Public Trust in Physicians — U.S. Medicine in International Perspective
Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero, M.P.H.
N Engl J Med 2014; 371:1570-1572October 23, 2014DOI: 10.1056/NEJMp1407373
The U.S. health care reform process is entering a new phase, its emphasis shifting from expanding health coverage to improving our systems for delivering patient care. One emerging question is what role the medical profession and its leaders will play in shaping future national health care policies that affect decision making about patient care.
Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession’s views and leadership. But an examination of U.S. public-opinion data over time and of recent comparative data on public trust in physicians as a group in 29 industrialized countries raises a note of caution about physicians’ potential role and influence with the U.S. public.
In a project supported by the Robert Wood Johnson Foundation and the National Institute of Mental Health, we reviewed historical polling data on public trust in U.S. physicians and medical leaders from 1966 through 2014, as well as a 29-country survey conducted from March 2011 through April 2013 as part of the International Social Survey Programme (ISSP), a cross-national collaboration among universities and independent research institutions (ISSP 2011–2013) (see Opinion Polls on Public Trust in Physicians for poll information). We found that, as has been previously reported, public trust in the leaders of the U.S. medical profession has declined sharply over the past half century. In 1966, nearly three fourths (73%) of Americans said they had great confidence in the leaders of the medical profession. In 2012, only 34% expressed this view (Harris 1966–2012). But simultaneously, trust in physicians’ integrity has remained high. More than two thirds of the public (69%) rate the honesty and ethical standards of physicians as a group as “very high” or “high” (Gallup 2013). Our review of numerous analyses of public-opinion data about public trust in institutions and professions suggests that the decline in trust is probably attributable to broad cultural changes in the United States, as well as rising concerns about medical leaders’ responses to major national problems affecting the U.S. health care system.1,2 Today, public confidence in the U.S. health care system is low, with only 23% expressing a great deal or quite a lot of confidence in the system (Gallup 2014). We believe that the medical profession and its leaders are seen as a contributing factor.
This phenomenon does not affect physicians in many other countries. Indeed, the level of public trust in physicians as a group in the United States ranks near the bottom of trust levels in the 29 industrialized countries surveyed by the ISSP. Yet closer examination of these comparisons reveals findings similar to those of previous U.S. surveys: individual patients’ satisfaction with the medical care they received during their most recent physician visit does not reflect the decline in overall trust. Rather, the United States ranks high on this measure of satisfaction. Indeed, the United States is unique among the surveyed countries in that it ranks near the bottom in the public’s trust in the country’s physicians but near the top in patients’ satisfaction with their own medical treatment.
The United States is tied for 24th place in terms of the proportion of adults who agree with the statement, “All things considered, doctors in [your country] can be trusted.” About 6 in 10 U.S. adults (58%) agree with this statement, as compared with more than three fourths in Switzerland (83%), Denmark (79%), the Netherlands (78%), and Britain (76%) (ISSP 2011–2013)
Part of the difference may be related to the lack of a universal health care system in the United States. However, the countries near the top of the international trust rankings and those near the bottom have varied coverage systems, so the absence of a universal system seems unlikely to be the dominant factor.
By contrast, the United States ranks third in terms of the proportion of adults who say they were completely or very satisfied with the medical treatment they received at their last physician visit (56%). Of the 10 countries that rank lowest in public trust in their countries’ physicians, all but the United States also rank 19th or lower in patients’ satisfaction with their own medical care.
The United States also differs from most other countries in that U.S. adults from low-income families (defined as families with incomes in the lowest third in each country, which meant having an annual income of less than $30,000 in the United States) are significantly less trusting of physicians and less satisfied with their own medical care than adults not from low-income families. Less than half (47%) of low-income Americans surveyed agreed that U.S. doctors can be trusted — significantly less than the 63% of non–low-income Americans who expressed that view. Low-income Americans were also less likely than non–low-income Americans (48% vs. 59%) to be completely or very satisfied with their treatment at their last physician visit (ISSP 2011–2013) (see the Supplementary Appendix, available with the full text of this article at NEJM.org).
Although non–low-income Americans expressed greater trust in physicians than their low-income counterparts did, when responses were analyzed by income group, the United States still ranked 22nd in trust among the 29 countries. On the flip side, although low-income Americans were less likely than non–low-income Americans to report being completely or very satisfied with their own care, the United States still ranked seventh in satisfaction among low-income adults (ISSP 2011–2013).
The same pattern is seen in subpopulations defined by age or sex. Americans 65 years of age or older were significantly more likely than younger Americans to agree that U.S. physicians can be trusted (69% vs. 55%), and U.S. men were significantly more likely than U.S. women to think so (63% vs. 54%). However, the United States ranked lower in terms of trust in the profession than most other countries among both men (21st) and people 65 years of age or older (22nd) (ISSP 2011–2013).
In drawing lessons from these international comparisons, it’s important to recognize that the structures in which physicians can influence health policy vary among countries. We believe that the U.S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries. Moreover, the U.S. medical profession, unlike many of its counterparts, does not share in the management of the health system with government officials but instead must exert its influence from outside government through various private medical organizations. Some other countries’ systems have more formal structures through which physician leaders may bargain and negotiate with the government over such issues as payment, professional autonomy, and quality of care.3 Moreover, in terms of health policy recommendations, the U.S. medical profession is split among multiple specialty organizations, which may endorse competing policies.
Nevertheless, because the United States is such an outlier, with high patient satisfaction and low overall trust, we believe that the American public’s trust in physicians as a group can be increased if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation’s health and health care, even if doing so might be disadvantageous to some physicians.4,5 In particular, polls show that Americans see high costs as the most important problem with the U.S. health care system (RWJF/HSPH 2011), and nearly two thirds of the public (65%) believes these costs are a very serious problem for the country (NPR/RWJF/HSPH 2012). To regain public trust, we believe that physician groups will have to take firm positions on the best way to solve this problem. In addition, to improve trust among low-income Americans, physician leaders could become more visibly associated with efforts to improve the health and financial and care arrangements for low-income people. If the medical profession and its leaders cannot raise the level of public trust, they’re likely to find that many policy decisions affecting patient care will be made by others, without consideration of their perspective.