Communication by the physician, attachment style
of the patient and their association with trust in an
oncological setting.
E. P. G. (Emma) Ruigt, BA
Student number 6079563
Masterthesis Clinical Psychology
10th October 2013
Supervisors
M. A. (Marij) Hillen, Msc
Dr. G. (Gerly) de Boo
Dr. E. M. A. (Ellen) Smets
University of Amsterdam
Amsterdam Medical Centre
Abstract
Purpose – The aim of this study was to examine verbal communication by the physician (caring, honest or
competent) and the effect on cancer patients’ trust. Moreover, it was examined whether attachment style of the
patient (avoidant or anxious) significantly predicts trust. Finally, the influence of attachment style as a moderator
on the relationship between communication by the physician and subsequent trust was researched.
Methods – A total sample of 345 hospital patients and patients recruited from the Dutch Federation of Cancer
Patient-organizations each watched two videos (690 observations) of an oncological consultation where the
physician communicated either as in a standard consultation or conveyed enhanced caring, honest or competent
communication, resulting in a 2x2x2 factorial design including 8 videos. Patients completed the Trust in
Oncologist Scale and Experiences in Close Relationships Scale, measuring trust and attachment style,
respectively. Data were analysed using stepwise multilevel modelling in SPSS.
Results – Subjects reported more trust in the oncologist when he showed enhanced care (b=.37, p<.001),
honesty (b=.30, p<.001) and/or competence (b=.18, p<.001) compared to the standard consultation. Anxious
attachment style of the patient did not moderate this relationship. However, for patients with a more avoidant
attachment style, the effect of enhanced care (b=-.13, p<.01) and of honesty (b=-.11, p<.05) on trust was weaker
compared to those with a less avoidant attachment style.
Discussion – Physicians, who add words of care to a standard consultation, are more open and honest with the
patient and/or reassure the patient by asserting their competence, can positively influence their patients’ trust.
There was a negative relationship between attachment avoidance and trust, which was completely explained by
the interaction with communication style; this effect is thus that the effect of caring or honest communication is
weaker for those with a more avoidant attachment style. These findings can guide interventions to improve trust
through physician education and training. Limitations and implications of these findings are discussed, as well as
possibilities for further research.
For questions regarding this thesis, please contact the author, E.P.G. Ruigt. Telephone number:
+31(0)6 37335020, e-mail: [email protected] or postal address: Europaplein 586, 3526WL, Utrecht.
Acknowledgements
First I would like to express the most gratitude to my supervisor drs. Marij Hillen at the AMC, in charge
of the currently ongoing larger research about trust and communication together with dr. Ellen Smets,
who has collaborated in and executed most of the experimental manipulations and data collection.
Furthermore, she has provided elaborate feedback to the paper as it was written. Without her faith and
support, it would not have been possible to finish this thesis. Further thanks go to my supervisor dr.
Gerly de Boo at the UvA, who has also provided feedback, checked the research on its requirements
for the master and provided comments on the paper where necessary. Specials thanks go to my
mother and sister for their emotional support and to my friends, among whom especially to Bart
Tuinman for his everlasting optimism and Inge Ploegmakers for her discipline and relativism. The
times during which I have written this thesis have been trying and these attachment figures provided
the safe haven from which it was possible to explore.
2
Index
Page
1. Introduction
4
1.1 Trust and communication
4
1.2 Attachment theory
5
1.3 Research questions
6
1.4 Hypotheses
7
2. Methods
8
2.1 Sample
8
2.2 Experimental manipulation
8
2.3 Questionnaires
9
2.4 Procedure
10
2.5 Research design
10
2.6 Power analysis
10
2.7 Data analysis
11
2.8 Multilevel models
11
3. Results
13
3.1 Manipulation check
13
3.2 Main analyses
15
4. Conclusion and Discussion
18
5. References
23
3
1. Introduction
Trust is essential in human relationships. It is impossible to keep every important thing safe without
sometimes leaving it to the care of others (Gordon, Street, Sharf, Kelly & Souchek, 2006). In the
medical setting, there is a great potential for trust (Baier, 1986; Hall, 2001). The patient-physician
relationship is an asymmetrical one, because patients are ill and in a vulnerable position, in which they
cannot help themselves but instead have to rely on the physician to have sufficient knowledge and
expertise to help them (Salmon, 2009). The patient thus often needs to trust the physician (Pellegrino
& Thomasma, 1993). Especially for patients dealing with cancer, a chronic and life-threatening
disease, where treatment is often invasive and uncertainty is abundant, trust in the physician might be
almost unconditional (Mechanic & Meyer, 2000; Salkeld, Solomon, Short, & Butow, 2004). In
oncology, patients have to put their most valuable possession, their life, in hands of the doctor.
Trust in the physician can be defined in multiple ways (see Hillen, de Haes & Smets, 2010 for
a review). However, in the current research, trust in the physician will be defined as patients
optimistically accepting the vulnerable situation they find themselves in, and believing the physician
will care for their best interests (Hall, 2001).
