Trust but verify: the interactive effects of trust and autonomy preferences on health outcomes

Epistemic Trust as an Interactional Accomplishment in Pediatric Well-Child Visits: Parents' Resistance to Solicited Advice as Performing Epistemic Vigilance

Epistemic trust - i.e. the belief in knowledge claims we do not understand or cannot validate - is pivotal in healthcare interactions where trust in the source of knowledge is the foundation for adherence to therapy as well as general compliance with the physician's suggestions. However, in the contemporary knowledge society professionals can no longer count on unconditional epistemic trust: boundaries of the legitimacy and extension criteria of expertise have become increasingly fuzzier and professionals must take into account laypersons' expertise. Drawing on a conversation analysis-informed study of 23 videorecorded pediatrician-led well-child visits, the article deals with the communicative constitution of healthcare-relevant phenomena such as: epistemic and deontic struggles between parents and pediatricians, the local accomplishment of (responsible) epistemic trust, and the possible outcomes of blurred boundaries between the layperson's and the professional's "expertise." In particular, we illustrate how epistemic trust is communicatively built in sequences where parents request the pediatrician's advice and resist it. The analysis shows how parents perform epistemic vigilance by suspending the immediate acceptance of the pediatrician's advice in favor of inserting expansions that make it relevant for the pediatrician to account for her advice. Once the pediatrician has addressed parents' concerns, parents perform (delayed) acceptance, which we assume indexes what we call responsible epistemic trust. While acknowledging the advantages of what seems to be a cultural change in parent-healthcare provider encounters, in the conclusion we advance that possible risks are implied in contemporary fuzziness of the legitimacy and extension criteria of expertise in doctor-patient interaction.

Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial?

Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P = .003; effect = 0.506 (.172-.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P = .003; OR = .509 (.326-.792)), patients in the No-Trial group endured fewer infections (P = .006; proportion difference = .43 (.007-.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.

Does Online Community Participation Contribute to Medication Adherence? An Empirical Study of Patients with Chronic Diseases

Effectively improving the medication adherence of patients is crucial. Past studies focused on treatment-related factors, but little attention has been paid to factors concerning human beliefs such as trust or self-efficacy. The purpose of this study is to explore the following aspects of patients with chronic diseases: (1) The relationship between emotional support, informational support, self-efficacy, and trust; (2) the relationship between self-efficacy, trust, and medication adherence; and, (3) whether chronic patients’ participation in different types of online communities brings about significant statistical differences in the relationships between the abovementioned variables. A questionnaire survey was conducted in this study, with 452 valid questionnaires collected from chronic patients previously participating in online community activities. Partial Least Squares-Structural Equation Modeling analysis showed that emotional support and informational support positively predict self-efficacy and trust, respectively, and consequently, self-efficacy and trust positively predict medication adherence. In addition, three relationships including the influence of emotional support on trust, the influence of trust on medication adherence, and the influence of self-efficacy on medication adherence, the types of online communities result in significant statistical differences. Based on the findings, this research suggests healthcare professionals can enhance patients’ self-efficacy in self-care by providing necessary health information via face-to-face or online communities, and assuring patients of demonstrable support. As such, patients’ levels of trust in healthcare professionals can be established, which in turn improves their medication adherence.

A systematic review of patient access to medical records in the acute setting: practicalities, perspectives and ethical consequences

Background

Internationally, patient access to notes is increasing. This has been driven by respect for patient autonomy, often recognised as a primary tenet of medical ethics: patients should be able to access their records to be fully engaged with their care. While research has been conducted on the impact of patient access to outpatient and primary care records and to patient portals, there is no such review looking at access to hospital medical records in real time, nor an ethical analysis of the issues involved in such a change in process.

Methods

This study employed a systematic review framework in two stems, to integrate literature identified from two searches: Medline, CINAHL and Scopus databases were conducted, (for (1) hospitalised patients, patient access to records and its effects on communication and trust within the doctor-patient relationship; and (2) patient access to medical records and the ethical implications identified). The qualitative and quantitative results of both searches were integrated and critically analysed.

