Functions and Limitations of Trust

The Functions and Limitations of
Trust in the Provision

of Medical Care
David Mechanic
Rutgers University
Abstract Trust, the expectation that institutions and professionals will act in
one’s interests, contributes to the effectiveness of medical care. With the rapid pri-
vatization of medical care and the growth of managed care, trust may be diminished.
Five important aspects of trust are examined: technical and interpersonal compe-
tence, physician agency, physician control, confidentiality, and open communication
and disclosure. In each case, changing health care arrangements increase the risks
of trusting and encourage regulatory interventions that substitute for some aspects
of trust. With the increased size and centralization of health care plans, inevitable
errors are attributed to health plans rather than to failures of individual judgment.
Such generalized criticisms exacerbate distrust and encourage micromanagement of
medical care processes.
The privatization of our health care system and the increased prevalence
of managed care practices are significant sources of growing public dis-
trust of medicine (Mechanic and Schlesinger 1996). The growth of dis-
trust has unleashed efforts by public agencies, state legislatures, Con-
gress, and professional organizations to restrain managed care. Some
one thousand bills were introduced in state legislatures in 1996 to con-
trol such practices (Bodenheimer 1996), and these efforts show no signs
of abating. Interest groups who have something to lose from changing
health care arrangements are a source of much of the ferment but leg-
islative efforts also are a response to public anxieties.
Work on this article was supported by a Robert Wood Johnson Investigator Award in Health Pol-
icy Research.
Journal of Health Politics, Policy and Law, Vol. 23, No. 4, August 1998. Copyright © 1998 by
Duke University Press.
662 Journal of Health Politics, Policy and Law
It may seem ironic that public concern about health care is so high at
a time when biomedical science is advancing rapidly and medical care
is more effective than ever before. It may be that the public’s idealization
of medicine and the doctor, so out of touch with reality (Malmsheimer
1988), makes medical care vulnerable to any indication that motives
other than loyalty to patients are important. Such indications are now
abundant in every form of media. As Eric Cassell has noted, the medical
posture of omnipotence annoys the healthy, but “the patient borrows it,
clothes his nakedness in it until such time as his own becomes whole
again” (1979: 142). Trust, thus, serves the patient’s needs especially well
during periods of greatest vulnerability.
Trust is the expectation that individuals and institutions will meet their
responsibilities to us. It affects almost every aspect of doctor-patient
interaction, from personal disclosure to cooperation in treatment. With
the changes now taking place in medical care, patients’ trust is less secure,
and medical organizations and medical leaders are viewed with dimin-
ished confidence (Blendon and Taylor 1989; Blendon, Steltzer-Hyams,
and Benson 1993). Patients continue to express high confidence in their
personal physicians but changes in employer health insurance decisions
and increasing market penetration of HMOs are disrupting many exist-
ing relationships and eroding patient trust. Trust is strongest when
patients make their own care choices and are not restricted by either
employer decisions or health plan constraints.
Trust in medical care arrangements and in one’s physician are to some
degree interdependent. Trust in one’s physician typically comes from
direct experience but trust in medical institutions and arrangements is
shaped to a considerable degree by the media and by informal public
opinion. When patients become suspicious of the motives and practices
of organizations, this can affect the way they interact with their doctors,
particularly if they become doubtful that their doctors are acting solely
in their interest.
As our health care system focuses on cost issues, trust is at best only
a secondary consideration in health policy. Yet trust is an essential “glue”
that holds communities together and allows us to pursue our affairs with-
out excessive suspicion, policing, and regulation. The erosion of trust,
therefore, damages the effectiveness of medical interventions, and invites
legislative and regulatory micromanagement of health affairs. Until recent
years American medicine was an extraordinary example of achievement
of public respect (Starr 1982), and was left to a considerable degree to
govern its own affairs with little legislative interference. Medicine’s legit-
Mechanic ■ Functions and Limitations of Trust 663
imacy was so great that it raised serious questions about whether the
public was too trusting (Friedson 1970).
The challenge is to differentiate appropriate skepticism from damaging
distrust. Patients today are better educated, more informed, and increas-
ingly aware of medical uncertainties and variabilities in practice. They
are accordingly more demanding and more critical. Increasingly sensi-
tive to issues of personal autonomy, they are less likely to accept pater-
nalistic behavior that was common and unremarkable just a few decades
ago. Patients now seek more control over their options and how they
receive their care, as exemplified by the woman’s and disability rights
movements and by the growth of self-help and consumerist ideologies
(Rodwin 1994: esp. 153 – 166).
Many health professionals and institutions recognize that patient par-
ticipation in decision making may be constructive for the quality of care
and are developing patient-centered models that seek to reduce paternal-
ism and make the doctor-patient relationship more of a partnership
(Gerteis et al. 1993). It is also anticipated that such partnerships can be
the basis of renewed trust — trust more consistent with a diverse and
better educated population and with greater complexity in health care
arrangements. Increased distrust of the structures and orientations of
health care also encourages public and private regulations that serve as
alternatives to trust. Identifying the proper balance between trust and
regulation is a challenging task of public policy. Good regulatory policy
makes trust more possible by deterring or controlling its most risky
aspects and by reassuring patients that they can trust safely. Measures to
bolster trust between patient and clinician, whether originating from ini-
tiatives developed by clinicians and medical settings or from regulatory
agencies, are stabilizing influences in the context of rapid change and
uncertainty in health care.
Dimensions of Trust
Trust, itself, is a multidimensional concept and its aspects may vary in
importance and salience as circumstances change. Although persons
willingly report global opinions on whether they trust or distrust vari-
ous institutions, focusing on specific aspects is more instructive. In this
article I consider five dimensions of trust: (1) expectations about phy-
sicians’ competence, (2) the extent to which doctors are concerned with
their patients’ welfare, (3) physician control over decision making, (4)
physicians’ management of confidential information, and (5) physi-
cians’ openness in providing and receiving information. Changes in