Trust in the physician has been associated with several measures of good medical care. More trust is
associated with better treatment adherence (Safran et al., 1998; Trachtenberg, Dugan & Hall, 2005;
O’Malley, Sheppard, Schwartz & Mandelblatt, 2004), more satisfaction with care received (Hall et al.,
2002; Dugan, Trachtenberg & Hall, 2005), more disclosure of relevant information and greater
continuity in care (Kao, Green, Davis, Koplan & Cleary, 1998). Trust has even been suggested to
underlie placebo effects and as such to mediate clinical outcomes (Hall, Dugan, Zheng & Mishra,
2001). Given the apparent importance of trust for effective medical care it is important to conduct
empirical research on how patients’ trust is established, especially in serious disease with often long
and aggressive treatments such as in cancer. However, few empirical studies have investigated
patient trust in an oncology setting and the factors that contribute to that trust (Pearson & Raeke,
2000). Moreover, most research on trust in the physician thus far is cross-sectional, instead of
experimental. This limits the conclusions of these papers, as causal inferences about the antecedents
and consequences of trust cannot be made.
1.1 Trust and communication
Physician-patient trust has to develop quite quickly at the onset of the relationship because of the
vulnerable situation where the patient is in. When a patient falls seriously ill, there is not always
enough time for trust to develop through repeated interaction. Therefore, he or she has to make a
judgement of trustworthiness of their physician relatively quickly. Previous research has found only
weak associations between the length of a doctor-patient relationship or the total number of visits with
trust (Kao, Green, Zaslavski, et al. 1998; Safran, Kosinski, Tarlov, et al. 1998). This seems to indicate
that patients form their impressions relatively quickly and that trust does not depend greatly on how
well patients know their doctors (Hall, Dugan, Zheng & Mishra, 2001).
4
It is important for the current research to realize that both actors in the dyad can influence patientphysician trust. Both characteristics of, and communication by the physician, as well as characteristics
and preferences of the patient are of importance when trust is concerned (Salmon, 2009). Patient
characteristics such as age, gender, ethnicity and educational attainment might influence how they
tend to trust and perceive communication by the physician. On the other hand, physician
characteristics such as age, gender and ethnicity might influence the relationship. However, these are
not factors they can control. Physicians do have the possibility to establish trust through non-verbal
and verbal communication. Firstly, physicians can show they care for the patient by showing concern
and compassion (Hillen, Onderwater, van Zwieten, de Haes & Smets, 2011; Thom, 2001). Secondly,
they can also show technical competence, which the patient might assess by reputation or
interpersonal cues. A third quality often valued by patients is honesty, for example about possible
negative outcomes of a procedure. Fourth, fidelity, which means that the doctor seems to be acting in
the best interests of the patient, is a relevant aspect of communication (Mechanic & Meyer, 2000).
These factors would be expected to increase trust, although there is not much correlational evidence
to support this. Moreover, to date, no experimental research has been done to examine the relation
between physician communication and patient trust.
Turning to the other actor in the dyad; because the ‘message’ is not an objective entity and
relationships are subjectively defined, the question is to what extent patients’ sense of relationship is
indeed ‘built’ by clinicians’ good communication or rather arises from patients’ own needs and history
(Salmon & Young, 2005). Especially in the oncology setting, in longer lasting contact where repeated
interaction can take place, patients’ own needs and previous experiences may eventually play an
important role.
1.2 Attachment theory
Patients have developed certain trust mechanisms over their lifespan. Attachment theory is a logical
starting point for understanding trust and dependence because it concerns people’s propensity to seek
relationships with individuals who can help them feel safe when they are vulnerable (Bowlby, 1998).
Although attachment theory cannot by any means provide a complete explanation of how patients
experience health care, it is a possible ‘lens’ through which one can understand patients’ experience
(Salmon & Young, 2005). In psychological theory, an ‘attachment style’ is defined as a consistent and
enduring pattern of how an individual relates to people when in a dependent relationship. The concept
originates from Bowlby’s attachment theory (Bowlby, 1969), which proposes that people form mental
representations of themselves and others during childhood by interacting with attachment figures. It
also proposes that these initial relationships keep influencing cognitions, affect, and behaviour in
future close relationships. There is evidence that the attachment styles frequently observed in children
are maintained throughout adulthood (Waters & Hamilton, 2000; Roisman, Collins, Sroufe & Egeland,
2005). Bowlby argued that adults also rely on attachment at times of vulnerability and noted that, in
adulthood, the focus of attachment shifts from parents to romantic partners or close friends (Bowlby,
1988). Following Bowlby’s theorem, Ainsworth, Blehar, Waters and Wall (1978) made a typology of
attachment styles that include a secure style, defined by comfort with closeness and interdependence,
5
and two types of insecure styles: avoidant, defined by insecurity about others’ intentions and
preference for distance, and anxious-ambivalent, defined by a fear of being rejected and constant
proximity- and reassurance-seeking behaviour. Since the initial typology, several models have been
proposed that try to capture attachment (e.g. Collins & Read, 1990; Griffin & Bartholomew, 1994;
Feeney, Noller & Hanrahan, 1994). For example, Hazan and Shaver (1987) followed the same
typology as Ainsworth and colleagues, but found it difficult to capture people in one of these
categories, as many people displayed a mixture of attachment styles. After a comparison of these
models in factor analyses (Kurdek, 2002; Brennan, Clark & Shaver, 1998) there is now a relative
consensus that adult attachment consists of two dimensions, namely attachment anxiety and
attachment avoidance (Brennan et al., 1998). Being subjected to a serious illness like cancer is likely
to activate the attachment system. Illness is a bodily threat and hospitalization involves novel
environments, the need to trust strangers and separation from significant others (Hunter & Maunder,
2001). Assuming this crisis activates the attachment system, patients’ trust in their physician might be
dependent on their attachment style. Moreover, patients’ attachment style might influence how they
perceive their physician’s communication, and how this communication impacts on trust.