Results

3954 empirical and 4929 ethical studies were identified; 18 papers representing 16 studies were identified for review (12 empirical and 6 ethical). The review reveals a consensus that our current approach to giving information to patients – almost exclusively verbally – is insufficient; that patient access to notes is a welcome next step for patient-centred care, but that simply allowing full access, without explanation or summary, is also insufficient. Several ethical implications need to be considered: increased information could improve patient trust and knowledge but might transfer an (unwelcome) sense of responsibility to patients; doctors and patients have conflicting views on how much information should be shared and when; sharing written information might increase the already significant disparity in access to health care, and have unforeseen opportunity costs. The impact on medical practice of sharing notes in real time will also need to be evaluated.

Conclusions

The review presents encouraging data to support patient access to medical notes. However, sharing information is a critical part of clinical practice; changing how it is done could have significant empirical and ethical impacts; any changes should be carefully evaluated.

Patient Involvement in Care and Breast Cancer Patients’ Quality of Life- a Structural Equation Modeling (SEM) Approach

In cancer patients, improving the quality of life is a basic goal of treatment, with the patient – physician relationship as a major factor. Therefore the aim of this structural equation modeling study was to analyze the influence of patient involvement in care on quality of life in 411 breast cancer patients undergoing outpatient chemotherapy and radiotherapy. Two questionnaires were used: 1-patient-physician questionnaire, 2-EORTC QLQC-30 (to measure QOL). The structural equation model exhibited an excellent data fit (Chi-Square= 31.04 / RMSEA= 0.042), T-values for all paths with the exception of that between patient satisfaction and emotional- cognitive function, were significant. According to the findings, various aspects of the physician-patient relationship are significantly and positively associated with quality of life and increasing patient involvement in care by increasing trust and satisfaction, was associated with marked improvement. The findings of this study emphasized the importance of an effective relationship between doctor and patient as a contributing factor for improving the quality of life. Therefore it is suggested that policymakers and decision-makers active in strategic planning for the health system and physicians responsible for treatment pay more attention to developing and improving relationships with patients as an approach to improving patient outcomes, particularly with reference to quality of life.

Mature or Emerging? The Impact of Treatment-Related Internet Health Information Seeking on Patients' Trust in Physicians

Years of clinical trials have proven the maturity and safety of certain treatments, however, some of these mature treatments may not be highly effective. Several treatments have emerged through technological innovations, but their long-term safety, efficacy, and adverse effects remain unknown. At present, many patients seek information related to their treatments on the Internet, which may impact their attitudes towards different treatments and their trust in physicians. In this study, a research model was developed to examine how patients’ trust in their physicians is influenced by related online information on mature or emerging treatments. The hypotheses were tested using confirmatory factor analysis (CFA) and structural equation modelling (SEM). A total of 336 valid responses were collected through an online survey. Mature treatments related health information was found to significantly improve patients’ trust. Thus, physicians should pay more attention to mature treatments, and encourage their patients to seek related information online. Moreover, the quality of online information should be developed further to increase patients’ satisfaction. Physicians should also consider their patients’ psychological safety in communication with patients to strengthen their trust.

Trust and Its Role in the Medical Encounter

This paper addresses two research questions. The first is theoretical: What is trust? In the first half of this paper we present a distinctive tripartite analysis. We describe three attitudes, here called reliance, specific trust and general trust, each of which is characterised and illustrated. We argue that these attitudes are related, but not reducible, to one another. We suggest that the current impasse in the analysis of trust is in part due to the fact that some writers allude to these distinctions, but unclearly so, whilst others elide them altogether. The second research question focuses on doctor-patient interaction. Trust is often said to be central in medical encounters but this strikes us as too vague. The success of doctor-patient relations in part depends on adopting the most appropriate of the three attitudes we delineate. We argue that reliance is the appropriate attitude for most medical encounters. When circumstances do require trust, the distinction between specific trust and general trust is crucial. We describe medical encounters requiring specific trust. General trust is less often required in medicine; but it is appropriate in some cases and, when called for, it is called for strongly.

Perspectives on Research Participation and Facilitation Among Dialysis Patients, Clinic Personnel, and Medical Providers: A Focus Group Study

BACKGROUND

Most prospective studies involving individuals receiving maintenance dialysis have been small, and many have had poor clinical translatability. Research relevance can be enhanced through stakeholder engagement. However, little is known about dialysis clinic stakeholders' perceptions of research participation and facilitation. The objective of this study was to characterize the perspectives of dialysis clinic stakeholders (patients, clinic personnel, and medical providers) on: (1) research participation by patients and (2) research facilitation by clinic personnel and medical providers. We also sought to elucidate stakeholder preferences for research communication.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

7 focus groups (59 participants: 8 clinic managers, 14 nurses/patient care technicians, 8 social workers/dietitians, 11 nephrologists/advanced practice providers, and 18 patients/care partners) from 7 North Carolina dialysis clinics.

