planck Institute for Brain Research in Frankfurt, Germany and two years in the Department of Anatomy at Harvard Medical School. Dr. Blanks is on the Advisory Board of the International Spinal Health Institute, is a Board Member of the Council on Chiropractic Practice and is actively involved in chiropractic research. To learn more about health outcomes research and RCS, call 800‑909‑1354 or 480‑303‑1694.)