1.3 Research questions
The question in this research is threefold. The main question will focus on the aspects of
communication by the oncologist that may have an influence on cancer patients’ trust in the oncologist
– 1) do patients have more trust in their physician if he communicates more a) care, b) competency or
c) honesty, compared to standard conditions? Secondly, this research will look at trust as something
that can be inherent to patients’ personality and previous experience, investigating first if patient
characteristics such as age, gender and education influence the intensity of trust and then 2) if
patients’ attachment style predicts higher or lower trust in the physician. Thirdly, it is researched 3) if
attachment style is a possible moderator between communication by the oncologist and subsequent
trust in the oncologist – is the effect of communication style (care, competency, honesty) on trust
stronger or less strong, depending on the attachment style of the patient? The model tested in this
research will thus look like the figure below.
Attachment style of the patient;
- Avoidance
- Anxiety
3
Standard or enhanced
communication by the physician;
- Care
- Honesty
- Competence
1
2
Trust in the
physician
Figure 1. Hypothesized model, where the physicians’ communication is hypothesized to influence
trust, attachment style of the patient predicts trust and attachment style of the patient moderates on
the impact of the different communication approaches on trust.
6
1.4 Hypotheses
With regard to the main research question it is hypothesized, based on the literature on trust (Hillen,
Onderwater, van Zwieten, de Haes & Smets, 2011; Thom, 2001; Mechanic & Meyer, 2000) that
enhanced care, honesty or competence, communicated by the physician, will yield higher patient trust
than a standard consult. Factors that cannot be manipulated - age, gender, educational attainment
and ethnicity of the patient have been found to have inconsistent, weak or no relationships to trust
(Kao, Green, Davis, et al. 1998b; Thom, et al., 1999; Pescosolido, Tuch & Martin, 2001). Therefore the
relationship between these background characteristics of the patient and trust in the physician will be
explored. Regarding the second research question it is hypothesized that patients exhibiting a more
avoidant attachment style will have less trust in the physician, because a difficulty to trust is inherent to
the definition of avoidant attachment (Hazan & Shaver, 1987). Moreover, avoidantly attached
individuals are less likely to seek security and proximity to close others, whereas people with anxious
attachment styles are focused on security attainment (Mikulincer, 1998; Hazan & Shaver, 1987). It is
therefore hypothesized that avoidant attachment (with high scores signifying more avoidance) and
trust are negatively correlated to one another, whilst anxious attachment and trust would be positively
correlated.
With regard to the third research question it is hypothesized that for patients with higher
attachment anxiety, the positive correlation between the communication of care and trust in a
physician will be stronger. A patient who scores higher on attachment avoidance, however, might be
more likely to seek control (Mikulincer, 1998) and rebuke attempts at empathy (Hunter & Maunder,
2001). Therefore it is hypothesized that higher scores on attachment avoidance are associated with a
weaker positive relationship between the communication of care and trust. Besides that, enhanced
honesty could give a more avoidantly attached individual a feeling of a more strictly professional
relationship between them and the physician and thus providing safety to trust. Therefore the positive
relationship between honesty and trust might be stronger for patients with high attachment avoidance.
On grounds of the theoretical considerations above, the hypotheses are formulated as follows:
Hypothesis 1: The connection between communication and trust:
Enhanced communication of care, honesty and competence by the physician lead to more patient trust
than a standard amount of care, honesty and competence.
Hypothesis 2: Attachment style and trust:
a) Having a more avoidant attachment style leads to less trust in the physician than having a less
avoidant attachment style.
b) Having a more anxious attachment style leads to more trust in the physician than having a less
anxious attachment style.
Hypothesis 3: Attachment style moderates between communication characteristics and subsequent
trust.
(a) Enhanced caring communication will have a stronger effect on for patients with high
attachment anxiety.
(b) Enhanced caring communication will have less effect on trust for patients with high attachment
avoidance.
7
(c) Enhanced honest communication will have a stronger effect on trust for patients with high
attachment avoidance.
2. Methods
2.1 Sample
Patients were recruited via three channels. Firstly, announcements were placed in newsletters of all
patient-associations of the Dutch Federation of Cancer Patient-organizations (NFK). Patients
interested in participating were requested to apply. Secondly, patients of the departments of
radiotherapy and oncological surgery of the AMC were contacted via direct mailing of a recruitment
letter. Thirdly, cancer patients treated at the surgery and oncology department of the Deventer
Hospital (a regional non-academic hospital) were invited to participate by a physician or nurse.
Inclusion criteria were: a) informed consent; b) having been treated for, or currently in treatment for, a
malignant disease; c) a life expectancy of more than six months; d) age over 18 years. Excluded were
patients with a) insufficient mastery of Dutch and b) a serious cognitive disorder.
