How to Promote Health? Patient Trust in Physicians and Internal Locus of Control

Trust in Physicians: What is it and Why Is It Important?

Trust is a voluntary action based on one’s expectations that others will behave in a positive, expected manner. Interpersonal trust is a defining element in any interpersonal relationship, and is an essential, central, foundation between the patient and the physician. Trust of patients in physicians is the acceptance of vulnerability by patients. The importance of patient– physician trust emerges from findings that link trust to higher medication-adherence and adherence to therapeutic instructions. A higher level of adherence results in improved health. When trust is suboptimal, patients look online for a diagnosis, may turn to fellow patients for advice on coping with health situations and under-utilize health services, leading to deterioration in chronic illnesses. Thus, patient trust in the physician promotes health.

How Is Patient Trust Established?

Known contributors to trust are demographics, health conditions, conduct of the physician, communication style, expectations of patients from the physician, and patient satisfaction with the physician. I will now elaborate on these.

When education was lower, the patient trust was higher, and when age was higher the patient trust was higher. Secular people and members of minorities trusted their physicians more than religious people or people belonging to the majority group in the population.

Also, the poorer the health of the patient, the higher the trust in the physician. Naturally, the longer the existence of the patient–physician relationship, the higher was the trust. As for the conduct of the physicians, patient trust was higher when the physician demonstrated technical competence, listening abilities, confidentiality, honesty, and an impartial concern for the patient's wellbeing. When the patient perceived the physician as compassionate, reliable, dependable, and communicative, trust was higher. In contrast, interactions that created anxiety, fear, doubt, irritation, or other negative feelings. developed into distrust, particularly consequent to patients experiencing pill pushing, lack of bedside manners and lack of cultural competency of physicians. The communication style of the physician was pivotal in facilitating patient involvement in decision making.

Communication Style and Trust

When patients were involved in decision-making to a lesser degree than they preferred, the effect on trust was more detrimental than when patients were involved in decision making to a greater degree than they preferred. Satisfaction with clinical outcomes nurtured trust. Low satisfaction with the physician was related to lower trust, to higher anxiety and depression and to lower general life satisfaction. Repeated interactions with the physician allowed patients to develop expectations based on the history of the interactions and to anticipate future interactions.

What is New?

Patient involvement in health is driven by perceptions that ultimately affect whether one stays healthy or becomes ill. It is important to note that this link between perceptions and health behaviors exists regardless of the truth of the perception. The most frequently studied health perception is perceived control over health. What is perceived control? Why is it important in health promotion?

Perceived control is anchored in the social learning theory which classifies people along a continuum of perceived control. In 1975, Rotter presented a continuum that ranges from internal to external locus of control. People with a strong internal locus of control believe that success or failure is due to their own efforts. People with external locus of control believe that reinforcements are controlled by luck, chance, or others. Patients with internal locus of control support self-directed actions. Traditionally, internal locus of control reflected personal mastery. Since 2015 the internal locus of control in health was found to be modifiable.

Behaviors such as information seeking, alertness, and decision making are attributed to people with internal locus of control who actively and willingly rely on internal and external resources to improve their health. Internal locus of control is facilitated by one’s perceived ability to resolve a health problem while relying on internal resources and resources of others, especially in situations of vulnerability.

Perceived control is a path to enhance patient trust, beyond known contributors to trust. Perceived control over health, as explicated by internal locus of control, uniquely contributes to trust. Internal locus of control entails the promotion of optimistic beliefs of patients in their ability to modify their health behaviors. Internal locus of control may reflect an expectation of patients that their physician, as a respected authority, will inspire them to take on a self- directed, higher level of awareness, attention, and manage their illness. Physicians may enhance patients’ own sense of control over their health. The encouragement of patients to take a self-directed role will enhance trust and result in greater adherence. The active involvement of patients in decision making is pivotal. The rise of patient autonomy and the erosion of the physician as the ultimate authority may require new communication skills with patients, particularly patients who are more challenged in seeking help and adherence.

Internal locus of control facilitates health behaviors and is a major factor in recovery from diseases and overcoming health-damaging behaviors. Internal locus of control is related to higher levels of cooperation and lower distress. The perceived control of the patient directly and indirectly enhances the trust of patients in their physician. Figure 1 presents contributors to trust.

Figure 1. Contributors to Patient Trust in Physicians

Practical Recommendations

To involve patients, physicians may focus on enhancing internal locus of control by stressing ‘how each patient can better manage the disease’ rather than on ‘what is the disease’. Also, patients may be encouraged to use external resources such as guidance on how to familiarize themselves with the disease; how to use social networking; how to plan health improvements and to gradually implement them in little steps. Managers of health systems and policy makers might consider training programs to create awareness among physicians regarding the effect of Internal locus of control on health promotion.

Higher awareness of physicians may encourage them to adopt participative communication skills not only with more involved, proactive patients, but also with uninformed patients with external locus of control. Physicians are called upon to engage in a dialogue with their patients about their expectations of care to minimize any potential gaps and enhance perceived control, The strong effect of trust on illness prevention and on adherence makes these managerial implications pivotal for patients, healthcare insurers, and health policymakers.

Additional Reading

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H.M. Lefcourt (Ed.), Locus of Control: Current Trends in Theory & Research, Psychology Press, 2014.

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J.B. Rotter, Some problems and misconceptions related to the construct of internal versus external control of reinforcement, J. Consult. Clin. Psychol. 43 (1975) 56–67.

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