METHODOLOGY

Clinics and participants were purposively sampled. Focus groups were recorded and transcribed.

ANALYTICAL APPROACH

Thematic analysis.

RESULTS

We identified 11 themes that captured barriers to and facilitators of research participation by patients and research facilitation by clinic personnel and medical providers. We collapsed these themes into 4 categories to create an organizational framework for considering stakeholder (narrow research understanding, competing personal priorities, and low patient literacy and education levels), relationship (trust, buy-in, and altruistic motivations), research design (convenience, follow-up, and patient incentives), and dialysis clinic (professional demands, teamwork, and communication) aspects that may affect stakeholder interest in participating in or facilitating research. These themes appear to shape the degree of research readiness of a dialysis clinic environment. Participants preferred short research communications delivered in multiple formats.

LIMITATIONS

Potential selection bias and inclusion of English-speaking participants only.

CONCLUSIONS

Our findings revealed patient interest in participating in research and clinical personnel and medical provider interest in facilitating research. Overall, our results suggest that dialysis clinic research readiness may be enhanced through increased stakeholder research knowledge and alignment of clinical and research activities.

Building trust and diversity in patient-centered oncology clinical trials: An integrated model

BACKGROUND/AIMS

Trust is the cornerstone of clinical trial recruitment and retention. Efforts to decrease barriers and increase clinical trial participation among diverse populations have yielded modest results. There is an urgent need to better understand the complex interactions between trust and clinical trial participation. The process of trust-building has been a focus of intense research in the business community. Yet, little has been published about trust in oncology clinical trials or the process of building trust in clinical trials. Both clinical trials and business share common dimensions. Business strategies for building trust may be transferable to the clinical trial setting. This study was conducted to understand and utilize contemporary thinking about building trust to develop an Integrated Model of Trust that incorporates both clinical and business perspectives.

METHODS

A key word-directed literature search of the PubMed, Medline, Cochrane, and Google Search databases for entries dated between 1 January 1985 and 1 September 2015 was conducted to obtain information from which to develop an Integrated Model of Trust.

RESULTS

Successful trial participation requires both participants and clinical trial team members to build distinctly different types of interpersonal trust to effect recruitment and retention. They are built under conditions of significant emotional stress and time constraints among people who do not know each other and have never worked together before. Swift Trust and Traditional Trust are sequentially built during the clinical trial process. Swift trust operates during the recruitment and very early active treatment phases of the clinical trial process. Traditional trust is built over time and operates during the active treatment and surveillance stages of clinical trials. The Psychological Contract frames the participants' and clinical trial team members' interpersonal trust relationship. The "terms" of interpersonal trust are negotiated through the psychological contract. Contract renegotiation occurs in response to cyclical changes within the trust relationship throughout trial participation.

CONCLUSION

The Integrated Model of Trust offers a novel framework to interrogate the process by which diverse populations and clinical trial teams build trust. To our knowledge, this is the first model of trust-building in clinical trials that frames trust development through integrated clinical and business perspectives. By focusing on the process, rather than outcomes of trust-building diverse trial participants, clinical trials teams, participants, and cancer centers may be able to better understand, measure, and manage their trust relationships in real time. Ultimately, this may foster increased recruitment and retention of diverse populations to clinical trials.

Erosion of Trust in the Medical Profession in India: Time for Doctors to Act

In India, over the last decade, a series of stewardship failures in the health system, particularly in the medical profession, have led to a massive erosion of trust in these institutions. In many low- and middle-income countries (LMICs), the situation is similar and has reached crisis proportions; this crisis requires urgent attention. This paper draws on the insights from the recent developments in India, to argue that a purely control-based regulatory response to this crisis in the medical profession, as is being currently envisaged by the Parliament and the Supreme Court of India, runs the risk of undermining the trusting interpersonal relations between doctors and their patients. A more balanced approach which takes into account the differences between system and interpersonal forms of trust and distrust is warranted. Such an approach should on one hand strongly regulate the institutions mandated with the stewardship and qualities of care functions, and simultaneously on the other hand, initiate measures to nurture the trusting interpersonal relations between doctors and patients. The paper concludes by calling for doctors, and those mandated with the stewardship of the profession, to individually and collectively, critically self-reflect upon the state of their profession, its priorities and its future direction.

