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Published 7/1/2010
S. Terry Canale, MD

Patient-physician trust

Patient satisfaction surveys show that how patients feel about their physicians are influenced (determined) by the following three factors:

  • how the patient perceives what the physician knows about him or her
  • trust
  • empathy

For many reasons, not the least of which are the population and technology booms, today’s world is both fast-paced and impersonal. In such a world, trust becomes very important, because a close personal relationship may not be possible.

Medicine is one of the few professions that enjoys the trust of the public on three levels. The public not only trusts the medical profession, it also trusts medical practitioners (physicians, primarily, but also nurses, therapists, and other healthcare personnel), and what they stand for. Think about that for a minute. No longer does the public, at least in my mind, trust the legal profession, the banking industry, the large car companies, the giants on Wall Street, the professional athletes, the mega-oil companies, or the majority of politicians. The public doesn’t trust the airlines, but does trust the pilots. Medicine enjoys both—trust in the profession and trust in the medical personnel, especially doctors. As stated simply in the military, “You, Doc, have got my back.”

The importance of trust
Why is trust so important in the medical field? Because of one simple concept—“adherence.” I am not going to let anyone put me to sleep—much less operate on me—if I don’t trust the situation or the person performing the surgery. I’m not going to take my medication if I don’t trust the person prescribing it. Even if you don’t believe in trust, believe that adherence is vitally important for the well-being of our patients.

Today in the United States, one third of all new prescriptions are not filled, one third are only partially taken, and one third are filled and taken as prescribed. Some of that may be due to economics, when a physician says “Take this,” the trusting patient will speak up, ask for help, and bend over backwards to do what needs to be done.

So how do we as physicians maintain the trust of our patients? By being honest with others and honest with ourselves. Rigorous honesty is the key to trust.

Recently, medicine—orthopaedics in particular—has come under scrutiny from the Department of Justice. Device companies were hit hard. We should learn from this—transparency is extremely important and there is nothing wrong with being a consultant as long as the arrangement is legitimate and transparent, one you’d be proud to have featured on the front page of The Wall Street Journal.

That’s one reason the AAOS recently updated its disclosure program and opened it to the public. You can be transparent by disclosing any relationships you have on the AAOS Web site.

Patients will appreciate your disclosing what prosthesis or plate you use in surgery or, more important, whether you have any financial reason for using a specific prosthesis or plate. In 2008, an article in The Journal of Bone and Joint Surgery—American discussed the increase in the use of intramedullary nailing for fixation of intertrochanteric hip fractures over the use of a sliding compression screw and plate. The authors hypothesized that one reason for the shift was the higher reimbursement for the nailing procedure (approximately $250). I laughed at that because it is such a small amount that I, at least, wouldn’t even consider that as a motive. But if you choose a nail over a plate, the patient should be made aware of your choice and the reasons for it.

Up front and honest
Similarly, the important point about implants is to be up front with the patient about his or her total joint prosthesis or any implant. Recently, a higher-than-anticipated rate of revision was found with metal-on-metal (MOM) implants, based on registry data, and the United Kingdom’s Medicines and Healthcare Regulatory Products Agency (MHRPA)(similar to the U.S. Food and Drug Administration [FDA]) issued an alert to its members.

It should be noted that the FDA has not issued any recall or alert on this topic, and that the implant that was the subject of a second alert from the MHRPA is not available for sale in the United States. This issue includes a roundtable discussion on MOM prostheses by six noted total joint surgeons, some who use MOM prostheses and some who don’t. The message of the roundtable is not whether one prosthesis or one combination of surfaces is better than another or whether MOM prostheses are good or bad, but to alert our members and, more important, to alert our patients.

Some orthopaedists may argue that the probability of problems is small and the alert is not justified. I can’t comment on that fact, but I can comment that in the world of ligitation, it is important to inform the patient of potential problems—no matter what the probability of occurrence. I can hear it now: “Doctor, when did you learn about the alert?” and “Doctor, when did you inform your patient about the problem?”

As medical professionals and orthopaedic surgeons, we must be honest with our patients concerning the latest alert about MOM implants. Although only a small percentage of patients may be involved, we must take responsibility, do the “next right thing,” and be transparent when dealing with our patients. For the public, it may be perception, which is an important component of trust, but for our patients, it is real—both perception and reality are important.

So, how do we do the right thing?

  • Disclose to the patient and discuss the type of implant being used and our reasons for its selection.
  • Stay up-to-date on any patient safety alerts or device recalls from manufacturers, the FDA, or similar agencies.
  • Follow the recommendations when an alert is issued, particularly with regard to patient notification and follow-up.
  • Take responsibility to identify why and to rectify any “malfunctioning” implant.

We need to be honest with our patients to maintain their trust. We need to be transparent with them, fully disclosing any and all relationships with industry. Just as we have a frank discussion with our patients about the possible complications of a surgical procedure or medication, we should discuss the implant and any relationship with its manufacturer. At this critical time in medicine, we need to maintain our patients’ trust, not lose it.