2.2 Experimental manipulation
In a qualitative interview-study performed by Hillen et al. (2011), elements considered essential by
cancer patients’ for trust in their oncologist were identified. The most crucial elements for trust were
their perception of the oncologist’s caring, honesty, competence and fidelity behaviour. In the
subsequently constructed ‘Trust in Oncologist Scale’ (TiOS), these dimensions were incorporated and
validated (Hillen et al., 2012). Because of practical limitations, it was decided to use only three of the
four dimensions of trust for the present study. The three dimensions considered most tangible and
best possible to manipulate were a) caring, b) honesty, and c) competence. Next, data from the
qualitative study was re-examined to investigate how patients ‘operationalized’ these dimensions, i.e.,
what communicative behaviours they judged as especially indicative of the oncologist’s competence,
honesty or caring attitude. These three dimensions would be manipulated in the script.
After transcribing audio-recorded consults of three different oncologists at three different hospitals, a
script of an ‘average’ consultation was developed, containing as much of the real conversations as
possible. The conversation in the video is between a male surgeon and a (middle-aged) patient, both
played by professional actors. The patient in the conversation has been diagnosed two weeks earlier
with colon cancer. After the diagnosis, tests have been performed to see if the cancer has spread. The
patient was referred to the surgeon to discuss the treatment options. In their first conversation they
have decided to operate the colon. The video shows the second conversation, where they discuss the
specifics of this operation. Two versions were made; one with a female patient and one with a male
patient, to maximize the ability of participants to identify with the patient.
To create manipulations of enhanced care, honesty and expertise, small adaptations were made to
the standard script. For each of these elements, the adaptation consisted of two or three small
additions to the standard consultations. Caring behaviour is demonstrated by the surgeon reacting on
a cue of the patient regarding a concern about the spreading of cancer, exploring the patients concern
about the possibility of colostomy and indicating that he is always available for further questions.
8
Enhanced honesty is demonstrated by the surgeon introducing possible side effects with the wish to
fully inform the patient of all possible outcomes and stressing his inability to rule out metastasis with
complete certainty. Demonstration of competence was enhanced by the surgeon indicating to be upto-date on recent research literature and by stating that he is specialized and very experienced with
this particular operation. These adaptations to the script were combined in a 2 x 2 x 2 factorial design.
As a result, a set of eight different versions of the standard video recording was made with a male
patient and eight versions with a female patient. The versions are identical (the same footage was
used) except for the manipulations. Several experts commented on the scripts, resulting in small
adaptations.
Figure 2. Eight different versions of the video: underlined quality of communication indicates enhancement, as
opposed to standard communication.
2.3 Questionnaires
Adult attachment was measured with the ‘Experiences in Close Relationships scale, short form’ (ECRSF, Brennan et al., 1998; Wei, Russel, Mallinckrodt & Vogel, 2007), a twelve item self-report measure
with a seven point Likert response scale ranging from 1 (disagree strongly) to 7 (agree strongly). Point
4 on the scale is anchored by neutral/mixed. Participants rate how well each statement describes their
typical feelings in close relationships. Higher scores indicate higher attachment anxiety and avoidance,
respectively. For this research, the term ‘partner’ was changed into ‘people close to me’, in order to
measure a more general kind of attachment. Furthermore, the English version of the ECR-SF was
translated into Dutch by means of forward-backward translation involving two forward, and two
backward translators. Where possible, previously translated items of the Dutch ECR (Hinnen,
Sanderman, & Sprangers, 2009) were used. The ECR-SF created and validated by Wei et al. (2007),
has six items pertaining to Avoidance (e.g. ‘I want to get close to my partner, but I keep pulling back’)
and six items measuring Anxiety (e.g. ‘I worry that romantic partners won’t care about me as much as I
care about them’). Internal consistency was found to be acceptable with coefficient alphas of .78
(anxiety) and .84 (avoidance) in a college sample. Test-retest reliabilities over a three week interval of
the six-item Anxiety and Avoidance subscales were relatively stable with r = .82 and r = .89,
respectively. Next, discriminant validity was measured in additional studies by Wei et al. (2007).
Attachment anxiety as measured by the ECR-SF was positively associated to excessive reassurance
seeking and emotional reactivity. Attachment avoidance was positively associated with emotional cutoff (a deactivating emotional style) and negatively associated with fear of intimacy and comfort with
self-disclosure. Finally, both anxiety and avoidance were positively correlated to depression, anxiety,
interpersonal distress, loneliness and psychological distress, consistent with earlier research (e.g.
Lopez & Brennan, 2000; Wei et al., 2004, 2005; Fuendeling, 1998).
9
Trust in the observed oncologist was measured with the ‘Trust in Oncologist Scale’ (TiOS, Hillen et al.,
2012). This measure includes 18 items and is designed specifically for cancer patient populations. An
example of an item is ‘Your doctor strongly cares about your health’, to be answered on a 5-point
Likert scale (1 = strongly disagree to 5 = strongly agree). Four items were negatively phrased. An
overall trust score (range 1 - 5) is obtained by averaging the responses, with higher scores indicating
higher trust. The TiOS has good reliability (α = .92). It measures four subscales; Competence (α =
.65), Honesty (α = .75), Fidelity (α = .87) and Caring (α = .73), that had inter-item correlations ranging
between .2 and .6. Test-retest reliability for the total score was high, rs = .93. Construct validity is
good, as overall trust was positively associated to satisfaction, willingness to recommend the
oncologist to others, trust in healthcare, and number of consultations, as would be expected by
findings in earlier research (e.g. Hall et al., 2001, 2002; Carpenter et al., 2009). The items were
adapted for this study so they referred to the observed physician instead of their own physician.
