From the President: Good Journey
I am not good at ‘goodbye’. I had to say goodbye thousands of times during my three years as WONCA President: to my family, patients, practice colleagues, and family doctors I watched at work. It was never easy to do. Sadness about leaving my family washed over me whenever I entered the parking structure at our local airport. I felt guilty about leaving my patients and practice colleagues whenever I discussed my next trip with them. I worried that something might come up during my absence that I should not miss or that I should have anticipated better
More than 200 times in more than 50 countries, I thanked and said goodbye to family doctors, I had just observed with their patients. Each time, I left impressed with their commitment to their patients and communities. I marveled at their practical and clever solutions to the problems their patients brought to them. I noted their compassion and skill. Their dedication to duty humbled me, especially given their often difficult circumstances. I wished I could spend just a bit more time with all of them to get to know them better, to have them teach me more. There was always however, a next place to go and a next plane to catch.
En route to my next destination, I often reflected on the people and place just visited. It still amazes me that so many family doctors allowed me to observe them with their patients. I know how anxious I become when watched at work, worried that I will not measure up. I decided that the family doctors were willing to trust me in much the same way that patients trust us. Since my earliest days as a medical student, I wondered why patients were generally so willing to open themselves up to show their flaws and to describe their suffering. I concluded back then that most likely patients viewed me as a part of their care team or that they wanted to contribute to the learning of the next generation of physicians.
Yet, why would patients and their family doctor permit me to witness their private consultations knowing that I was merely a one-time visitor? There seemed to be little in it for them. Perhaps they thought they had no choice (hope not). Perhaps they expected I would offer a brilliant insight into their condition (most unlikely). Perhaps they wanted to be the center of attention for more prying eyes (unlikely). Perhaps they believed they were promoting Family Medicine or advancing world peace (also unlikely). I think they gave permission because they trusted that good things would come from my visit and that it would benefit them in some way.
Relationships and Trust
These reflections caused me to ponder the nature of relationships and trust. People are generally quick to trust, but slow to trust a person again if they felt betrayed by that person. In health care, it seems that trust is good medicine. Patients are 2.5 times more likely to adhere to treatment recommendations when they highly trust their doctors1. Given its therapeutic benefits, it is striking that there is such a scant literature on trust between patients and doctors2.
Several factors appear to influence patients’ trust in their doctors, including rapport, compassion, understanding, honesty, and technical competence3. Attributes that are not significantly associated with trust include patient age, gender, race, education, income, health status, or number of consultations4. Shortly after the diagnosis of breast cancer, patient trust depends on receiving helpful informational, emotional, and decision-making support. Later, only emotional support seems to be significantly important5.
There have been few studies done to determine how to improve patient-physician trust. It appears that a one day workshop to improve trust building skills is not effective6. What then can we do to obtain and maintain the trust of our patients? As I wrote last month, the key strategies can be remembered in the acronym TRUST – time (more is better), reliability (be consistent and dependable), unity (show empathy and create a sense of shared purpose and goals), skill (demonstrate that we know our stuff), and transparency (be open and honest).
While we know little about patients’ trust in doctors, we know less about doctors’ trust in patients. Yet, doctors must trust patients throughout our interactions with them. Our diagnostic conclusions depend heavily on the history they provide. We rely on them to follow our treatment recommendations and to present for follow up as advised. Even though we learn techniques for exposing patients’ hidden agendas and enhancing their adherence to treatment plans, most of the time we must believe what they tell us and have faith they will do what we ask.
A major challenge for health care in the future will be to address the widening gap in trust between patients and doctors. Even as our diagnostic acumen and technologies improve, rising and unmet patient expectations and the potentially greater and uncertain harms of new interventions will cause patients to be less trusting. Similarly, doctors will have less trust in patients who seem intent on getting what they want when they want it with little regard for those providing the service.
Individual needs, shared goals
The way forward, it seems to me, is to rethink our model. A caricature of our current model views patients as passive recipients of the interventions provided by physicians whose only aims are to serve and to receive sufficient compensation. There is more to it than that. In my experience, patients are rarely passive. While they may not verbally challenge their doctor during an encounter, their words and behaviors afterwards prove that they are leading actors in their own health care drama. Physicians seek more than service and appropriate payment. They also look for personal meaning and joy in their work7, which often depends on the quality of the relationships they have with their patients and colleagues.
Recognizing that both actors have legitimate needs and expectations can go a long way toward establishing and maintaining trust. Yet, we are usually silent on such issues when dealing with patients. We assume that we know what they want (cure, relief of suffering, comfort). They assume that we know what they want. Better is to make explicit that which has for too long been implicit. Encouraging patients to identify their goals will help us make better recommendations (“I want to dance at my daughter’s wedding”). Informing patients of our limitations helps them to better calibrate their expectations (“I am not available on Thursday afternoons because I volunteer at a homeless shelter.”) When both are clear on what the other expects and can do, then both are more likely to be satisfied with the relationship. Said more directly, it is not only that patients need to trust their doctors, doctors need to trust their patients.