medical practice raise important issues in each of these areas. I then
examine ways of eliciting trust and explore medical and regulatory
structures that might help limit the extent to which ongoing changes
increase distrust.
Trust in Competence
Patients want their physicians to be highly competent but assessing med-
ical competence is difficult even among experts. In a simple way, we are
reassured by our knowledge that medicine is a highly competitive aca-
demic endeavor, that entry into medicine is selective and requires talent
and perseverance, that training is uniformly careful and rigorous, and
that the profession controls entry and licensing through high standards.
The medical profession has been extraordinarily successful, much more
than other professions, in conveying the perception that doctors, ran-
domly chosen, would provide competent service and could be trusted.
But any realist appreciates that in every endeavor, however careful the
selection and training, there are those more and less competent and the
range is large. When one is seriously sick, and the stakes are high, one
wants security that trust in one’s doctors is well placed.
Most patients have at least some opportunity to choose a doctor. Over
time most find one they regard as satisfactory, as indicated by high rat-
ings of one’s personal doctor in repeated patient surveys. In such selec-
tions, patients, unable to assess competence directly, depend on such
proxies as reputation, affiliations, and interpersonal cues. They typically
seek the suggestions of relatives, friends, neighbors, and health profes-
sionals they know, and such recommendations have high credibility.
Choosing among health plans is more difficult since these are large orga-
nizations with considerable diversity of practitioners and services. But
individuals still depend substantially on trusted informal sources of infor-
mation (Mechanic, Ettel, and Davis 1990). A great deal of effort is now
being devoted to developing health plan “report cards” but they will not
easily replace informal advice. Patients with more awareness of medical
arrangements may be sensitive also to the reputation of the doctor’s med-
ical school and residency training, hospital and medical school affilia-
tions, board certification, or other indicators of attachment to respected
institutions. Images of institutions like the Mayo Clinic and Harvard
Medical School allow patients to make attributions of competence while
knowing nothing of the particular skills of the clinician. It is widely
assumed that such institutions select among the best and carefully screen
and supervise their professional staff.
Early in their encounters with new clinicians, patients also actively
seek cues that affirm the physician’s competence. The patient may be sen-
sitive to how the physician takes a medical history, carries out a physical
examination, and communicates important medical information. Those
more knowledgeable and inquisitive compare and contrast what they are
told with what they already know, or seek further information that tests
the validity of the information provided. There is some indication that
patients make these judgments reasonably well and often come to con-
clusions that agree with more expert assessments (Roter and Hall 1992:
132 – 139).
Competence includes more than knowledge, judgment, and skill in
technical functions. It also includes interpersonal skills such as the abil-
ity to help the patient feel at ease; interviewing sensitively and effectively
to elicit not only relevant symptoms but the patient’s concerns; convey-
ing a sense of listening carefully; and providing responsive and mean-
ingful feedback. Physicians with good technical competence may convey
a sense of disinterest, abruptness, awkwardness, and evasion. Patients
are sensitive to these aspects of the interaction and poor interpersonal
competence may undermine the patient’s trust in the physician’s overall
competence, result in an unwillingness to follow medical advice, and lead
to a change in doctors (Roter and Hall 1992: 132 – 146).
Patients have a psychological need to trust the competence of their
doctors but also feel considerable ambivalence. As Malmsheimer (1988)
astutely observes, “to distrust one’s doctor is to be vulnerable in the most
fundamental and undesirable ways” (1) and such trust “reflects people’s
hopes rather than their actual experiences” (45). When physicians fail to
conform to this idealized expectation, as many inevitably must, the reac-
tion is often excessive, akin to the lover betrayed. The stake seriously ill
patients perceive in this relationship significantly raises the risks of trust,
but the information they have is always incomplete. The product of med-
ical care is in part the process of doctoring, and how physicians maintain
the relationship and manage problems. Thus, in any instance, patients
cannot know the product before experiencing it (Arrow 1963: 949), and
even the highest reputation is not necessarily predictive of how a treat-
ment episode will unfold.
In hundreds of millions of transactions, errors and negligence occur
with some frequency. For example, the Harvard Medical Practice Study
in New York State found that of the adverse events that occurred in 3.7
percent of hospital admissions, more than one-quarter were due to neg-

ligence (Brennan et al. 1991). Because of the intense interest of the pub-
lic and media in such events, even rare but dramatic events receive wide
publicity and may disproportionately color how the public views med-
ical competence. In centralized systems such as the United Kingdom’s
National Health Service (NHS), local incidents involving an unusual
medical error, a long delay in the arrival of an ambulance, or difficulty in
locating an intensive care bed may become national news and a basis for
a parliamentary question for the prime minister (Lawson 1992: 612). A
motive often attributed to Margaret Thatcher for initiating the 1991
reforms in the NHS was a desire to devolve responsibility for such inci-
dents to the local level and to private organizations. The growing cen-
tralization of medical decision making by large organizations in the U.S.
context may have the unintended consequence of making issues more vis-
ible and more public and political (Mechanic 1997). Proponents of par-
ticular regulations often attribute problems to organized health plans
rather than to mistaken judgments on the part of individual clinicians. In
this context, and particularly in the context of growing distrust of the
motivations underlying new medical arrangements, anecdotes can be
extremely powerful incitements. This is reflected in the way atrocity sto-
ries were used in the 1996 referendum campaign in California to try to
restrict managed care practices (Pear 1996).
Large nationally recognized health plans such as Kaiser Permanente, a
highly regarded HMO serving more than 7 million people, are suscepti-
ble to significant reputational damage when one of its many contracting
partners is alleged to have denied a needed referral or engaged in some
other disapproved practice. An influential New York Times article in
December 1995 quoted a directive in an Ohio Kaiser Permanente physi-
cian group that prohibited discussing proposed treatments with patients
(Pear 1995). The Kaiser Permanente logo encouraged the assumption that
this was a widespread Kaiser Permanente policy, although the incident
was an aberration out of conformance with Kaiser Permanente policy.1
Trust in Physician Agency

