On June 1, 2022, a patient purchased an AR-15 rifle, entered a medical building in Tulsa, Oklahoma, and murdered four people, including the noted surgeon who had recently operated on him. While such targeted fatal attacks on doctors are rare in the United States, violence against healthcare workers is extremely common. In 2018, health and social care workers were five times more likely than those in other sectors to experience workplace violence and accounted for “73% of all non-fatal occupational injuries and illnesses requiring days off work.” work “. Nearly half of emergency department doctors have been physically assaulted. Nurses have been kicked in the ribs, thrown against walls, bitten, choked and concussed, and 60% have been sexually harassed.
COVID-19 has further exacerbated the vulnerability of these “frontline” workers. More than 600 pandemic-related incidents against healthcare providers were recorded between February and July 2020 alone, and a notable spike in racist attacks against Asian Americans has occurred since the pandemic began. . A man followed a Chinese-American woman doctor on the subway from Massachusetts General Hospital, shouting, “Why do you Chinese people kill everyone?” Why the hell are you killing us?” A New York medical student from Thailand was called “Chinese Virus” before being dragged to the floor and left bloodied and bruised. Such incidents have added to an already serious problem abuse between patients and physicians in the form of racism and discrimination. A study found that 59% of American physicians had heard offensive remarks targeting personal characteristics such as their race, age, gender, weight or gender. sexual orientation, and almost half had seen a patient ask another doctor.
Recognizing the magnitude of this problem, in June 2022, U.S. Representatives Madeleine Dean (D-PA) and Larry Bucshon, MD, (R-IN) introduced the Safety from Violence for Healthcare Employees (SAVE) Act, legislation bipartisan federal government that would establish criminal penalties for knowingly assaulting or intimidating a hospital employee. The bill provides enhanced penalties for acts involving the use of a dangerous weapon or committed during a public emergency, and would also provide $25 million in grants to hospitals for programs aimed at reducing violent incidents in health care institutions. In a letter supporting the bill, the American Hospital Association (AHA) pointed out that the impacts of such violence go beyond harming their staff members – they also make it harder for healthcare providers of health to do their job. Workplace violence has been shown to reduce employee productivity and patient satisfaction while increasing the potential for adverse medical events. In other words, violence in health care can be a vicious cycle, leading to further disenchantment among patients and their families and increasing the risk of aggression.
These repercussions could be particularly devastating given that public trust in health care institutions is in decline. A 2018 Gallup poll found that only 34% of the general public had a positive view of the healthcare industry, down from 80% in 1975. More than one in five American adults said they had experienced discrimination in the healthcare system. health. Hospital settings can also be hotbeds of stress caused by illness and fear. The vulnerability and emotional volatility that patients and their families experience are major factors of distrust and aggression. But while it has long been established that patients place their health in the hands of physicians and must manage trust issues that arise from this vulnerability, the increase in violence and other harmful behaviors towards healthcare workers healthcare has made it clear that workers need to be able to trust their patients is an equally critical topic that has been largely overlooked.
The nature of trust
These double lines of trust, patient-doctor and doctor-patient, have more in common than it might seem at first glance – one side (ideally) trusts the other not to harm them. Patients typically make this assessment along two main lines: whether physicians are competent to provide accurate diagnoses, prescribe treatment regimens, or undertake procedures; and whether physicians have good will, that is, they are willing to put patients’ interests before their own. Although physicians are highly trusted as a profession and committed to “do no harm,” individual patient decisions about whether to trust a physician remain strained as breaches of trust occur. Some doctors fail to correctly diagnose conditions or successfully undertake procedures, even when they have the best of intentions. And sometimes doctors even intentionally harm patients.
But as recent events have made clear, the potential for harm to physicians also forces them to assess the reliability of their patients. They too must assess whether their patients have goodwill towards them or, at least, do not wish them harm. And they must also assess whether patients are able to reason soundly, manage their emotions, and communicate about their health issues in nonviolent ways. Indeed, some patients harm their doctor not because they harbor ill will, but because their ability to regulate their behavior is reduced due to the temporary influence of drugs and alcohol, a seizure mental health or a chronic illness such as dementia.
Admittedly, there are asymmetries in these relationships, and the perimeter of trust required by each is imperfectly aligned. There are different power and funding dynamics, varying stakes, and the two sides face markedly different jurisdictional issues. That said, the nature of trust in a doctor-patient relationship remains reciprocal. Each version of trust informs the other – in which a patient believes that their doctor doubts or distrusts them, they are more likely to doubt or distrust their doctor.
But also: the more patients harm their healthcare providers, intentionally or unintentionally, the harder it will be for those providers to trust them, leading to another unfortunate trend: doctors are abandoning some of the behaviors considered most trustworthy. building, for example, talking about their personal life, building relationships, showing compassion, or giving out their personal cell phone numbers. This model can fuel the erosion of trust between patients and providers, because the less providers do to signal reliability, the less patients will be willing to be vulnerable to them and, in turn, the less providers will be willing to be. vulnerable to their patients. .
Forge ahead, center trust
There have been myriad calls to restore a sense of trust and security in the health care community, and it may seem obvious that this is the way to go. But, as shown in a recent review of the literature on trust in health services and health policy research by three of the co-authors of this article (forthcoming in Milbank Quarterly) revealed, for all that has been written about trust (~725 papers over 50 years), less than a handful of those papers dealt with provider trust in patients. This may be the result of an assumption that physicians must trust patients as part of their professional duties. Nevertheless, trust is so central to the therapeutic relationship that concerted efforts must be made to address this oversight in light of the continuing threats.
Whether through the proposed SAVE Act and accompanying grant funding, or through alternative mechanisms to address the growing problem of violence against healthcare workers, we urge the research community as well as Federal and institutional actors to recognize the value of incorporating the issue of patient trust provider into future research. This potential value should inform communities’ decisions about whether and how to devote more resources to unpacking the difficult question of trust – how to assess it, how to build it, and how to use it to create a world safer for doctors and patients. . We also see an important role for health systems in gaining patient trust, supporting clinicians, and breaking the cycle of mistrust between patients and clinicians.
The healthcare community is right to be concerned about emerging evidence that patients are increasingly distrustful of the healthcare system as a whole, as well as the rise in violence and other wrongdoings perpetrated against healthcare workers. health. It’s no exaggeration to say that trust is what the entire healthcare delivery system relies on – and where it’s absent, we see major breakdowns. But so is the trust that needs to pass from doctors to patients. Without it, the system will also be in danger. Therefore, our efforts to build patient trust must be matched by careful consideration of how to maintain physician trust in patients.
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