At the start, patients also filled in the TiOS in order to measure trust in their own physician, in order to
check for possible differences between their own physician and the physician in the video.
In order to be able to check the manipulation for effectiveness, items were added asking whether
subjects thought the physician seemed caring, honest or competent. Another item was added asking
whether subjects thought the consultation to be realistic, on a scale from 1 (“not realistic at all” to 10
“very realistic”). Also, to check whether observation order influenced trust because of familiarity with
the doctor in question, an item was added asking whether subjects trusted the physician in the first or
in the second video more.
2.4 Procedure
After subjects had agreed to participate in the research, an appointment was made by telephone for
them to come to one of eight hospitals that was located closest to them. They were given a short
description of the research and what they were supposed to do. Participants were told specifically that
this research was not about their own physician, but about the videos. Some were unavailable or
chose not to participate.
After agreeing, they were sent an information letter, which included the route to the hospital and the
specific time and date of their appointment. Testing would take about one hour and fifteen minutes,
including watching of two videos, two sets of questionnaires and a short break in-between. Also, they
answered questionnaires concerning their socio-demographical information, information about their
treatment and the ECR-SF before the video (T0) and the TiOS before and after the first video (T0, T1)
and the TiOS after the second video (T2). The DVD’s were shown on a flat-screen television in a room
resembling a normal doctor’s office. The versions that were shown were randomly selected out of the
8 possible versions (see Figure 2 above). Participants were asked to sign an informed consent form at
the beginning of the first questionnaire and were informed that at any time they had the possibility to
cease further participation. Finally, they were given a gift certificate at the end of the research and
were asked if they wanted to be informed about the results of the research. The AMC ethical
commission has approved this procedure and research.
10
2.5 Research design
A randomized experimental study comprising a 2 (standard versus enhanced competence) x 2
(standard versus enhanced caring) x 2 (standard versus enhanced honesty) factorial design, using
standardized video-recorded consultations. This design follows earlier studies that have investigated
the influence of physician-patient communication on patient outcomes (Swenson et al., 2004; Fogarty,
Curbow, Wingard, McDonnell & Somerfield, 1999; Dowsett et al., 2000).
2.6 Power analysis
In this study 345 subjects were included who each watched two videos, resulting in a total number of
690 observations. In order to calculate the effect size that could be achieved with such numbers in a
linear multiple regression analysis, the number of observations had to be corrected for the fact that the
data was nested. The number of independent observations was calculated using the ‘design effect’
(Bell & McKenzie, 2012), where the total number of observations (N = 690) was divided by 1 + the
correlation between TiOS scores and observations 1 and 2 (rs = .65), resulting in 418 independent
measurements. Using the statistical program G*Power (Faul, Erdfelder, Buchner & Lang, 2009) it was
calculated that with an alpha of α = .05 and a power of β = .8 and a total number of 12 predictors
(three communication styles, three background variables - age, educational attainment and gender two variables pertaining to attachment, three interactions and one variable controlling for the order in
which participants watched the videos), the minimal effect size that can be found in the complete
2
model is f = 0.04, which is small (Cohen, 1988).
2.7 Data analyses
Socio-demographic descriptives of the research sample were summarized. Means and standard
deviations for the TiOS and ECR-sf scores were summarized. A manipulation check was carried out,
correlating the three experimental manipulations with patients’ perception of care, honesty and
competence demonstrated by the physician. Hypotheses were tested using both observations of each
patient to increase power. To account for the interdependence between the two observations a
stepwise multilevel regression model with random intercepts was performed using SPSS 20.0 (IBM
Corp., 2012). Missing data was accounted for using Expectation Maximization (Tabachnick & Fidell,
2000). Then, if necessary, responses to reversely phrased items were recoded to be able to calculate
sum scores on the separate questionnaires. Independent and dependent variables were standardized.
2.8 Multilevel models
Common multilevel models consist of a two-level structure that would entail, for example, clients
(Level 1) with the same therapist (Level 2), or pupils (Level 1) nested within schools (Level 2). In this
case however, two observations by a patient (the two videos; Level 1) are nested within persons
(Level 2). The most basic two-level model can be specified as two interrelated equations:
11
Yij= b0j + εij
(1)
and
b0j = b0 + uj
(2)
Equation 1 is the microequation and pertains to observations: The response, the amount of trust in the
observed physician as a score i in person j, is a function of the mean level of trust in the observed
physician in each of the j units plus a residual unaccounted for variation at Level 1 between
observations. Equation 2 is the macroequation and pertains to individuals: The response, the mean
trust score in unit j, is a function of the overall mean level of trust across all units plus a residual
unaccounted for variation at Level 2 between individuals. The intercept (intrinsic variation between
individuals) is assumed to be random, which adds an error term to the intercept b0 whereas the
variance of the slopes is assumed to be fixed - the direction of change in trust by the experimental
manipulation is assumed to be similar over individuals. The two equations can be combined into a
multilevel model including random intercepts:
Yij = b0j + (uj + εij)
b0j = b0 + uj
(3)
This so-called null model contains no independent variables (yet) and trust in the observed physician
depends only on the mean score of trust over both observations in all persons and a differential for
each person and for each observation. These two differentials are summarized in two variances,
var(u0j) and var(εij). Consequently, trust is summarized in three parameters: the overall mean, the
variance between individuals and the within person, between-observations variance. The null model
simply allows the variance to be separated into each level, but the model can be extended to include
independent variables for both observations and persons. If these variables are important
determinants of the trust in the observed physician, their inclusion in the model would lead to a
reduction of the residual variance between individuals. The goodness-of-fit was assessed by the loglikelihood statistic, which is a measure of error or unexplained variation. A smaller log-likelihood
statistic indicates a better fit of the model (Field, 2007; Elovainio, Kivimaki, Steen & KalliomakiLevanto, 2000).