Particularly when they are seriously ill and highly dependent, it is essen-
tial for patients to believe that their physicians are their agents and will
1. Interview by the author with Dr. David Lawrence, CEO, Kaiser Foundation Health Plan,
2 March 1997, Oakland, California.
represent their interests effectively. The notion of physician agency has

an honorable history in medical philosophy and ethics, and the public
legitimacy of the medical profession rests substantially on the perception
of physicians as dedicated patient advocates. All such commitments are
bounded. Thoughtful patients have always understood that physicians
have their own personal interests to earn a decent living and to have some
control over their schedules. But beyond these obvious constraints, med-
icine has been viewed as a selfless endeavor in which physicians would
suffer inconvenience and even hardships when major patient interests
were at stake. Although there was always some threat that economic
incentives might induce the physician to prescribe unnecessarily or to
encourage the patient to visit too often, or refer patients to facilities in
which the doctor had a financial interest for remunerative reasons, there
was little ambiguity about the expectation that the physician’s loyalty
was to the patient. Changing organizational arrangements, managed care
practices, and a growing gap between economic constraints and what
medical knowledge and technology allow potentially erode this key
assumption.
The American Medical Association’s code of ethics has long prohib-
ited fee-splitting and kickbacks as inappropriate behavior that under-
mines trust and has appealed to physicians to resolve all conflicts of
interest on the patient’s behalf, arranging alternative patient care if
needed to deal with such situations. This code expressed the ideal, often
at variance with physician behavior (Rodwin 1993). But this norm is
even less realistic with the growth of corporate medicine and the need for
physicians to accommodate organizational expectations, competing val-
ues, and colleague pressures. In the early stages of managed care, doc-
tors were reasonably successful in protecting their vision of themselves
as expert professionals, not simply as employees of bureaucratic organi-
zations (Friedson 1975). In the United States they have resisted direct
employment, preferring to develop their own professional groups to con-
tract with HMOs and other bureaucratic organizations. In the British
National Health Service, the only fully nationalized health service among
modern nations, general practioners (GPs) nominally retained their inde-
pendence by contracting with the NHS for their services (Eckstein 1964:
193 – 194; Klein 1995). It is arguable whether this made much difference
but it may have protected the voice of GPs in response to government
policies more than if they were salaried employees. In any case, central-
ization of management in medical care and changing power and depen-
dence relations between large insurance organizations and physicians in
surplus have increasingly put physicians in positions where they face

more tangible conflicts between their patient advocacy and allocation of
care responsibilities, and between their motivation to serve their patients’
needs and their own economic “survival.”
Patients place high priority on the belief that the physician is their
agent and not simply a neutral decision maker. Even in HMOs most mem-
bers believe it is very important that their doctors be concerned only with
their health and not with limiting costs for the plan (Mechanic, Ettel, and
Davis 1990). Reconciling this expectation with the understanding that
HMOs ration care and that their physicians’ economic decisions are
reviewed by cost-conscious administrators may appear difficult. Many
patients who choose HMOs do not understand clearly how they func-
tion, a problem that should subside with time. The belief, however, that
HMO physicians practice largely independent of financial pressures has
probably matched the experience of most members. While there occa-
sionally may be difficulties in gaining immediate access because there is
more gatekeeping to schedule an appointment, most patients are unlikely
to be denied any needed service, and some preventive and other services
may be more accessible with fewer economic barriers than in traditional
practice.
Rationing in HMOs is mostly implicit and patients may perceive no
tensions at all between their needs and the HMO’s financial constraints.
Tensions may increase in the case of a serious and costly illness episode
where efforts are made to avoid hospitalization, to keep the length of stay
short, or to deny an experimental treatment. But such problems have lit-
tle salience for most members who are healthy or have routine illnesses.
One suspects (and the anecdotal evidence affirms) that conflicts are typ-
ically more salient in utilization review where denials are more explicit
and clear-cut. Allegations are frequently made that refusal to hospitalize
patients results in illness complications and sometimes death, that
patients are being discharged from inpatient units “quicker and sicker,”
and that the most efficacious drugs are being withheld because they cost
more than alternative medications. Errors of judgment obviously occur.
The issue for which there is little data is whether such errors are system-
atic. In fact, there is great variability in practice. In a survey of utilization
review organizations, Schlesinger and his colleagues reported that 17
percent of such organizations had denial rates of 1 percent or less while
30 percent of respondents reported denial rates of 10 percent or more
(Schlesinger, Gray, and Perreira 1997). Because explicit denial makes
rationing obvious, many believe that future managed care will depend
more substantially on transfer of risk to providers, which keeps medical

allocation implicit and more difficult to identify (Mechanic 1995).
Depending more on implicit rationing and on sharing risk with pro-
viders through capitation, bonuses, withholds, and other devices does not
solve the trust problem; it simply makes processes of denial less visible.
But the publicity given to managed care practices and financial arrange-
ments with physicians and other providers makes the public aware of
growing threats to physician agency. Media attention to “gag rules,”
income arrangements, and pressures to reduce hospital stays keep these
issues in the public eye and potentially threaten patient confidence. It also
contributes to the mobilization of political advocacy and regulatory ini-
tiatives. These issues have not reached their damaging potential because
U.S. health care is richly funded and managed care has had a great deal
of “fat” to work with. Anecdotes abound, but there is no systematic evi-
dence that needed efficacious care is being denied.
There is large variability within all practice types. HMOs, with some
exceptions—for example, the treatment of elderly and poor persons with
serious chronic illness (Ware et al. 1996)— appear to offer no less quality
of care than more traditional arrangements (Miller and Luft 1994). Stud-
ies that find some poorer outcomes in HMOs, especially the Medical
Outcomes Study (Ware et al. 1996), provide insufficient understanding of
the basis for these aggregate differences between fee-for-service and
HMOs and fail to explain the variability within different types of HMOs.
Moreover, HMOs are changing rapidly, making the generality of results
uncertain. HMOs are still a work in progress (Ellwood and Lundberg
1996). Nevertheless, it is inevitable that rationing either by cost sharing
(Newhouse and the Insurance Experiment Group 1993) or by utilization
review strategies will limit not only trivial care, but some useful and effi-
cacious care as well. As insurance plans ration care more rigorously,
they will have to convince the public that the quality assurance processes
they put in place allow their clinicians and managers to select appropri-
ately between what is more or less worth doing, and that there are
enough checks and balances in the system to protect patients. In the final
analysis, no health plan can sustain public trust without evidence that
physician advocacy is strong and protected.
Trust in Control
In selecting a physician we take it for granted that the clinician has access
to the means needed to maintain our health, to the extent that medical
knowledge realistically allows. Researchers involved in the study of

