Introduction
According to a recent Edelman Trust Barometer study (2010), Ireland was the only country out of 22 surveyed to record declining levels of trust in all four institutions measured — business, government, media and NGOs. This holds significance to social development as trust is a central ingredient to the development of social capital, and to the survival of social cohesion upon which society depends (Durkheim, 1951). With reference to a number of scandals that had shaken the country in the mid-1990s and to a process of transcended distrust born out of several critical and deeply damaging attacks on what were previously considered pillars of Irish society, a “community of distrust” is now said to pervade (Peillon, 1998). With this erosion of trust across the Irish society, one must question whether this has impacted upon another pillar of the Irish society; the medical profession, and in particular the local general practitioner.
As part of the “Europortrait Study” led by the French College National des Généralistes Enseignants (CNGE) which sought to identify patients’ representations of their general practitioner in 23 European countries, an exploration of the trust held in the Irish general practitioners by their patients was undertaken.
Literature Review
According to Fugelli (2010), trust is to general practice like blood is to the body. It is the belief that within the general practitioner there exists a sincerity, commitment, benevolence and truthfulness that the patient can rely upon as soon as they enter the surgery for treatment. On a personal, one to one level, the gaining of trust is a function of, among a myriad of factors, confidence, reliability and time embodied mostly in the continuity of personal care — a continued caring relationship between the patient and the physician (Gulliford et al., 2006). According to Schers et al. (2002), “high levels of personal continuity are related to patients having increased trust in physicians, feeling more satisfied with consultations, and more enabled afterwards”. In terms of its value for patients, research from the UK shows that up to three quarters of patients have what they term a “personal GP” (Kearley et al., 2001). Across Europe, previous studies have shown that aspects associated with this personal continuity, such as the ability to listen to and understand patient problems, comfort in the confidentiality of records and the time given in each consultation, are central to the “generally very positive views about their GP and general practice” that respondents offered (Grol et al., 2000). The sentiment underlying these offered opinions is trust.
In recent research carried out in the United Kingdom by IPSOS MORI (2011), doctors rated higher than any other profession in terms of general public trust. This article investigates the position of general practice in Ireland in this time of general upheaval and institutional mistrust. With reference to the views of a small sample of patients, we seek to enquire if patients have trust in their physician and the medical profession.
No such work has been conducted in an Irish context.
Research Question
Do Irish patients trust their local General Practitioner?
Methods
The “Europortrait Study”, led by the French College National des Généralistes Enseignants (CNGE), sought to identify patients’ representations of their general practitioner in 23 European countries. As part of the Irish contribution to this project, the research team carried out a focus group lasting one hour and forty five minutes, and a series of in-depth semi-structured interviews lasting twenty minutes each with patients located in rural and urban locations across five counties in the Republic of Ireland. Implementing purposive sampling, participants were selected due to their response to a notice inviting patients to take part placed in the waiting room of ten practices across the country. Seventeen participants took part in this research, 14 female and 3 male. No further demographic information was recorded about the participants. Ten participants were interviewed and seven took part in the above mentioned focus group. The participants of the focus group were registered patients of the same primary care centre in which up to four GPs hold their practice. The interviewees were registered patients in five different practices across the Republic of Ireland. Study researchers, neither of whom were general practitioners, entered the field with the expressed desire to facilitate the open discussion of patient experience in relation to their primary care provider. Further, study researchers held no professional relationship with interviewees or focus group participants prior to study commencement.
Participants were asked to describe their GP in detail, giving account of the doctor’s personality and personal attributes and also how they would characterise their patient-doctor relationship. Participants were asked about their preferences for a GP in terms of gender, age and background as well as what they felt were important characteristics for a GP to possess aside from medical expertise. Issues were discussed relating to the patient’s opinions about their typical GP consultation in terms of its duration, the extent to which the GP will examine, both physically and verbally, the problem in question and also in terms of the GP’s ability to dedicate time to listen to the patient’s description of their problems and provide relevant information (opinion, literature, websites etc.) where possible. Participants were also asked about their perceptions pertaining to their own personal involvement in their treatment and whether they felt actively involved in, and/or felt comfortable to question, important decisions relating to their healthcare. In the final sections, participants were asked their views on the competence of their GP and their knowledge of their GP’s professional and academic background, together with questions attempting to elucidate perceived and experienced differences in care between the privately insured and medical card holders, and between GP and specialist consultations.
While a topic guide was used to facilitate the discussions, the questions were asked in an open, non-directive manner.
The Research Ethics Committee of the Irish College of General Practitioners approved the study.
Krueger’s (1994) framework analysis approach was used to analyse the data. This thematic approach allows for themes to develop both from the research questions and the participants’ narrative. Recorded data from the focus group and interviews was transcribed. Patterns and/or themes were sought separately by two researchers using open coding techniques. Themes deduced by these researchers were compared, recorded and all data specific to these themes throughout the transcripts were noted. Sub-themes were then sought in order to provide a full view of the group’s opinions (Braun and Clarke, 2006).