In the present study, six models were constructed, first adding background characteristics that
have previously been found to influence trust: age, gender and education (e.g. Kao, Green, Davis, et
al. 1998b; Thom, et al., 1999; Pescosolido, Tuch & Martin, 2001). Only ethnicity was excluded
because of a lack of nationalities in the sample. After adding these background characteristics,
independent variables were added step by step, a method recommended by Raudenbush and Bryk
(2002) and Twisk (2006). There was no strict elimination of variables based on significance for their
possible small contributions and seeing as the influence of those variables can change as other
variables are included. Each resulting model thus includes all the variables of the previous steps.
12
Model 1. At first, besides the fixed intercept for trust in the observed physician, random intercepts on
Level 2 (individuals) were added, which means individuals’ baseline scores are allowed to vary.
Model 2. Second, to account for the possibility that observations might be influenced by the order in
which the two videos were viewed, the observation order was included.
Model 3. Then, background variables or characteristics of the individuals were added; gender, age in
years and level of education (eight possible educational levels, from no education to a university
degree). These variables were added to explore possible correlations of basic patient characteristics
to trust and to increase internal validity.
Model 4. In the fourth model we tested whether enhanced care, competence and honesty expressed
by the oncologist would positively influence trust in the observed physician (hypothesis 1).
Model 5. In the fifth model it was tested whether attachment anxiety and attachment avoidance of the
patient influenced trust in the observed physician (hypothesis 2).
Model 6. In the sixth and final model we tested whether attachment style indeed moderated trust as
hypothesized (hypothesis 3). The three expected interactions were added, respectively attachment
anxiety x enhanced care, attachment avoidance x enhanced honesty and attachment avoidance x
enhanced care.
3. Results
The socio-demographic makeup of the sample is shown in Table 1. The final sample contained 345
subjects, of whom 51.6% women and 48.4% male. The mean age was 61.3 years (SD = 10.6). There
was little variation in ethnicity. About half of the patients were highly educated – 47.2% studied HBO or
WO, and almost all except 3.1 % had some form of education after primary school.
There was a great variety in the sample concerning primary cancer site.
3.1 Manipulation check
Generally, people considered the consultations to be moderately realistic (M = 6.24, SD = 2.3, on a
scale from 1 (“not realistic at all”) to 10 (“very realistic”)). A significant majority of the subjects, 65.3%,
tended to trust the doctor in the second video more than the doctor in the first video. Enhanced caring
was positively correlated to the observed physician seeming caring (r = .17 ; p < .001). Enhanced
competence was positively correlated to seeming knowledgeable (r = .08 ; p < .05) and enhanced
honesty was significantly positively correlated to the doctor seeming honest (r = .10 ; p < .05). This
means the experimental manipulations were successful. Trust in the observed physician was relatively
strong (M = 3.65, SD = .73, range = 1 - 5), as was trust in the own physician (M = 4.21, SD = .59,
range = 1 - 5). Attachment avoidance had a mean score of 2.86 (SD = 1.10, range = 1 - 7), similar to
the mean score on attachment anxiety (M = 2.72, SD = .95, range = 1 - 7).
13
Table 1. Sample descriptives (N = 345)*
%
n
29-49
15
53
50-59
60-69
70-79
80-89
22
42
17
3
76
146
60
9
Male
48
167
Female
52
178
None / primary school
Secondary school / lower level
vocational school
3
49
11
168
College / university
48
166
Single
11
39
Married / living together / in
relationship
Divorced
76
263
7
25
Widower
5
17
Yes
78
267
No
22
75
Colon
Breast
23
23
80
79
Prostate
19
64
Gynaecological
7
26
Lymph Node
Bone Marrow
Head/neck
Other
7
5
3
17
25
17
11
57
Currently in treatment
Yes
Only check-ups
No
26
68
6
88
236
21
Ethnicity
Dutch
Other
98
1
339
5
Religion
No religion
Christian
Other
51
43
6
177
148
19
Socio-demographic
Age (years)
Gender
Highest education
Marital status
Children
Primary cancer site
*Note. Not all percentages add up to 100% due to missing data.
14
3.2 Main analysis
The successive fits of the models to the data, with their relative improvement in explaining variation
are shown in Table 2. Parameter estimates (b) including standard errors and confidence intervals for
the variables entered in each model can be found in Table 3. Including baseline variation between
individuals on Level 2, i.e., random intercepts, significantly improved on the null model (b = .66, SE b =
.06, p < .001) and remained highly significant in all subsequent models. This indicates that subjects’
initial amount of trust differs significantly. Observation order significantly predicted higher trust in the
observed physician F (1,344) = 11.6, p<.01, indicating that the patients reported more trust in the
physician observed in the second video than the one in the first video. Of the socio-demographic
variables entered in model 3, age was related to stronger trust (F (1,344) = 20.3, p < .001) whereas
patients with higher education reported less trust (F (1,344) = 9.2, p < .01). Gender did not predict trust
in the observed physician (F (1,344) = .30, p = .583).