Perceptions of physicians in civilian medical practice on veterans' issues related to health care

CONTEXT

The percentage of total US residents in the military is lower than ever before. Many civilians, including civilian physicians, have little knowledge of US military actions or the day-to-day experiences and working environments of veterans.

OBJECTIVE

To assess civilian physician knowledge of veterans' issues using a survey.

METHODS

A 10-item survey was distributed to physicians at 2 primary care-focused medical conferences in Ohio to determine self-reported levels of comfort and familiarity with veteran-oriented topics.

RESULTS

Of 350 surveys that were distributed, 141 surveys were returned. Of the 141 respondents, 101 practiced primary care, 19 practiced internal medicine, 16 practiced other specialties, and 5 did not report a specialty affiliation and were excluded from final analysis. A single respondent reported pediatrics as a specialty but indicated "not applicable" for all answers. This individual was excluded from final analysis. Overall, physicians reported feeling moderately comfortable with military terminology and uncomfortable with the diagnosis and management of traumatic brain injury. More than half of the respondents indicated that they were not comfortable discussing health-related exposures and associated risks that veterans might experience and that they were unfamiliar with referral and consultation services for veterans. The data collected had a high degree of reliability (Cronbach α=0.88). Respondents of both primary care and internal medicine specialties scored statistically significantly higher than the other respondents in questions on veterans' medical conditions, military terminology, and military health risks (P<.05), although these 2 groups scored similarly (P>.05). Specialty orientation did not affect responses for questions on other topics (P>.05).

CONCLUSION

The data indicated an overall moderate level of familiarity among civilian physicians with veterans' issues. The results did not reveal an overall high level of comfort with any issues included in the survey. More research is needed to determine reasons behind the findings and methods to improve civilian physician comfort with various veterans' issues.

Patient-Physician End-of-Life Discussions in the Routine Care of Medicare Beneficiaries

OBJECTIVE

Medicare reimbursement for physicians who discussed end-of-life care and planning with a patient during an office visit was cut from the 2010 Affordable Care Act. We assessed the characteristics of patients who reported having had such discussions, and whether these discussions are associated with trust in one's physicians and with rates of family advance care planning (FACP).

METHOD

The sample consisted of 5,199 Medicare beneficiaries who reported having an ongoing relationship with a primary care physician. We estimated ordinal and multinomial logistic regressions that controlled for health care utilization, current health, and recent family deaths.

RESULTS

Less than 1% (n = 310) reported an end-of-life conversation with a physician during the course of routine care. However, conversations were associated with greater trust in one's physician and higher rates of completion of FACP.

DISCUSSION

Findings support renewed efforts to reimburse physicians for discussing end of life with their Medicare patients.

Dimensions and determinants of trust in health care in resource poor settings--a qualitative exploration

BACKGROUND

Trust in health care has been intensely researched in resource rich settings. Some studies in resource poor settings suggest that the dimensions and determinants of trust are likely to be different.

OBJECTIVES

This study was done as a qualitative exploration of the dimensions and determinants of trust in health care in Tamil Nadu, a state in south India to assess the differences from dimensions and determinants in resource rich settings.

METHODOLOGY

The participants included people belonging to marginalized communities with poor access to health care services and living in conditions of resource deprivation. A total of thirty five in depth interviews were conducted. The interviews were summarized and transcribed and data were analyzed following thematic analysis and grounded theory approach.

RESULTS

The key dimensions of trust in health care identified during the interviews were perceived competence, assurance of treatment irrespective of ability to pay or at any time of the day, patients' willingness to accept drawbacks in health care, loyalty to the physician and respect for the physician. Comfort with the physician and health facility, personal involvement of the doctor with the patient, behavior and approach of doctor, economic factors, and health awareness were identified as factors determining the levels of trust in health care.

CONCLUSIONS

The dimensions and determinants of trust in health care in resource poor settings are different from that in resource rich settings. There is a need to develop scales to measure trust in health care in resource poor settings using these specific dimensions and determinants.