access to care usually assume that access to a primary care physician is
a reasonable proxy for general access. Once the patient is linked to a
larger system of services, any needed medical care becomes possible as
long as the services are covered by insurance or are economically afford-
able. In theory, everything is possible; in fact, most physicians’ referral
networks are restricted to a relatively small number of hospitals and spe-
cialists with whom they have regularized relationships. Doctors’ atti-
tudes, knowledge, and embeddedness in particular practice networks are
important determinants of patient access.
This process is seen more clearly in contexts like the United Kingdom
where resources are highly constrained and lack of availability of spe-
cialists or appropriate referral facilities sets tough limits on what is pos-
sible (Aaron and Schwartz 1984). For example, in 1993 – 94, rates of
coronary angioplasty among districts in the United Kingdom varied
thirty-four fold (Langham and Black 1994). Queues typically are estab-
lished for referrals and specialized care and patients may wait for extended
periods for nonacute services. But there are also districts where available
capacity is not completely utilized because GPs’ ignorance or attitudes
inhibit referrals of patients who could benefit from the service.
Group and staff HMOs may reduce some types of specialized referrals
but they may make other services of utility to patients more available,
such as preventive health clinics or specialized programs in chronic dis-
ease management. Some HMOs appear to do well in these low technol-
ogy areas relative to conventional practice (Miller and Luft 1994). Large
health plans, like Kaiser Permanente or Harvard Pilgrim Health Care,
have a greater capacity to develop a broad range of treatment interven-
tions than individual practices and small groups. Such plans can more
easily develop behavior change approaches, use nurse practitioners and
midwives, organize special services for subgroups of enrollees, or develop
treatment pathways for clinicians and patients.
From a trust perspective, the key issue is whether patients believe that
their doctors have control over the medical resources necessary for their
care. However much I may believe my doctors to be competent agents,
they have less value to me if they cannot command the authority to mobi-
lize needed resources on my behalf. Such difficulties in agency have
been quite common in situations where physicians have been “double
agents,” as in involuntary psychiatry and military and corporate medi-
cine. Corporate physicians are not only limited in how they can serve
their patients when patient and company needs conflict, but also they
may control patients in the interests of the company (Walsh 1987: 139 –
142). In a more limited sense, managed care, whether in the form of HMOs
or utilization management, limits the doctor’s control over decision mak-
ing by imposing capacity restraints, by restricting the range of special-
ists, and by requiring prereview of varying types of decisions.
Whatever the method, and however sensible the logic, medical admin-
istrative review in HMOs restricts the clinical authority of doctors. As
patients become aware of it they may lose some confidence that their
physicians, however competent and well-meaning, have the capacity to
get them what they need or want. Alternatively, health insurance plans
may make efforts to convince enrollees that the systems of review and
quality assurance they have in place increase quality of care and provide
added protections for their welfare. To the extent that there are signifi-
cant differences between the plan’s and the physician’s judgment about
what is necessary and desirable, physicians and plans compete for the
patient’s trust.
Physicians have significant advantages over plans because patients
trust them more. This, in part, explains why many physicians support the
idea of provider service organizations. They believe they can success-
fully compete with plans for patients and retain the profits associated
with such plans. There is some likelihood, however, that when the inter-
ests of plans and physicians become intermeshed, the types of conflicts
of interest that arise will erode trust in the physician (Mechanic and
Schlesinger 1996). It seems prudent to keep a reasonable distance between
insurance and benefit management on the one hand and clinical decision
making on the other. Benefit management, however, should not under-
mine physician control over clinical decision making.
Trust in Confidentiality
It has long been accepted in custom and in law that doctor-patient com-
munication is privileged, and that patients could trust that anything they
told their doctors would be protected and only revealed with the patients’
explicit permission. There are exceptions where physicians have been
required by law to report certain infectious diseases, the physical abuse
of minors, and threats to persons in imminent danger. But these are clear
exceptions that reinforce the greater principle. The protection of confi-
dentiality has made it possible for patients to communicate freely with
doctors without fear that the information revealed could be used against
them. Medicine has always had a sustaining role in society, providing
assistance and support across a wide range of human problems. The

strength of the norm of confidentiality makes this goal more achievable.
Ironically, just as educators are calling for a broader scope of practice
and for physicians to give greater attention to psychosocial and behav-
ioral factors, professionals are being required to share medical informa-
tion more broadly, not only with others on the treatment team, but also
with insurance administrators, utilization reviewers, and clerks. It is quite
one thing to share confidential information with members of the treat-
ment team and quite another to have detailed confidential information
moving readily between medical contexts and insurance companies whose
personnel may have little ethical training. The management of care fur-
ther complicates the issue. Patients commonly complain about intrusive
personal questions asked by claims personnel, for example.
Trust in confidentiality is essential for medicine to carry out expanded
functions but organizational and administrative changes in medicine
may well contribute to an erosion of patient trust that what they tell
their health providers is secure. In highly stigmatized areas, such as in
care for sexually transmitted diseases, it is common to offer services on
an anonymous basis. In other areas patients are known to use aliases in
seeking care. In 1995, in Massachusetts, the Office of the Attorney General
announced an investigation of complaints of violations of confidential-
ity by managed care organizations after newspaper reports alleged that
mental health providers at Harvard Community Health Plan were putting
detailed psychiatric notes into computerized medical records (Rochefort
1996: 24). While not the most prominent of confidentiality issues, this
dispute resulted in thoughtful consideration of alternatives (Sabin 1997).
Trust in Disclosure
Patients have a right to expect that their physicians will share with them
the information necessary to make informed decisions about their treat-
ment options. Physicians may at various times withhold or pace the pro-
vision of information to maintain patient morale, but increasingly, in
practice as well as in law, doctors are expected to ensure that patients are
properly informed. As they get to know patients, physicians develop
some sense of how much information their patients want, although most
research in the area indicates that doctors underestimate patients’ desire
to receive information and provide too little (Waitzkin 1985; Roter and
Hall 1992: 96 – 104). While there is ambiguity in cases where the doctor
controls information in patients’ interests, nondisclosure of information
to protect the doctors’ interests or to hide conflicts of interest has little

