Public Trust in Physicians — U.S. Medicine in International Perspective

By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero, M.P.H.
The New England Journal of Medicine, October 23, 2014

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.

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. 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).

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. 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.

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.

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.

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. 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. In particular, polls show that Americans see high costs as the most important problem with the U.S. health care system, and nearly two thirds of the public (65%) believes these costs are a very serious problem for the country. 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.

Another unique feature of the U.S. health care system that sets us apart from other nations: “You just can’t trust doctors nowadays, but my doctor is really good.” What can we make of this?

In general, individuals are relatively satisfied with their personal care. Low-income individuals are less satisfied, but that is likely related to the deficient financing of their care and the consequences of that – a characteristic of our fragmented, dysfunctional system of financing health care. But, overall, our system is capable of ensuring patient contentment.

It is the confidence in physician leadership that has deteriorated. The authors of this article suggest some possible explanations, but it is more likely that the image of the profession at large has changed from that of the dedicated personal physician steeped in the Hippocratic tradition, to that of the high-tech, entrepreneurial agent of the medical-industrial complex. Combine that perspective with the very high costs of health care today – costly care which physicians orchestrate – and it is no wonder that the public is no longer as trusting of the profession. Only “my doctor” is immune to this.

When you look at the role that the AMA had in the enactment of the Affordable Care Act, it is evident that they were not there to represent patients; they were there alongside the other elements of the medical-industrial complex – especially the insurance, pharmaceutical and hospital industries – to be sure that they got their own share of the action. The only patient advocates present were the consumer organizations that chose the default option of “political feasibility,” becoming “strange bedfellows” of the private insurance industry.

There are many dedicated individual physicians and other health care professionals who clearly place patients first. They are well represented in organizations such as Physicians for a National Health Program. They are also well represented in the AMA and the various specialty organizations, but, as a collective voice, they are ineffective in communicating the tradition of caring; rather they passively communicate the acceptance of the medical-industrial complex – a very sterile advocacy position.

Let’s indulge in a fantasy. Let’s imagine that our professional organizations all joined together in a clarion call for comprehensive, affordable, high-quality care for absolutely everyone – including those low-income individuals who distrust the profession today. Single payer would bring us such quality that is truly affordable.

With a voice unified in support of the patient, what do you think would then happen to the level of confidence that the public has in the medical profession? Physicians would once again relish respect as a noble profession advocating for their patients.  As an aside, it would also mean that they would have a very pleasant work environment and be adequately compensated for their efforts. If the system works for patients, it will work for physicians.