Looking outside the square: the use of qualitative methods within complementary and alternative medicine: the movement towards rigour

This paper explores why qualitative research in the field of complementary and alternative medicine (CAM) is underused and, when used, done so defensively. It argues that qualitative research methods can encompass the complexity of CAM and identify richer veins for research exploration. The rigorous application of holistic research methods, used non-defensively, can only benefit CAM and the knowledge base of science.

Cancer patients' experience of combined treatment with conventional and traditional Chinese medicine: a biopsychosocial phenomenon

BACKGROUND

Traditional Chinese medicine (TCM) is used worldwide as a complementary and alternative medicine, but little is known about cancer patients' experience when using combination therapy of TCM and conventional medicine.

OBJECTIVES

The goal of this study was to understand the experiences of Taiwanese cancer patients undergoing conventional chemotherapy and using TCM at the same time.

METHODS

For this qualitative descriptive study, 9 cancer patients (42-63 years old) were interviewed individually and in depth using a semistructured guide. All interviews were audiotaped and transcribed verbatim. Data were concurrently collected and analyzed using a constant comparative method to develop major themes and categories.

RESULTS

Data analysis revealed 3 themes: (1) biomedical aspect: TCM as a supplementary force to conventional medicine, (2) psychological aspect: different beliefs about TCM create different TCM uses, and (3) social aspect: interactions among patients, physicians, and economic issues.

CONCLUSIONS

Our study reveals that the phenomenon of using TCM is captured in a biopsychosocial model.

IMPLICATIONS FOR PRACTICE

When assessing the issue of TCM use among cancer patients, healthcare providers must take into consideration its biological, psychological, and social aspects.

How much does trust really matter? A study of the longitudinal effects of trust and decision-making preferences on diabetic patient outcomes

OBJECTIVE

To examine the impact of trust on patient outcomes (satisfaction, HbA(1C), physical and mental health-related quality of life (HRQoL)) and to investigate the role of decision-making preferences in the trust-outcome relationship.

METHODS

We conducted a one-year longitudinal analysis of 614 type 2 diabetic patients (mean age: 59.3 years; mean disease duration: 6.7 years). Patients' self-administered questionnaires and medical record were used for the research. Multiple regression analyses were conducted to investigate the relationship among variables during a 12-month follow-up. Further, we used latent growth modeling (LGM) to assess changes in health outcomes and to examine how these changes were related to trust.

RESULTS

Regression analyses revealed that trust was positively related to glycemic control, physical HRQoL, and satisfaction at 12 months. Patients with higher decision-making preferences experienced a greater increase in subsequent satisfaction. The results of LGM showed that higher levels of trust were associated with greater increases in physical HRQoL.

CONCLUSION

Trust contributes to improvements in health outcomes. The relationship between trust and satisfaction may be stronger among patients with higher decision-making preferences.

PRACTICE IMPLICATIONS

For healthcare providers, efforts should be made to cultivate patients' trust and enhance their decision-making preferences to maximize satisfaction and improve outcomes.

Inconsistencies in patient perceptions and observer ratings of shared decision making: the case of colorectal cancer screening

OBJECTIVE

To compare patient-reported and observer-rated shared decision making (SDM) use for colorectal cancer (CRC) screening and evaluate patient, physician and patient-reported relational communication factors associated with patient-reported use of shared CRC screening decisions.

METHODS

Study physicians are salaried primary care providers. Patients are insured, aged 50-80 and due for CRC screening. Audio-recordings from 363 primary care visits were observer-coded for elements of SDM. A post-visit patient survey assessed patient-reported decision-making processes and relational communication during visit. Association of patient-reported SDM with observer-rated elements of SDM, as well as patient, physician and relational communication factors were evaluated using generalized estimating equations.

RESULTS

70% of patients preferred SDM for preventive health decisions, 47% of patients reported use of a SDM process, and only one of the screening discussions included all four elements of SDM per observer ratings. Patient report of SDM use was not associated with observer-rated elements of SDM, but was significantly associated with female physician gender and patient-reported relational communication.

CONCLUSION

Inconsistencies exist between patient reports and observer ratings of SDM for CRC screening.

PRACTICE IMPLICATIONS

Future studies are needed to understand whether SDM that is patient-reported, observer-rated or both are associated with informed and value-concordant CRC screening decisions.