ambiguity.
There are at least three types of nondisclosure that potentially erode
trust. First are those arrangements where physicians make referrals to
facilities in which they have a significant financial interest. Studies con-
sistently show that such arrangements result in more utilization and
higher costs (Rodwin 1993: 67 – 79). These arrangements have been the
subject of much discussion and legislative interest within government
programs, and certain restrictions now apply. The area is complicated
and contentious, but nevertheless, it seems self-evident that such conflicts
of interest should be disclosed, if not entirely avoided. A second area of
potential conflict occurs when physicians have financial arrangements
with medical groups or insurance plans that tie the physicians’ reim-
bursement to utilization targets (Hillman 1987; Gold et al. 1995). The
extent of the conflict of interest depends on the size of this incentive and
on the extent to which utilization is measured solely in relation to the doc-
tor’s patients or in terms of a larger pool of patients aggregated among
doctors. It also depends on the quality assurance procedures in place. A
third area related to disclosure involves “gag rules”— where HMOs or
managed care companies’ contracts with doctors forbid them from reveal-
ing details of their financial arrangements with the program, or from even
discussing treatment options with patients before the options have been
approved by administrative reviewers (Woolhandler and Himmelstein
1995). Directives not to discuss treatment options with patients cut to the
core of doctor-patient relationships, and violate the physician’s respon-
sibility to appropriately inform the patient about treatment benefits and
risks (Mechanic and Schlesinger 1996).
The requirement of informed consent has only evolved in recent
decades and its formulation has been difficult in the face of a long history
of medical paternalism (Katz 1984). Effectively conveying appropriate
information and understanding patients’ preferences involve many
uncertainties (Burt 1979) but these goals are unlikely to be achieved in a
paternalistic system. This is the basis of Katz’s classic argument for the
importance of two-way conversation between doctor and patient so that
each understands how their interests diverge and uncertainties are appro-
priately acknowledged (Katz 1984). Full disclosure of treatment options,
including decisions made in part on the basis of cost, is a significant
requirement for the maintenance of trust. Practicing cost-effective medi-
cine must be part of an ongoing conversation, and not achieved by stealth.
Patients are learning how to live in a world where their medical wants
will be limited by some reasonable and appropriate care standards. Dis-

tressing issues are likely to arise, however, when physicians feel some
type of care is essential but utilization reviewers or some administrative
authority denies such care. Patients have a moral right to be informed
about such denials both to permit them to undertake appeals, or even lit-
igation, or to allow them to purchase the denied services out-of-pocket. If
they are uninformed, patients have no real options.
In the short run, disclosing potential conflicts between doctors and
plans may engender distrust in the physicians’s competence (is he being
overruled because he made a poor treatment decision?), and suggests
why some doctors may find it convenient to accept “gag rules.” Initially
this may help both the doctor and the plan avoid discomfort and incon-
venience, but the consequences are likely to be more severe when patients
come to understand that important information has been kept from them.
Disclosure also makes it likely that physicians will feel the need to advo-
cate vigorously for their patients, seeking to get them the services
deemed most necessary. Future physicians may need to receive specific
training on how to advocate effectively. Patients who believe that their
doctors are strong advocates for them are likely to trust them more.
Eliciting Trust
The capacity to elicit trust in medicine depends both on organizational
arrangements and on interpersonal skills. In this section I briefly discuss
how medical organizations can structure activities to attain more effec-
tive clinical arrangements. My main focus, however, is on the doctor-
patient relationship and the various ways doctors can convey compe-
tence and caring.
Organizational Approaches to Develop Trust

Organizations develop reputations with the public by the way they orga-
nize their affairs, their responsiveness to community needs and patient
concerns, and by demonstrating a high level of expertise. Efforts to build
such reputations are pursued through a wide range of marketing strate-
gies and organizational innovations, ranging from patient satisfaction
studies and use of focus groups to preventive health efforts and sponsor-
ship of patient support groups (Mechanic 1996).
Organizations also affect patient trust by how they arrange patient
care sequences, how they pace processes of care, and how they manage
responsibility for patients and avoid fragmenting care and conflicting

communications. Organizational environments that give clinicians flexi-
bility in arranging complex tasks, that establish fixed points of clinical
responsibility for each patient among doctors and nurses, that facilitate
cooperative teamwork, and that are attentive to problems of morale and
burnout among their personnel commonly engender higher levels of per-
formance and greater satisfaction and trust among patients (Scott et al.
1995).
Improving Communication to Increase Trust

Organizational arrangements are enabling. They do not guarantee the
effectiveness of clinical relationships. But as increasing numbers of hos-
pitals and health plans now appreciate, skills can be taught that increase
the credibility of clinician communication, and it is common now for
such organizations to support workshops and courses on communication
for their physicians. Some develop their own programs while others use
organizations, such as the Bayer Institute for Health Care Communica-
tion, that organize courses on doctor-patient relationships. Such instruc-
tion also is now common in undergraduate medical education and in
many residency training programs. Including such instruction in the con-
tinuing education of physicians by health plans themselves suggests the
increased importance of communication issues. Some plans now adjust
physician remuneration to take account of patient complaints, satisfac-
tion, and retention (Gold et al. 1995).
There is a large body of useful knowledge on the credibility of com-
munication and on the social psychology of interaction and persuasion.
Very simple efforts like giving patients time to tell their stories, listening
intently without distractions, eliciting questions and providing feedback,
maintaining eye contact with the patient and providing appropriate non-
verbal cues — all contribute to developing a foundation for trust (Roter
and Hall 1992). Physicians are increasingly being trained to elicit the
patient’s perspective, to seek empathic opportunities, to provide appro-
priate information, and to involve patients in decision making.2
There are tensions between the ways doctors have learned to assess
patients’ symptoms and the types of communication that best build trust.
The medical interview designed to arrive at a differential diagnosis seeks
2. There are now many written materials and training aids for improving physician commu-
nication, some developed by health plans. See, for example, Frankel and Stein 1996.
to narrow the acquisition of information to pursue specific hypotheses.

