Indicators for Medical Mistrust in Healthcare–A Review and Standpoint from Southeast Asia

The relationship based on trust is exceptionally important in healthcare, where life or death and quality of health are major concerns. Relational crack jeopardises the provision of quality healthcare when trust is taken for granted. Trust is believed to be the vital key to minimise medical negligence, lawsuits and patient complaints towards healthcare providers while acting as an empowering agent to significant clinical outcomes. Trust is indispensable to healthcare. However, to identify its deterioration is not a simple feature. Moreover, lack of research and public dissemination complicate this topic further. Hence, understanding medical mistrust issues and their associated indicators is urgently needed to ensure the top-notch provision of healthcare. We employed narrative review methodology together with key terms matching for the selected electronic databases for this article. Our review concluded that an “Increasing number of medical litigations and complaints towards physicians”, “Physicians’ low mastery of interpersonal communication skill” and “Patients’ demand, practice, and non-disclosure of alternative treatments” are the possible indicators to predict mistrust. Efforts to restore and strengthen trust can only be made when these indicators are well understood firsthand.


Introduction
Being able to trust each other in healthcare is a requirement for beneficial and long lasting partnership. Bonding forged with trust requires mastery of both technical and social competencies for it to last continually. This point is exceptionally important in the health sector, where life or death is a major constant concern. Patient-physician relationship (PPR) is a prime example of bonding where serious concerns need to be prioritised. The term medical trust used in this article integrates the concept of collaborative trust. It is defined as a form of trust which was birthed due to a partnership between patient and physician, where goals are shared, personal contributions to the relationship, as well as mutual respect are emphasised (1). This type of trust focuses on the exchanges of knowledge, emotional and professional bonding developments, honesty and respect towards an ongoing relationship. When trust is left unattended, it jeopardises the core principle of healthcare profession, which is to bring forth positive health outcomes to its clients (2).
Mistrust in healthcare is associated with the increment of medical negligence, complaints and lawsuit cases. In addition, patients' display of lack of concern and knowledge of trust and refusal to disclose their alternative treatment practices also are connected with trust issues with their physician. From the patient perspective, the physician's low mastery of interpersonal skill is perceived as incompetence and thus contributes to patients' mistrust. All these issues which are believed to be the outcome of taking medical trust for granted shall be discussed further. What is evident is that when a databases (Google Scholar and Google search engine) used.
The following selection criteria were employed: Return results were restricted to only original publications in the English language, from the year 1984 to 2015. Only full-text journals, published theses and online articles which contribute to the following objectives were reviewed: i) Evidence and statistic on malpractice, misconduct, complaints and medico-legal cases aimed at physician or health institutions ii) How trust is being perceived in healthcare and, iii) Modifiable indicators which possibly contribute to the deterioration of medical trust. In this paper, possible nonmodifiable factors which could encompass demographic, socio-cultural determinants and political aspects were omitted.
Other databases not subscribed by our institution and involve payment to view were excluded. Materials from the distant past were included to ensure the originality of the conceptual idea of trust is retained and comparison with the recent literatures can be made. In addition, a reference list of the retrieved articles was considered to determine other relevant literatures. This warrants the breadth and depth of the reviewed topic and objectives.

Results and Discussion
Methodology and study design used for the reviewed papers are not the main emphasis for this study because not all were clearly stated. Moreover, the main goal of this paper is to develop a preliminary conceptualisation which elaborates on the phenomenon of medical mistrust and its possible indicators based on the integration of the reviewed materials. We tried to include studies which mostly took place at clinical settings and between patients and their healthcare providers. The majority of the included papers were crosssectional studies and consist of 15 non-randomised and eight randomised sampling studies, as well as 12 other materials which encompass review papers, reports, commentary articles and letter to editors.
Overall, a total of 40 articles which met the selection criteria were included for this writeup. These 40 articles range between the years 1984 to 2015, with 21 references were under year 2010. From the screened materials, general themes were derived based on the triangulation party failed to keep their word or perform the act of betrayal, these actions can definitely diminish or destroy trust.
Interest in trust in clinical relationship is growing steadily around the globe. Brennan et al. (3) pointed out that literatures on this aspect have increased in recent years and approximately 44% have been carried out in United States. This figure reflects the crucial need for trust being the central research area in patient-physician relationships in advanced countries, specifically in health counseling and therapeutic relationship aspects. However, the situation differs in eastern culture where trust remains a secret topic due to its delicate nature. Therefore, the foundation of medical trust is not well explored and literatures highlighting its indicators are scarce (4). This justifies the necessities for trust to be thoroughly researched, fathomed and exposed to the public. These indicators are urgently needed to prevent, and to put a stop to the uprising issues associated with mistrust in PPR and consequently, in parallel with the global health need to provide the best caring services.
Overall, this review attempts to highlight issues leading to medical mistrust and its possible indicators for future prediction in health care. This scientific piece is conceived as the initial step to prevent further tarnishing medical relationships, as well as to enhance public trust and cooperation with healthcare institutions. Shedding light on medical mistrust proves to be vital for more quality and efficient health service provision in the future (5).

