Editor’s Note: On July 31, JAMA Network published the results of a survey that found patients’ trust in doctors and hospitals dropped 31 percentage points from April 2020 to January 2024. The findings came as no surprise to Chad Savage, M.D., founder of a direct primary care (DPC) practice, president of DPC Action, and a policy advisor to The Heartland Institute, which co-publishes Health Care News. We talked with Dr. Savage about why trust in doctors is declining and what effects it is having.
Health Care News: A recent study showed that doctor trust has plummeted, especially during the pandemic years. Do you believe the pandemic is largely to blame for patients’ loss of trust or, could something else be happening?
Savage: This is a complex issue with clear financial conflicts of interest in medicine, where a doctor’s self-interest can sometimes clash with the patient’s best interests, eroding trust.
The third-party payer system, meaning insurance companies and the government, has become deeply intertwined with the actual provision of care.
These entities often dictate the pace at which doctors see patients, the tests they can order, and the treatments they can prescribe. This loss of autonomy diminishes the doctor’s role and accelerates the pace of visits, hindering the development of a trusting doctor-patient relationship.
Health Care News: One could argue health care resources are limited and efficiency in a practice is a good thing. What problems does the loss of trust create?
Savage: Loss of trust is highly detrimental because a patient’s adherence to treatment protocols is closely linked to the trust they have in their physician. Furthermore, when patients don’t understand the reasons behind their treatment plans, they are less likely to follow them. If given sufficient time, doctors can more thoroughly explain their reasoning, thereby improving patient compliance.
The abbreviated visits incentivized by the third-party system have also led to greater pharmaceutical prescribing. Time-constrained physicians may see prescribing medication as the quickest route to the next exam room, rather than focusing on the more time-consuming task of lifestyle modification.
This excessive prescribing feeds into the perception that physicians are in collusion with pharmaceutical companies, when in reality they may simply be rushed and overwhelmed by the demands of a bureaucratized health care system.
Health Care News: What role do health insurance plans play in influencing practice behavior?
Savage: As mentioned earlier, direct financial conflicts of interest do exist between doctors and patients. The seemingly appealing “pay-for-performance” insurance payment programs can incentivize physicians to avoid the sickest patients, who might negatively impact their scores and thus reduce their reimbursements. Additionally, “performance” as defined by insurance companies may not be what patients consider performance.
Doctors may be rated by insurance companies based on their ability to defend insurance companies’ coffers, whereas patients may consider a doctor high-performing based on their advocacy for the patient’s best interest. For instance, doctors may receive higher compensation by denying expensive tests like MRIs, potentially putting their self-interest in conflict with the patient’s best interest.
Such conflicts of interest should have no place in the medical system. Even if a doctor is altruistic and strives to remain unbiased, the mere existence of these incentives can erode patient trust. Patients now must question the doctor’s motivation behind their recommendations.
This is just the beginning. I could write a textbook on this topic, without even touching on the corruption in licensing that was used to force doctors to adhere to specific narratives during COVID, or the censorship of doctors with opposing viewpoints creating the false impression of uniformity of opinion from the perceived health care monolith.
Health Care News: If patients understood these forces, would that be enough to restore trust, or do physicians have some responsibility here?
Savage: These issues have collectively eroded, in just a few short years, the hard-earned trust that physicians have built over a millennium. As mentioned, this loss of trust will lead to reduced patient participation in their treatment plans. Fewer cancers will be detected, and there will be increased illness and death.
Doctors must vigorously oppose the forces that have undermined this trust and work to reestablish the altruistic relationships upon which our patients’ health depends. This starts with eliminating the trust-eroding third parties from the doctor-patient interaction.
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