Physicians typically cut off and sidetrack patient communications that
divert from this task (Waitzkin 1991: 31). This can result in patients’ per-
ceptions that such doctors care too little about their concerns and can
result in inhibiting the exchange of valuable information, not only for
clinical purposes but for building a trusting relationship. Studies of
doctor-patient interactions indicate that allowing patients more opportu-
nity to tell their stories early in the interaction, without interruption,
improves the quality of the patient’s experience without serious efficiency
costs (Roter and Hall 1992: 6 – 8). Listening can often give the doctor
vital clues to the deeper concerns of the patient than the initial presenta-
tion of symptoms might reveal.
Physicians have the important responsibility of explaining treatment
decisions to patients and advocating for them when in the clinician’s
judgment the plan’s denial of services is inappropriate. In an important
sense the advocacy discussion is about the relative power and depen-
dence of patient and clinician and clinician and plan. New institutional
relationships make clinicians far more dependent on external organiza-
tions for patients and for their livelihoods. In a context of professional
surplus, patient advocacy beyond what is acceptable to the plan may
result in a physician being deselected from plan networks. Clinicians
commonly indicate informally that they will accommodate their treat-
ments to what they know case managers will accept to avoid the time,
paperwork, and conflict often necessary in sustained advocacy. Those
more dependent and fearful of deselection are less likely to advocate
strongly. Developing an effective framework for clinician advocacy in
the short run may seem like an irritation to plans, but public trust in the
physician’s advocacy is in their long-term interests.3 To the extent that
patients—and their political representatives—doubt the physician advo-
cacy role, they will encourage legislative micromanagement.
Trust and Its Alternatives: Some

Policy Considerations
Mechanisms that serve as alternatives to trust and provide reassurance
that some basic level of trust is merited come from physician organiza-
3. David Lawrence, CEO of Kaiser Permanente, reports that it is the plan’s policy not to
interfere with patient care decisions made by Kaiser physicians. While cost and quality of care
incentives are used, the physician is the ultimate authority on any clinical decision (interview
by the author with David Lawrence, 2 March 1997, Oakland, California).
tions, health care plans and their representatives, from consumer groups
and other nonprofit independent entities, and from public regulators.
They range from certification and accreditation processes for profession-
als and institutions to efforts to voluntarily develop standards for plans,
such as those developed by the National Committee for Quality Assur-
ance (NCQA) (Iglehart 1996). Public regulation by large government
programs like Medicare and Medicaid and by health, insurance, and
other departments of state government fill in gaps through certification of
providers, by imposing volume and other restrictions on who can per-
form certain specialized procedures, and through other specific standards
and requirements. These activities all take place within a broader public
context framed by the criminal and civil law and more intrusively by the
threat of malpractice litigation. The extent to which these mechanisms
are effective deterrents to wrongdoing is arguable but the range of pub-
lic and private regulation limits the anxieties that might result if the sys-
tem was simply governed by a caveat emptor approach.
Various approaches are being taken by employers, state health regu-
lators, and health care plans that may address some of the anxieties of
patients about how much to trust. Some large employers are monitoring
the health care of their employers carefully, influencing health care plans
to improve quality and responsiveness, and working with organizations
such as the NCQA to improve standards. The interest of big business in
the accreditation process very much increases the leverage possible
through instruments such as the Health Plan Employer Data and Infor-
mation Set (HEDIS) and certification processes.
Similarly, state health departments are becoming more aggressive in
monitoring quality. An exemplary effort in New York State, for exam-
ple, developed a cardiac surgery reporting system that distributed risk-
adjusted mortality data to individual hospitals. These data became the
basis for a variety of quality improvement initiatives that were believed
to significantly reduce mortality following coronary artery bypass graft
(CABG) surgery (Hannan et al. 1994). A later study in Massachusetts
suggested a secular reduction in mortality after CABG surgery in the
absence of such ongoing efforts, raising questions about their efficacy
(Ghali et al. 1997). Whatever the ultimate evaluation, the fact is that
states are becoming much more involved in quality improvement initia-
tives and are developing greater capacity to do so.
Health care plans also are now giving attention to quality assurance
processes and performance measures, sometimes with the prodding of
the employer community. There is now increasing emphasis on evidence-
based medicine, the development of process measures of quality, practice