Public needs, public expectations
The drama that unfolds in the privacy of the consultation room takes place against the backdrop of public needs and expectations. Legitimate actions to safeguard the public’s health (e.g., quarantine to prevent outbreaks of drug resistant tuberculosis) and wealth (e.g., efforts to reduce the rise of health care expenditures) can clash with personal goals (e.g., freedom of movement, desire to have done all that can be done).
Policy makers find it difficult to reconcile their beliefs about the greater good with patients’ personal expectations. At one extreme, health care is a social good only because it gets people back to productivity sooner. Society contributes significantly toward health care services and is entitled to a return on that investment in human capital. People resist however, when their health care becomes a means to society’s ends. At the other extreme, health care is about informed consumers making rational market decisions. Free societies believe in the rights of individuals to make their own choices about what they most value. Those rights however, are not unlimited when they affect others and the choices are not always truly informed. Thus, both of these views in the extreme are illusory.
For patient and doctor, the tension between the greater good and individual preference is not an abstract exercise in social utility theory. It plays out in every patient-doctor encounter as personal values and expectations bump up against resource limits and professional customs. Consequently, experienced family doctors understand that many recommendations mark the start of a negotiation rather than a definitive declaration. Trust allows the negotiations to proceed in good faith and improves the chance for a successful conclusion.
These past three years have been incredible. It has been life changing to meet high level policy makers in numerous countries while observing family doctors in the front lines of their health care systems. These meetings have convinced me that Family Medicine and primary care are on the ascendancy around the world, in countries rich and poor. The World Health Organization (WHO) and United Nations (UN) have recognized that chronic or non-communicable diseases (NCDs) cannot be addressed adequately without universal coverage. In turn, universal coverage cannot be achieved without robust primary care. Our already insufficient numbers are going to worsen as the demand grows for more care in the primary care setting.
To succeed, we will need to develop new tools and strategies that enable us to meet the two basic aims of primary care: trusted continuous relationships and comprehensive services. There were times in my travels when I despaired that we were at risk of losing sight of these aims. Sometimes it was because physicians wanted better work life balance and protected themselves by developing a limited work shift mentality. Others narrowed their scope of practice because the local practice environment made it difficult for them to provide comprehensive services or because they had inadequate experience in certain services or felt that those services were too stressful.
Emerging forms of electronic communication (text messaging, web consultation, email, etc.) will make it easier to stay in touch with patients while preserving sufficient personal and family time. New technologies such as handheld information devices, decision support tools, and simulators will make it possible to develop and maintain comprehensive skills throughout our careers. The most important lesson is to stay true to our core values of continuity and comprehensive by innovating new and better ways to accomplish them.
All of this means we will need to open ourselves up more to patients, to trust them. We need to let go of the fear that patients will abuse us or use us up if we open ourselves to them. Our greatest source of power is derived from our trusted relationships with our patients. We must remember that skilled family doctors are like catalysts – we use our trust with the patients to make good things happen while not getting used up in the process. If we take good care of our patients, they will take good care of us. I believe that we can do all of this and also take good care of ourselves, our families, and each other.
Thank you, and good journey
I am so very grateful for the privilege over the last three years to have represented over the 122 member organizations and 350,000 family doctors who comprise WONCA. I have many people to thank for this opportunity: the Council who elected me, the other members of Executive who helped make the difficult decisions, our CEOs in Singapore (Dr Alfred Loh) and his successor in Bangkok (Dr Garth Manning) and their staff who helped turn good ideas into action. Special thanks must also go to my patients and practice colleagues who forgave my many absences. Most important to thank is my wife Laura and our four children: Matt, Ben, Maggie, and Alex – they gave up the most so that I could dedicate my efforts to advancing the cause of Family Medicine and WONCA around the world.
When bidding each other farewell, my West African friends like to say, “Good journey,” to each other. I like this phrase because it suggests that our travel will have us re-connecting at some point in the future. “Goodbye” on the other hand gives no indication of whether we will ever meet again. I am as excited and confident about the future of Family Medicine as I have ever been. I know we will succeed in our quest to improve the world by assuring that every person has access to a quality family doctor. I look forward to joining you and others when we finally reach the top of that mountain. So, rather than “goodbye,” I will close by saying, ”good journey.”
1. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-20.
2. Pearson SA, Raeke LH. Patients’ trust in physicians: many theories, few measures, and little data. J Gen Intern Med 2000;15:509-13.
3. Thom DH, Capmbell B. Patient-physician trust: an exploratory study. J Fam Pract 1997;44:169-76.
4. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients’ trust in their physicians: effects of choice, continuity and payment method. J Gen Intern Med 1998;282:261-6.
5. Arora NK, Gustafson DH. Perceived helpfulness of physician communication behavior and breast cancer patients’ level of trust over time. J Gen Intern Med 2009;24(2):252-5.
6. Thom DH, Block DA, Segal ES. An intervention to increase patients’ trust in their physicians. Acad Med 1999;74:195-8.
7. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med 2013;11:272-8.
Professor Richard Roberts
World Organization of Family Doctors
This is Professor Roberts’ final column as President of WONCA. It has been three years of hard work for him as he wrote his substantial and well considered columns. I am sure many of us who have followed his adventures around the globe, will miss his insights into the many health systems he has been exposed to. For those who wish to download a copy of his previous columns they have been collated into one document.
Download compilation of President Roberts' columns 2010-2013