Methodology
Narrative review methodology is employed. Electronic databases such as MEDLINE, Google Scholar, and Google search engine (open access materials) were searched. Key term search was performed by combining "Trust" with the following subterms: "Mistrust", "Malpractice", "Misconduct", "Healthcare", and "Patientphysician-relationship". The date of search for these databases was between the periods of 6 August 2015 to 10 August 2015. The search was performed without restriction to the year of publication using the mentioned search terms. Additionally, the search was also completed with the inclusion of the word "And" in between the terms. Supplementary key words and search methods offered by MEDLINE were avoided. The reason was to standardise the search method between MEDLINE and another two electronic job performance and professional satisfaction (7)(8). The bond forged with it comes together with a powerful constraint which prevents trust violation from being committed markedly among individuals who share PPR, familial ties and close friendship (6). This means, upon its attainment, mutual loyalty and confidentiality are necessities to be present along PPR.
However, when we fail to realise the advantages of trust, do not try to seek or learn about it, its attainment shall become complex. One wrong step in matters regarding trust could lead to greater consequences. For instance, the increment of complaints and legal cases towards healthcare providers, exclusively physicians and the credibility of medical institutions and staffs can be jeopardised. The aftermath will definitely be disastrous as it shall snatch away quality health services and leave the citizen-everyone's health exposed to a great deal of risks and thus endangers them. Therefore, mistrust is definitely a matter to be concerned, especially in a medical setting. Its associated indicators need to be thoroughly researched and the results should be used as an ingredient to derive its interventions.

Indicators for Medical Mistrust
Increasing medical litigations and complaints about physician In the past, Blendon et al. (9) stated that the public trust in medical leaders had critically diminished. The report also noted that about 47% of individuals with insurance and 61% of "heavy managed care" patients were more concerned about their financial security than spending on the best treatment when they are ill. Furthermore, about half of the surveyed population of total 3,700 American adults showed negative impressions about health care provided due to the decrease in quality in the past (9). A glimpse at the UK physicians' fitness to practice statistics clearly leaves us with a state of concern. An increasing trend of complaints about physicians was observed since year 2010 right up to the year 2013 with 64% increment of cases from the public were documented (10)(11). The percentage of UK medical physicians halted for medical practice also showed an increment to 42% between 2010 and 2013. Overall, 17% increment in the revocation and suspension of the medical licenses was noticed between 2008 and the subsequent five years (12).
These data on medical trust disputes clearly signifies the cracks of trust in health method which comprises a literature review, discussion of experts and authors' opinions. Thirty-five of the articles were thoroughly reviewed and were categorised based on three themes; Medical litigation and complaints (MLC), Interpersonal communication skill (IPC) and Complementary & alternative medicine/ medical practice (CAM). The number of reviewed articles with respect to the themes is proportioned as; 12:12:10 (Please refer Table 1).
From 35 papers reviewed, medical mistrust phenomenon can be theorised to possess interconnections between three indicators, namely i) Increasing medical litigation and complaints about physicians, ii) Physicians' low mastery of interpersonal communication skills and iii) Patients' demand, practice and non-disclosure of alternative treatments to the physician in charge (refer Figure 1). Most of these indicators are mostly healthcare providerdriven, particularly physician.