standards, clinical pathways, and outcomes assessment. These efforts are
all in an early stage but are likely to advance substantially over the next
decade. Such initiatives, however, are based on aggregate populations,
and thus the standards suggested may be inconsistent with the contin-
gencies and needs of particular cases as seen by patients and their doc-
tors. To the extent that these tools achieve legitimacy in professional
communities and with the public, they have the potential to contribute to
patient trust. They also have the potential to increase conflict and distrust
if applied inflexibly or coercively.
There is a significant association between trust in specific institutions
and trust in physicians, with spillover effects in both directions. Physi-
cians in respected institutions gain by their association, but institutions
have even more to gain by the bond that many patients form with their
physicians and from patients’ trust in them. Recent legislative efforts to
prohibit “gag rules,” to prevent retaliation by plans against physicians
who advocate for their patients, and to require disclosure of incentives
that encourage reduced utilization reflect the efforts of policy makers to
find ways to protect physician advocacy. Advocacy needs protection
because as physicians become dependent on a particular insurance plan
for patients, and as alternative sources of patients become more limited,
the willingness to vigorously speak out tends to be lessened. Extensive
regulations affecting these and other aspects of HMO practices, for
example, took effect in New Jersey in March 1997 (Preston 1997). Such
regulations are increasingly common in other states as well.
Proposals in Congress and in the various states to regulate managed
care are a mixed bag; some are useful initiatives but others will make
poor public policy. With growing success in restricting “drive-through”
deliveries and mastectomies, many advocates for particular disease groups
are mobilizing to protect their domains of interest. Managed care has
become a vulnerable target because of rigid decisions that violate psy-
chological sensibilities (Mechanic 1997). When managed care approaches
fail to respect the discretion of physicians in dealing with patients whose
needs and circumstances may differ, they invite the heavy hand of gov-
ernment in micromanaging medical decisions. In fact, early hospital dis-
charge may be appropriate for deliveries, or even mastectomies, with
appropriate home care arrangements and the consent of patient and
physician. Arbitrary limits on hospital care, irrespective of the circum-
stances, anxieties, and fears of the patient and family, however, will sim-
ply enrage the public and encourage hasty micromanagement. New Jer-
sey has taken one prudent step by requiring that only physicians can deny
medical services in HMOs.
The managed care industry has to appreciate the importance of setting
standards, establishing norms, and sanctioning managed care organiza-
tions that fail to operate responsibly. It is common for managed care
executives to point to abuses of fee-for-service medicine in arguing that
risks in managed care are not exceptional. Managed care, however, faces
very different public opinion dynamics than fee-for-service medicine.
First, fee-for-service medicine is typically built around a personal physi-
cian-patient relationship, and this engenders more trust than organi-
zational relationships. Second, patients are much more sensitive and
concerned about treatment withheld — treatment they may not even be
aware of — than about potential overtreatment that they can refuse if
they wish. Third, managed care offers a more centralized target than an
individual physician, and abuses are perceived as more systematic.
Fourth, problems with managed care attract more media attention than
the alleged behavior of any individual physician.
After extensive negative publicity and legislative initiatives to con-
trol managed care practices, the American Association of Health Plans
(AAHP) launched its “Putting Patients First” initiative in December
1996. This initiative called for disclosure of physician payment arrange-
ments and other managed care practices. Whether this was simply a
belated effort to keep pace with the politics of health care or a positive
indication of leadership is a matter of perception. In March 1997, the
AAHP announced that its health plan members would be expected to
uphold its patient-centered policies and that it was developing “a process
to assist health plans in meeting the association’s patient-centered poli-
cies, and enables the association to exclude health plans that do not.” It
also reiterated its policy announced in 1996 that health plans should not
require outpatient mastectomy (AAHP 1997).
The role of the media is central in reframing situations as social prob-
lems. The intensive work schedules of hospital residents, for example,
have long been common knowledge among observers even remotely
familiar with graduate medical education. However, when the media
focused on this issue in connection with the death of Libby Zion (Robins
1995), the extensive publicity resulted in much public concern and new
workload regulation in New York State. In this instance, the eighteen-
year-old daughter of a well-known journalist came to the emergency
room at New York Hospital with fever and flu-like symptoms, was admit-
ted, and died the next morning. Her parents alleged that her death was
due to overworked and unsupervised residents. Although it has never

been clear why Libby Zion died, the media attention to the case, and the
documentation of the long hours of work among house staff who cared
for her, made the claim credible that the exhaustion of house staff con-
tributed to her death. It is likely that this kind of public opinion dynamic
will characterize increasing indictments of managed care. Reputable
managed care companies have to work cooperatively with consumer
groups and with government to develop appropriate industry-wide norms
and practices before measures are enforced on them by an angry public.
Public policy must be distinguished from the advocacy of many inter-
est groups that have a stake in the debate. Managed care is an important
instrument for constraining unacceptable growth in medical expendi-
tures. The public role is to prevent abuses while protecting many of man-
aged care’s constructive features. For example, “any willing provider”
legislation is an initiative to protect physician independence and access
to patients, but such public intervention would seriously undermine the
ability of managed care organizations to carry out their business in a rea-
sonable way. In seeking quality and more economical care, managed
care organizations should be able to select their physicians and health
care settings, and to prune their networks when necessary. They should
be prohibited, however, from excluding doctors for sharing information
with patients or advocating for them. This is a difficult regulatory area
but having independent procedures in place for reviewing allegations of
improper exclusion may provide at least some protection.
Many health care managers regard transfer of financial risk to clini-
cians as a necessary condition for resource conservation and would argue
that such measures serve the public interest by encouraging efficient
allocative decisions. Few would contest the intent but it is hardly clear
that the physician’s personal remunerative interests should be the main
mechanism by which this is achieved. Constraining the fee-for-service
incentive for overutilization achieves part of our objective, but it is
equally prudent to avoid incentives that place clinicians at such high per-
sonal risk that they must weigh their clinical decisions in terms of their
own interests and needs. When this point is reached is a matter of judg-
ment and depends on the context. Experience around the world gives
some indication of what might reasonably be seen as a range of reason-
able neutrality. Simple capitation without other incentives has perverse
consequences and poses as many difficulties as the pure fee-for-service
payment system.
The history of capitating GPs in the United Kingdom is instructive for
understanding the need to moderate the effects of pure capitation. Capi-