Enhanced caring communication significantly produced higher trust in the observed physician
(F (1,443) = 48.3, p < .001). Also enhanced honest communication in comparison to standard
communication resulted in significantly higher trust (F (1,438) = 34.7, p < .001). Finally, enhanced
competent communication was also related to higher trust in the observed physician (F (1,427) = 12.4,
p < .001). The first hypotheses were thus confirmed.
Attachment anxiety was not related to trust (F (1,343) = 1.8, p = .183), but higher attachment
avoidance was related to lower trust (F (1,343) = 7.3, p < .01). However, this effect disappeared when
the interaction effect between caring communication and avoidant attachment style was added in the
subsequent model 6 (F (1,600) = .0, p = .893). The second hypothesis was thus rejected.
The interaction between enhanced care and attachment anxiety did not correlate to trust in the
observed physician (F (1,600) = .28, p = .594). The interaction between enhanced caring
communication and an avoidant attachment style did significantly correlate to trust F (1,449) = 5.3, p <
.05. The positive effect of caring communication on trust was weaker for patients with more avoidant
attachment styles (see Figure 3). This effect was significant at the p < .01 level, with a parameter
estimate b = -.13 (SE b = .05). Finally, the interaction between attachment avoidance and enhanced
honesty also significantly correlated to trust in the observed physician (b = -.11, SE b = .05, F
(1,469)=4.1, p < .05). Also here, when honest communication by the physician was enhanced, those
with a stronger avoidant attachment style had reported less trust in the physician. When the
communication was standard, this effect was smaller (see Figure 4). The first part of the third
hypothesis was thus rejected, while the other two parts were confirmed.
Table 2. Change in goodness-of-fit of successive models
178.00
Akaike’s Information
Criterion (AIC)
1779.46
<.01
1
11.45
1770.17
<.01
Model 3
3
35.77
1740.25
<.01
Model 4
3
90.53
1655.72
<.01
Model 5
2
8.88
1650.84
<.01
Model 6
2
11.43
1645.41
<.01
df change
χ change
Model 1
1
Model 2
2
p
15
Table 3. Stepwise Multilevel Regression Analysis
Model 1
Intercept
Random intercepts (level 2)
b
-.00
.66
SE b
.05
.06
p
ns
<.001
95% CI
-.10 - .09
.52 - .77
Model 2
Intercept
Observation order
Random intercepts (level 2)
-.23
.15
.64
.08
.05
.06
<.01
<.001
<.001
-.40 - -.07
.07 - .24
.53 - .78
Model 3
Intercept
Observation order
Random intercepts
Age
Gender
Education
-.31
.15
.57
.21
.06
-.14
.18
.05
.06
.05
.10
.05
ns
<.01
<.001
<.001
ns
<.01
-.66 - .04
.06 - .24
.46 - .70
.11 - .31
-.15 - .26
-.24 - -.05
Model 4
Intercept
Observation order
Random intercepts
Age
Gender
Education
Enhanced care
Enhanced honesty
Enhanced competence
-.77
.18
.60
.21
.06
-.14
.36
.30
.17
.18
.04
.06
.05
.10
.05
.05
.05
.05
<.001
<.001
<.001
<.001
ns
<.001
<.001
<.001
<.001
-1.12 - -.42
.10 - .26
.50 - .73
.11 -.31
-.14 - .27
-.23 - .05
.27 - .46
.20 - .40
.08 - .27
Model 5
Intercept
Observation order
Random intercepts
Age
Education
Gender
Enhanced care
Enhanced honesty
Enhanced competence
Attachment anxiety
Attachment avoidance
-.31
.18
.59
.22
-.17
.06
.36
.30
.17
-.04
-.11
.24
.04
.06
.05
.05
.10
.05
.05
.05
.05
.04
ns
<.001
<.001
<.001
<.001
ns
<.001
<.001
<.001
ns
<.01
-.78 - .16
.10 - .26
.49 - .71
.12 - .32
-.26 - -.07
-.15 - .26
.27 - .46
.20 - .39
.08 - .27
-.14 - .06
-.20 - -.03
Intercept
-.53
.22
<.01
-.97 - -.09
Observation order
.18
.04
<.001
.10 - .26
Random intercepts
.58
.06
.48 - .70
<.001
Age
.22
.05
<.001
.12 - .32
ns
Gender
.07
.10
-.13 - -.07
Education
-.16
.05
<.001
-.25 - .27
Enhanced care
.37
.05
<.001
.27 - .46
Model 6
Enhanced honesty
.30
.05
<.001
.20 - .40
Enhanced competence
.18
.05
<.001
.08 - .27
ns
Attachment anxiety
-.09
.06
-.20 - .02
ns
Attachment avoidance
-.01
.06
-.13 - .11
ns
Attachment anxiety x care
.08
.05
-.02 - .18
Attachment avoidance x care
-.13
.05
<.01
-.23 - -.03
Attachment avoidance x honesty
-.11
.05
<.05
-.21 - -.00
Note. b = parameter estimate of standardized variable, SE = standard error, sig.= significance
measured on the p < .05, p < .01 and p < .001 level, ns = not significant, CI = confidence interval
16
Figure 3 and 4. The interaction effect between trust in the observed physician and having an avoidant
attachment style. The effect of enhanced care and enhanced honesty in communication, respectively,
is different for those with a higher avoidant attachment style than those with a lower avoidant
attachment style. When caring communication is enhanced (the green line), a stronger avoidant
attachment style predicts lower trust in the observed physician. When caring communication is
standard, this effect is smaller. When honest communication is enhanced, trust is also lower for those
with a more avoidant attachment style than for those with a less avoidant attachment style.
