This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.

Context.-Trust is the cornerstone of the patientphysician relationship. Payment methods that place physicians at financial risk have raised concerns about patients' trust in physicians to act in patients' best interests. Objective.-To evaluate the extent to which methods of physician payment are related to patient trust. Design.-Cross-sectional telephone interview survey done between January and June 1997. Setting.-Health plans of a large national insurer in Atlanta, Ga, the Baltimore, Md-Washington, DC, area, and Orlando, Fla. Participants.-A total of 2086 adult managed care and indemnity patients. Main Outcome Measure.-A 10-item scale (␣ = .94) assessing patients' trust in physicians. Results.-More fee-for-service (FFS) indemnity patients (94%) completely or mostly trust their physicians to "put their health and well-being above keeping down the health plan's costs" than salary (77%), capitated (83%), or FFS managed care patients (85%) (PϽ.001 for pairwise comparisons). In multivariate analyses that adjusted for potentially confounding factors, FFS indemnity patients also had higher scores on the 10-item trust scale than salary (PϽ.001), capitated (PϽ.001), or FFS managed care patients (PϽ.01). The effects of payment method on patient trust were reduced when a measure based on patients' reports about physician behavior (eg, Does your physician take enough time to answer your questions?) was included in the regression analyses, but the differences remained statistically significant, except for the comparison between FFS managed care and FFS indemnity patients (P = .08). Patients' perceptions of how their physicians were paid were not independently associated with trust, but the 37.7% who said they did not know how their physicians were paid had higher levels of trust than other patients (PϽ.01). A total of 30.2% of patients were incorrect about their physicians' method of payment. Conclusions.-Most patients trusted their physicians, but FFS indemnity patients have higher levels of trust than salary, capitated, or FFS managed care patients. Patients' reports of physician behavior accounted for part of the variation in patients' trust in physicians who are paid differently. The impact of payment methods on patient trust may be mediated partly by physician behavior.

CONTEXT: Few data are available regarding the consequences of patients' problems with interpersonal aspects of medical care. OBJECTIVE:To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want. DESIGN: Telephone survey during 1997.PARTICIPANTS: Patients (N = 2,052; 58% response) insured by a large national health insurer. MEASUREMENTS:Patient trust, overall ratings of physicians, and having considered changing physicians. RESULTS:Most patients (78%) reported at least 1 problem experience. In multivariable analyses, each problem experience was independently associated with lower trust (all P < .001) and 5 of 6 with lower overall ratings (P < .001). Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3 to 3.0), not always taking enough time to answer questions (OR, 3.3; 95% CI, 2.2 to 5.2), and not always giving enough medical information (OR, 4.0; 95% CI, 2.4 to 6.6).CONCLUSIONS: Problem experiences in the ambulatory setting are strongly related to lower trust. Several are also associated with lower overall ratings and with considering changing physicians, particularly problems related to communication of health information. Efforts to improve patients' experiences may promote more trusting relationships and greater continuity and therefore should be a priority for physicians, educators, and health care organizations.

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OBJECTIVE:To evaluate the extent to which physician choice, length of patient-physician relationship, and perceived physician payment method predict patients' trust in their physician. DESIGN:Survey of patients of physicians in Atlanta, Georgia. PATIENTS:Subjects were 292 patients aged 18 years and older. MEASUREMENTS AND MAIN RESULTS:Scale of patients' trust in their physician was the main outcome measure. Most patients completely trusted their physicians "to put their needs above all other considerations" (69%). Patients who reported having enough choice of physician ( p Ͻ .05), a longer relationship with the physician ( p Ͻ .001), and who trusted their managed care organization ( p Ͻ .001) were more likely to trust their physician. Approximately two thirds of all respondents did not know the method by which their physician was paid. The majority of patients believed paying a physician each time a test is done rather than a fixed monthly amount would not affect their care (72.4%). However, 40.5% of all respondents believed paying a physician more for ordering fewer than the average number of tests would make their care worse. Of these patients, 53.3% would accept higher copayments to obtain necessary medical tests. T rust is a fundamental aspect of the patient-physician relationship. 1-5 Even well-informed and knowledgeable patients have to rely on their physicians to provide them with appropriate information, keep personal information confidential, provide competent care, and act in their best interests. In spite of the importance of trust to the patient-physician relationship, there are few studies of the factors related to patients' trust in their physicians. CONCLUSIONS:One predictor of trust in social relationships is the length of those relationships, 6-8 and there is reason to believe this would hold for patient-physician relationships. 9 Having a choice of physician is important to many patients, 10-13 and it is possible that wider choices would encourage greater trust in the physician eventually chosen. Recent developments in health care delivery also make it plausible that the way physicians are paid could influence patients' trust in them. Reports regularly appear in the popular press about how new managed care arrangements may compromise the care provided to patients. Health service researchers have shown that payment methods may have an impact on clinical decision making. 14-16 We know of no empirical studies that have examined whether patients' beliefs about how their physician is paid affect their trust in the physician. In the study described herein, we interviewed a probability sample of patients covered by a large health care insurer in Atlanta. We assessed how patients thought their physicians were paid and whether their perceptions were accurate. We also examined whether availability of a choice of physicians, length of patient-physician relationship, or perceived physician payment method was related to the patients' trust in their physician. METHODS Study Design and SampleThe study was con...