tation without other incentives allegedly led to excessive and inappropri-
ate referrals when the doctor, at no personal cost, could shift work onto
the hospital outpatient services. The establishment of GP fundholding
that ties some of the GPs’ decisions to a budget is believed to induce
greater thoughtfulness about the appropriateness of referrals, but doctors
do not receive any direct financial gain from making better decisions
(Glennerster et al. 1994). Even the possibility that doctors could benefit
from surpluses invested in their practice premises when they retired and
ultimately sold their practices was disturbing to many. The British also
learned over time that capitation by itself would lead to underprovision
of many types of valuable services, and GPs now have financial incen-
tives to address a variety of preventive and health behavior issues.
Money is a significant motivator in most realms of activity and we would
do well to link financial incentives more directly to our aspirations for
quality improvements.
Because the impact of financial incentives depends on their structure,
the context, and other quality assurance mechanisms in place, it is exceed-
ingly difficult to define appropriate regulatory action. The contention that
no financial incentives are justified is unreasonable given the perverse
effects of pure capitation. It is reasonable, however, to expect public dis-
closure of incentives so that regulators and consumer organizations can
monitor and assess when practices approach harmful thresholds, and can
make such information available to consumers who want it when they
choose among health care plans.
The standards for such disclosures can be set and monitored by state
health or insurance departments. In light of current uncertainties, the reg-
ulations recently issued by the Health Care Financing Administration
governing HMOs that participate in the Medicare and Medicaid programs
seem modest but reasonable. These requirements establish two thresh-
olds for the amount of physician income that can be at risk without addi-
tional regulation: the first threshold is 15 percent of income for HMOs
that distribute incentive payments more often than annually; the second
is 25 percent for those organizations that distribute incentive payments
no more than once a year. When such a threshold is reached, HMOs are
required to carry out specified surveys of its members, including those
who disenrolled, and provide stop-loss protection for physicians. New
Jersey has gone further by setting up an independent review panel to
which consumers can appeal any HMO decision to deny or curtail care.
While such decisions are not binding on HMOs, these organizations will
face public relations difficulties should they ignore them. Similar require-
ments will have to be extended to other types of managed care organiza-
tions as well.
Disclosure is important for regulatory agencies and consumer groups
to monitor managed care developments, although it remains uncertain
what types of disclosure will be meaningful to individual consumers. We
still need a framework for defining what information is appropriate to
give to consumers, in what forms such information should be provided,
and who should be responsible for providing it. Managed care is a form
of rationing organization that offers consumers advantages in return for
accepting limits on certain choices. Thus, it is essential that disclosure in
marketing be sufficient to allow purchasers and patients to make informed
decisions (Hall 1997: 193 – 239). If purchasers and patients are well
informed in a well functioning market, and truly understand the trade-
offs, there is increased likelihood that enrollees will have realistic expec-
tations and that competing plans will be deterred from engaging in prac-
tices that erode trust. As the market has become more competitive, for
example, HMOs are increasingly allowing enrollees to access certain
specialists more easily, and in some instances are providing direct access
(Freudenheim 1997).
Conclusion
The U.S. medical care system is presently in a state of rapid transforma-
tion — some might even say chaos. There is a great diversity of practice
and experimentation, and medical markets vary greatly in their structure
and competitiveness. Medical organizations are increasingly converting
to for-profit status, and states and other public authorities are increasingly
shifting from direct public provision of care to contracts with private ven-
dors. There is a great deal at stake in these emerging structures. Thou-
sands of interest groups are seeking advantageous arrangements, and
health affairs are now an everyday concern for the executive branch, Con-
gress, state legislatures, and regulatory authorities.
Health care arrangements are also a central concern of the media.
Monitoring these complex health changes is a difficult challenge and the
media typically depend on anecdotes and human interest stories. These
commonly focus on problems and abuses and increase public anxieties
over health care. Such concerns are especially salient because many peo-
ple are experiencing changes in their health insurance arrangements,
their health plan choices, and their personal doctors. This environment
contributes to increasing insecurity and distrust. And as I have indicated,

there is a basis for increased distrust as intrusions on physician agency
and control increase and as disputes about disclosure and protections of
confidentiality become more common.
Regulation provides a counterpoint to distrust by controlling its most
apparent causes. If such regulation can be appropriately targeted, it will
provide a stronger basis for trust. Because of the ferment and rapidity of
change, however, there is a growing tendency to micromanage health
care, which in turn produces its own threats and absurdities (Kassirer
1997). If such tinkering is to be controlled, health care companies and the
health professions will have to come together to devise and enforce high
standards of care in a way that earns the public trust. They will have to
work cooperatively with government and consumer groups to develop a
reasonable consensus on what practices are acceptable, what incentives
are appropriate, and what are unreasonable limits on clinical decision
making. If the public loses trust in physician agency and in the willing-
ness of physicians to advocate for them, it will be impossible to stop
politicians and legislators from “practicing medicine.” The effectiveness
of our entire health care system will be at risk.
Physicians must learn to practice medicine with an understanding of
economic constraints and participate constructively in allocative deci-
sions. But the incentives that guide them must neither encourage under-
nor overutilization, and they must be consistent with the need for patient
trust. Limits on open communication or incentives that put the doctor’s
income in serious conflict with decisions about patients must be avoided.
Most patients trust their doctors to make allocation decisions more than
they trust distant and unknown utilization reviewers. If physicians are
to have the authority to make such decisions without micromanagement,
they must be prepared to practice within a context that accepts economic
responsibility and that is guided by a serious knowledge base (Mechanic
1995). The transition will not be easy, but with appropriate incentives
and well organized practice, there will be opportunities not only to make
medical care more effective and efficient, but also to maintain and
enhance interpersonal trust in physicians and public trust in medical
institutions.
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Functions and Limitations of Trust

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Functions and Limitations of Trust

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The Functions and Limitations of

Trust in the Provision

cians’ openness in providing and receiving information. Changes in

percent of hospital admissions, more than one-quarter were due to neg-

Trust in Physician Agency

represent their interests effectively. The notion of physician agency has

surplus have increasingly put physicians in positions where they face

more substantially on transfer of risk to providers, which keeps medical

knowledge realistically allows. Researchers involved in the study of

assistance and support across a wide range of human problems. The

to protect the doctors’ interests or to hide conflicts of interest has little

will be limited by some reasonable and appropriate care standards. Dis-

Organizational Approaches to Develop Trust

responsibility for patients and avoid fragmenting care and conflicting

Improving Communication to Increase Trust

to narrow the acquisition of information to pursue specific hypotheses.

Trust and Its Alternatives: Some

based medicine, the development of process measures of quality, practice

due to overworked and unsupervised residents. Although it has never

understanding the need to moderate the effects of pure capitation. Capi-

contributes to increasing insecurity and distrust. And as I have indicated,

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