This survey of patients was broad in that it queried aspects of patient experience of primary care as well as seeking patient opinion on other national health service matters outside the scope of this paper. This paper reports on the theme of trust that arose within the discussions.
Results
All results detailed below presented in both the focus group and the individual interviews conducted.
The following themes emerged from the discussions undertaken:
(i) Communication Skills
(ii) Gender preference
(iii) Consultation- time management
(iv) Consultation — listening
(v) GP-competence
(vi) GP-personality
(vii) GP-Patient Relationship
(viii) Trust
The GP was described as an “intelligent”, “energetic” and “efficient” individual, who was defined by management skills that enabled the balancing of the stress and demands that accompanied the responsibility to the patient(s) and the need to care for dozens of people on a daily basis, with the need to dedicate time and attention to each individual in each consultation. GPs were described as “caring”, “attentive”, “considerate”, “level and compassionate” with excellent communication skills and strong technical knowledge which enables the practitioner to “listen to what is said and know the problem immediately”.
Most participants described having a positive relationship with their GP having constructed a “trust” relationship over a long period of time, with some cases pointing to an ongoing family relationship, for example, with some also having attended the father of their current GP.
While participants felt they could do so, overall the vast majority of participants never felt inclined to question the decisions or diagnoses made by their GP with, reflecting perhaps a level of dependency, the general feeling among patients being that failure to trust in this instance will leave the individual coping with further discomfort and uncertainty; “if you don’t trust them, then where are you?”. Some participants commented that in incidences where they and their GP had not come to a mutual agreement on either a diagnosis or course of treatment, that more often they felt that the GP would be persistent in the promotion of what s/he considered the correct course of action while remaining respectful of the patient’s views. This stated level of comfort is acknowledged to be a recent development with one participant outlining how her mother’s generation “would never question” decisions made nor feel comfortable to air their own opinions on the matter or introduce ideas such as alternative therapy into the discussion. Further, in relation to patient active involvement, participants were clear that they too had an important role to play both in the maintenance of this trust relationship and their health, acknowledging their obligations and being “clear on (their) responsibilities, staying active, eating well, etc”.
Participants felt that it could be “taken for granted” that the practitioner they met with to discuss their personal problems was appropriately qualified and that they had never had an experience that would encourage them to revise this assumption. The only cases in which participants intimated that they might query the physician tending their needs, is on the occasion when the doctor in question is a locum whom they have no previous relationship with, or knowledge of. Some participants spoke of seeing numerous certificates decorating the walls in the surgery and intimated that, in their opinion, the presence of these certificates amounted to sufficient evidence of a certain high level of achievement, intelligence, competence and ability. None of the participants had made enquiries directly to their GP about the significance of these certificates, the GP’s qualifications and/or areas of specialty, or their previous employment history. However, a small number of participants spoke of their knowledge of their GP’s specialist background as being a factor that leads them to visit that particular doctor when the need arises, and to informally appoint them as “my GP”. Others spoke of their general confidence in the GP’s abilities gained through witnessing firsthand the practical demonstration of skills as well as a “willingness to go over everything, listen and explain… and never rush the patient”.
Only a small minority of participants have ever sought a second opinion on a diagnosis or course of treatment with one stating to “have never come across an incident where he said something and it wasn’t true”.
While trust in and contentment with one’s GP was the predominant sentiment of the research, further to the mention of some participants seeking the “fresh look” of a second opinion in some instances, some dissent was also detectable in the data. Contrary to the detailed attentiveness of the GP, one participant lamented that their doctor appeared more preoccupied with documenting the consultation than with listening to them as they “always turned into the computer” during the consultation. Also, another participant spoke of feeling undermined by her GP in relation to her desire to pursue treatment which included the use of alternative medicines with her concerns given little consideration or dismissed entirely.
Discussion
Overall the research showed that the patients in this sample enjoyed a strong and contented relationship with their GP.
Continuity of care can be seen from the research as a key factor relating to patient satisfaction with their GP relationship. In many respects, the ongoing family relationships between GPs and patients, with some relationships based upon the solid foundations of generations of patient-doctor ties, points to the development of a form of localised, community-based institutional trust among these patients.
Perhaps providing an indication of a central component required by patients to allow for their truth telling within consultations — that of trust (Beauchamp and Childress, 2001), unwavering “total trust” was also evident from discussions about the decisions and diagnoses made by the GP. This support for GP decisions is all the more encouraging in a time when forms of self-diagnosis, informed mainly through internet research on the part of the patient, are becoming more prevalent (Ahmad, 2006). It was also noted, however, that a shift has occurred in terms of the patients’ position and responsibilities in relation to the management of their condition(s) with the patients in this sample being facilitated in taking a more active role. One could infer then, that it is the mutual respect noted by participants that led to the finding that most participants felt comfortable in raising any issue relating to their course of care with their GP for discussion.
