American College of Physicians: Internal Medicine — Doctors for Adults ®


The link between trust and physician satisfaction

From the October ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By William J. Hall, FACP

In my column in the July/August issue of ACP-ASIM Observer, I suggested that many College Members and Fellows are satisfied with their professional lives. I told the story of one such physician and invited readers to contact me with their "secrets" to a satisfying professional life.

I'd like to share the response from Minnesota general internist Karl Insogna, FACP:

"The patient-physician relationship is going strong, even though half of my patients are globally capitated. They thank me, refer their family members to me, challenge my clinical skills and present professor rounds cases every day. I work very hard. But I can't imagine any other job or profession I would rather do.

"We physicians have to stay focused. We need to push the regulators and business community to do what is right, but we have to continue to focus on our patients and their trust in us."


Among the many responses I received from College members, patient trust came up more than any other issue.

I found it interesting that satisfied internists independently identified patient trust as essential to their professional satisfaction. Trust, after all, is a term more commonly used by medical historians and sociologists, as in "there has been a dramatic decline in public trust in the medical profession." Thoughtful scholars such as Kenneth Ludmerer, FACP, Paul Starr and William M. Sullivan have hypothesized that a decline in patient trust since the mid-1960s may prove to be the most serious threat our profession has ever faced.

The larger obstacles to trusting relationships are familiar to us all. But the less tangible fallout from cost-conscious managed care, as well as corporate and governmental control of medical practice, is grave damage to the physician-patient relationship and the trust that it entails.

In an environment where patients choose their physicians from impersonal lists, medical care shifts every time a company changes providers, and medical encounters are a brief transaction involving "knowledge workers" who evaluate symptoms and prescribe therapy in the shortest time possible, what basis of trust can exist?

When we sit face to face with a patient in the examining room, it does not take long to discern whether we have a trusting relationship. I think we have to understand more fully what satisfied internists are doing that allows them to face the same obstacles, yet still nurture a trusting relationship that contributes to their professional satisfaction.

Earning trust

William T. Branch Jr., MACP, has been studying this issue for some time. In an Archives of Internal Medicine article published in the Aug. 14/28, 2000, issue, he commented on how some busy physicians are able to establish and maintain patient trust. Two of his observations struck home with me.

President's Column He said that physicians earn trust by consistently meeting their patients' expectations in seemingly minor ways. More specifically, they keep their promises. They follow through after saying, "I'll call you tomorrow with the lab results," or, "I'll talk this over with a colleague and get back to you." Over time, Dr. Branch concluded, this consistency reaps major benefits.

In addition, he observed that successful physicians build rapport by adapting open-ended interviewing techniques to a time-constrained environment. They use very concrete questions to immediately focus on their patient's specific complaints. Yet when successful physicians sense a patient need, they interrupt this rapid-fire style and change their pace and tone with simple questions such as "Do you want to talk about that more?"

Dr. Branch said that these interludes of discussing psychological and social issues last only a few minutes in most cases, but they lead to more trusting relationships with patients. The chemistry that develops improves not only "patient satisfaction" (a term so misused as to be almost meaningless), but also physicians' sense of satisfaction with their daily work.

New skills

Other observers have noted that to build trusting relationships with patients, we will have to acquire new attitudes and skills. We need to be able to deal with a future environment where, for example, physicians may have no monopoly on information and patients may unquestioningly accept complementary and alternative therapies.

Internists will need expertise to help patients evaluate information and to tailor advice based on patients' personal attitudes and values. Few of us have been trained to do this.

The College has touched on some of these themes in the Medical Professionalism Project ( The project, which includes input from leaders of the ACP-ASIM Foundation, looks at medical professionalism in the future and explores notions of trust and the physician-patient relationship. (For more about the project, see the July/August ACP-ASIM Observer online at

While these efforts will help, we must also continue to learn from members like Dr. Insogna who have already come up with answers of their own. We simply don't have time to wait for new books to be written on the topic. By improving our skills in eliciting trust, we not only address what is becoming the most pressing quality concern in health care, but we also emerge much more satisfied professionally.

I hope that more of you will send me your stories. Please e-mail me at, and let me know what reminds you each day why you entered this profession. Your fellow physicians would greatly benefit from your experiences.


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