Prologue to Medical Trust
Medical trust is one of the prerequisites for successful caring services. It is the product of reciprocity between patients and physicians in healthcare sector. Both parties need to communicate frequently, while exchanging knowledge, developing emotional and professional ties, as well as nurturing the bond with honesty and respect (1,6). Trust requires strong commitment from the parties to achieve one core objective, which is to work together towards a strong and ongoing relationship with mutual goals (1). They need to cast their ego aside-whether they prefer each other or not and just focus on the shared goal. This is much true in PPR where the situation requires patients to place trust in their physician whether he or she is a total stranger, merely known casually or more apparent in cases of life or death. Moreover, patients are the vulnerable party because of their ailment and limited medical knowledge. They do not have other choices but to expose their weaknesses to the tending physician and silently hugging close to their heart the possibility of being exploited. Patients have to place their bets on the physician's goodwill and competence as it is the only option viable.
In spite of being a delicate, reserved issue in eastern countries and complex to be garnered, trust has its own merits. When preserved in a medical relationship, trust is able to demonstrate its mutual clinical benefits, such as better therapeutic outcomes, efficiency in 8 used Patients reported that primary principle for using CAM was to prevent disease recurrence, as well as to lessen side effects and regaining strength prior to the current conventional treatment they are receiving The key reason for not disclosing or opening a discussion CAM use is fear of termination of therapy by physicians   (28).
Listening is one of the prominent interpersonal communication skills. A physician who is in a hurry to end their conversation or not able to stay long, may cause patients to get discouraged. Patients could not reveal the true story behind their ailment or decided to keep their questions to themselves (6,24). Despite being able to understand the physician's busy schedule, patients dislike being deserted, their opinions devalued, have limited time during routine visits, rushed during consultation and poor or insufficient feedback from their doctor (17,29). Additionally, Beckman and Frankel (29) uncovered that physicians prefer to interrupt patients' talk every 18 seconds, and most of the conversations were dominated by the physician with questions, instead of being patient-centered. Such discourteous habits further demerit patients' trust in the respective health authority and forbid them from disclosing further their qualms and details.
Lastly, a sense of partnership or precisely, shared decision-making and information is a strong trust-determinant in PPR. Repeated similar findings on this linkage were documented in the past (1,25,30) denoting that there is a high priority to believe physicians' IPC skill is an indicator for patients' medical trust. Smets et al. (30) found that one in every three patients was not informed at all about their prognosis details, hence leaving question marks on the credibility of the physician in charge and the health care decisions which were supposed to be made together with their clients. professionalism and requests us to reinstate the respective parties' trust (13)(14). Adding up to the previous point, the growth in comorbidity and mortality rates also triggered a great concern about the quality of care provided. Current advancements in medical care were said to be lacking in humanistic aspects, particularly patient care (15). This matter does not end easily as it further infects other patients' psyche, taints the grace of the healthcare professions, defiles health institutions' dignity and is capable of paralysing the entire country's healthcare system (16).
In regard to potential risks leading to a greater volume of malpractice, literatures suggest these factors were related to physicians; low interpersonal communication skill mastery, patients' perception of insufficient caring or collaboration, short length of patient-visit, long duration of workweeks, greater volumes of work, being in group practice and having longer working experience as a physician (17)(18)(19)(20).
A study by Philip and Peters (21) which took evidence from two decades concluded that claims on medical malpractice were strongly correlated with the quality of care provided and contributed to the shaping of trust. Hence, it is indeed important and timely that these issues be revisited with trust in mind. The foundation of trust needs to be thoroughly researched and revealed to the public to permit more effective management on relevant matters, as well as restore public trust and appreciation of health professions.
(ii) Physician's low mastery of interpersonal communication skill Rejection of social trust in healthcare is not uncommon. It is said to be closely bound to the physician's roles (6,22). Beckman and his teammates concluded that physicians' interpersonal communication incompetency accounted for more than 70% of malpractice cases in the past (17). This figure was also highlighted by a malpractice attorneys' report published back in the year 1985, which states that communication problems is the prime reason for patients to issue malpractice suits and accounted for more than 80% of the cases (23). When these reports were compared, physicians' low mastery of interpersonal communication skills remained to be an issue which has prolonged for at least eight years until currently.
More recent studies by Beckner and Roblin (24), Bova et al. (25), Cunningham et al. (26) and insisted on having a physician who is willing to listen carefully, talking seriously about patients' CAM use, inquires and is equipped with knowledge of both modern and traditional medications, as well as providing CAM information and knows who else they should communicate with in regard to CAM matters. However, only a minute amount patient, 9% were actually being referred to CAM practitioners by their physicians (33).
While the misfit between patients' expectations and physicians' incompetence to fulfil their requests existed, mistrust too was invited along. We believe the reasons why public demand and emphasis on CAM usages were due to its cost effectiveness, ease to comply and its being much more non-invasive than modern medication (39)(40). Moreover, some of CAM therapies were proven scientifically and deemed effective by the users. Additionally, patients insisted on its advantages to prevent disease recurrence and to cushion the potential side effects due to conventional medical practices, such as chemotherapy (36,(39)(40).
The current review has a number of limitations. Aside from limited resources and databases assessed, possible non-modifiable medical mistrust indicators such as patients' and physicians' ethnicity, gender and other cultural, societal, psychological, and political factors were excluded. This study is also limited by the search terms used, journals included, as well as the time period of the referred publications. Future reviews can be further improved by addressing a wider scope of studies by including more recent materials covering psychology and social sciences-based databases, implementing more systematically review designs and excluding studies without a well-defined methodology.