Perhaps the most encouraging finding from the research is that, in general according to this sample, the GP and the Irish medical institution of general practice appear to have avoided the contagion of transcended distrust from other institutions and have maintained their strong trust relationship among this sample of patients. When asked about their GP in terms of competence, academic qualifications and experience to date, all participants replied that while free to do so, they did not once question their GP in terms of these areas. This can be seen as a measure of confidence from this sample in both the GP as an individual, and also in the wider system that trains physicians in Ireland.
Given the main limitation of a small scale and small sample of participants for this research, (which was originally intended to contribute to a European wide picture, which has not yet transpired), the scope exists for future studies, including a larger sample, to revisit the notion of trust in the Irish general practice or also in secondary care, and assess what impacts upon this.
Study Limitations
This study is limited by the small sample size, and potentially by its use of focus groups as a felt need by participants to provide socially desirable responses in the company of neighbours may have featured.
Conclusions
In times of uncertainty, distrust is often rampant. In terms of institutional strength and integrity, it is encouraging that, in the opinions of this limited sample, for the above reasons, general practice settings have been preserved as a place where the patient feels safe and secure with a trust relationship which has survived and prospered. However, indications from this sample, point to a change in their attitude to their healthcare that can be generalized to encompass a more active and informed role for the patient with a willingness to question opinion and include alternative therapies in their quest for recovery.
Competing interests
None.
Authors’ contributions
All authors contributed to the study design.
CC co-ordinated the study with CNGE, adapted the materials for use in Ireland,sourced funding, obtained ethical approval and commenced the participant recruitment aspect.
CK & CV conducted the focus group and carried out the interviews with participants.
CK drafted the initial manuscript.
All authors read, offered suggestions and approved the final manuscript.
Acknowledgements
The authors would like to thank the five practices who allowed us to access their patients and to the participants in the focus group and interviews who gave generously of their time. We acknowledge the contribution of Professor Patrick Imbert and Dr.Robert Bochaton of the French College National des Généralistes Enseignants (CNGE) who co-ordinated the research on a European basis and provided a template of the study design and topic guide, which was then adapted for use in the Republic of Ireland. This study in the Republic of Ireland was made possible by the funding received from the Research and Education Foundation of the Irish College of General Practitioners.
References
1. Ahmad, F., Hudak, P.L., Bercovitz, K., Hollenberg, E. and Levinson, W. (2006) “Are
physicians ready for patients with internet based health information?” Journal of Medical Internet Research, 8 (3) e22.
Google Scholar
2. Beauchamp, T.L. and Childress, J.F. (2001) Principles of Biomedical Ethics, 5th edition, Oxford University Press, Oxford.
Google Scholar
3. Braun, V. and Clarke, V. (2006) “Using thematic analysis in psychology,” Qualitative Research in Psychology, 3 (2) 77-101.
Google Scholar
4. Durkheim, É. (1951) Suicide: A study in sociology, Routledge, London.
5. Edelman Trust Barometer (2010) “Trust in government and business in Ireland is the lowest in Europe according to pan-European survey,”, FinFacts. [Online], [Accessed 23/10/2013], Available: http://www.finfacts.ie/irishfinancenews/article_1018896.shtml
6. Fugelli, P. (2001) “James MacKenzie lecture. Trust — in general practice,” British Journal of General Practice, 51 (468), 575-579.
Google Scholar
7. Grol, R., Wensing, M., Mainz, J., Jung, H.P., Ferriera, P., Hearnshaw, H., Hjortdahl, P., Olesen, F., Reis, S., Ribacke, R., Szecsenyi, J., and European Task Force on Patient Evaluations of General Practice Care (EUROPEP). (2000) “Patients in Europe evaluate general practice care: an international comparison,” British Journal of General Practice, 50 (460), 882-887.
Google Scholar
8. Gulliford, M., Naithani, S. and Morgan, M. (2006) “What is ‘continuity of care’?” Journal of Health Services Research & Policy, 11 (4), 248-250.
Publisher – Google Scholar
9. IPSOS MORI (2011) Trust in Professions 2011 [Online], [Accessed on 23/10/2013], Available:
http://www.ipsos-mori.com/researchpublications/researcharchive/2818/Doctors-are-most-trusted-profession-politicians
-least-trusted.aspx
Publisher – Google Scholar
10. Kearley, K.E., Freeman, G.K. and Heath, A. (2001) “An exploration of the value of the
personal doctor — patient relationship in general practice,” British Journal of General Practice, 51 (470), 712-718.
Google Scholar
11. Krueger, R.A. (1994) Focus Groups: A Practical Guide for Applied Research, Sage Publications, Thousand Oaks, CA.
12. Peillon M. (1998) A community of distrust. In: Peillon, M. and Slater, E. eds. (1998) Encounters with Modern Ireland: A Sociological Chronicle 1995-96. Dublin, Institute of Public Administration, 117-124.
13. Schers, H., Webster, S., van den Hoogen, H., Avery, A., Grol, R. and van den Bosch, W. (2002) “Continuity of care in general practice: a survey of patients’ views”, British Journal of General Practice, 52 (479), 459-462.
Google Scholar