Conclusion
Study results suggest that patients' trust in conventional practitioners is probably diminishing. From the conducted review and its limitations and selection criteria in mind, investigators proposed three potential indicators for medical mistrust; (1) Increasing medical litigation & complaint about physicians, (2) Physicians' low mastery of interpersonal communication skills and (3) Patients' demand, practice and non-disclosure of alternative therapy practices to their physician.
Patient-health provider trust is a significant scope which shall be the answer to many (iii) Patients' demand, practice and nondisclosure of alternative therapies Complementary & Alternative Medicine (CAM) usage is more prominent in rural inhabitants who had more preferences for traditional modes of healing, despite well established modern medicine. Lacking in the numbers of studies which detail out the relationship between trust in conventional medicine (medical trust) and CAM usages leave us in the dark. We have only discovered one such study throughout our review (31). This study concluded that there is no relationship between public trust in conventional medicine and public trust in CAM practices. The same paper also emphasised that patients' practice of CAM and physicians' influence on, or recommendation for, them to try it have no connection, which is in contrast to another study (32).
Although aware that the prescribed treatment regimen by physicians must be strictly followed, some patients decided to deviate from obedience. They wish to try alternative treatments which integrate with their current treatment plans; meanwhile some other perceived CAM offered a more holistic approach (33). However, such a decision was made unnoticed, let alone being approved by the in-charge physician as patients refrain themselves from disclosing it. The attitude to not disclosing CAM practice or related information to physicians is viewed as an act of secrecy and being cautious against their healthcare provider. To be explicit, patients were behaving so possibly due to low levels of trust in physicians.
The disclosure rate to physicians varies, with as low as 7.6% which is one among 10 patients to 73.8% of the patients who used CAM according to three studies (35)(36)(37). They were worried about the setbacks after disclosing it. Patients were afraid physicians may get upset and terminate the existing treatment regimen (34). While others discerned physicians' lack of CAM knowledge, showed low interest in it, did not believe in it or showed indifference towards it, had insufficient time during consultation, physicians did not inquire about its practices, and patients do not know they have to disclose it, believe CAM is generally harmless as it is naturebased thus not affecting their current treatment and patients personally perceived that there is no need to disclose it (35)(36)(37)(38)(39).
To ascertain the previous point, the study conducted by Miek et al. revealed that patients questions about quality and effectiveness of healthcare provision and important clinical outcomes aimed by all health institution. Undeniably, it assists in promoting public policies and strengthening other forces which endanger the patient-physician relationship. Future studies on patient-health provider trust are encouraged to fill these gaps: (1) Prevalence of mistrust in physicians and health care with more emphasis on eastern continents, (2) Factors leading to medical negligence litigation, (3) Other modifiable and non-modifiable factors, which can promote patients' trust in physicians and, (4) Mistrust-related interventions to end this medical dispute permanently. The first step to prevent medical mistrust from reoccurring is to have more of its indicators researched and understood, especially by medical and health professionals and then promote awareness to the public.