17
4. Conclusion and discussion
The main aim of this study was to examine verbal communication by the physician and the effect on
patients’ trust in an oncological setting. It was expected that enhanced communication; in which the
physician would express more care and/or be more open and honest and/or would show more
technical competence than in a standard consultation, would lead to more patient trust. Also, it was
explored whether characteristics of the patient, among which age, gender and education would be
related to patient trust. The attachment style of the patient –avoidant or anxious- was expected to
moderate on the relationship between verbal communication by the physician and trust. More
avoidantly attached individuals were expected to have less trust in the physician than less avoidantly
attached persons. More anxiously attached persons were expected to have more trust in the physician
than less anxiously attached ones. Furthermore it was hypothesized that anxiously attached
individuals would report stronger trust in physicians communicating enhanced care. Those with more
avoidant attachment were hypothesized to have stronger trust in physicians communicating enhanced
care. Finally, patients with a more avoidant attachment style were hypothesized to have stronger trust
in the physician when he communicates more honestly.
The results support the first hypothesis of our research. In line with previous research (Hillen,
Onderwater, van Zwieten, de Haes & Smets, 2011; Thom, 2001; Mechanic & Meyer, 2000) we found
that if the oncologist communicated more care, this had a positive effect on the trust of the patient.
Furthermore, a physician who communicates more honestly, introducing possible side-effects and
owning to his inability to rule out a certain side-effect with complete certainty, has been found to
increase trust. This is in line with research claiming that most individuals desire from physicians all
information concerning possible adverse effects of prescribed medication and do not favour physician
discretion in these decisions (Ziegler, Mosier, Buenaver & Okuyemi, 2001). Also in line with previous
research (Hillen, Onderwater, van Zwieten, de Haes & Smets, 2011; Thom, 2001) patients reported
more trust in physicians that communicated more technical competence. Mechanic and Meyer (2000)
found that this kind of competence was often assessed by reputation or interpersonal cues, however
this research shows that the physician simply indicating to be up-to-date on recent research literature
and stating that he is specialized and very experienced with a particular operation can already
increase trust.
Our finding that oncologist communication positively influences patient trust is quite relevant for the
medical field, as trust is linked to several measures of good medical care such as better adherence to
treatment (Safran et al., 1998; Trachtenberg, Dugan & Hall, 2005; O’Malley, Sheppard, Schwartz &
Mandelblatt, 2004), more satisfaction with care received (Hall et al., 2002; Dugan, Trachtenberg &
Hall, 2005), more disclosure of relevant information and greater continuity in care (Kao, Green, Davis,
Koplan & Cleary, 1998). It underlines the importance of the communication by the physician. Relatively
‘simple’ improvements on a standard consultation could be sufficient for increasing trust. For example,
a physician reacting on a cue of the patient regarding a concern, exploring a concern and indicating
18
that he/she is always available for further questions (the manipulation in the ‘enhanced care condition’
of this research) is already sufficient to increase trust.
For the most part, patient characteristics have not always shown to be strong predictors of trust. Most
demographic variables in previous studies were found to have inconsistent, weak, or no relationships
to trust (Kao, Green, Davis, et al. 1998b; Thom, et al., 1999; Pescosolido, Tuch & Martin, 2001). This
is except for age, which has been found positively related to trust in previous studies (Thom et al.,
1999; Pescosolido, Tuch & Martin, 2001; O’Malley et al., 2004). We replicated this effect. The effect of
age may arise from greater contact with physicians. Older patients have a greater likelihood to have
more physical ailments and thus to have seen their physician more often. Repeated interaction (and
possibly more positive experiences with health-care) are likely to increase trust (Pearson & Raeke,
2000). Furthermore, it could possibly be explained as a generational effect. Some socio-medical
researchers have suggested that the “public’s view of doctoring” has shifted considerably (Pescolido,
Tuch & Martin, 2001), moving from the “unquestioning acceptance of physician authority” to a more
“consumerist” stance accompanied by a questioning and bargaining approach to medicine, physicians,
and the medical encounter (Lavin et al., 1987). Younger individuals were already found to be more
negative toward the authority of physicians in 1983 (Haug & Lavin, 1983). With the advancement of
modern technologies such as the Internet, this is likely to have grown. The Health Information National
Trends data (Hesse et al., 2005) show a large shift in the manner in which patients consume health
and medical information, with more patients looking for information online before talking with their
physicians. Younger patients are likely to adopt more critical attitudes towards physicians in light of the
multitude of information that can also be found elsewhere.
Besides age, we have also found that patients with lower educational levels reported greater trust in
the observed physician. Although education has not always has been found to be a significant variable
in predicting trust (Thom et al., 1999), the direction of this effect has been produced before (O’Malley
et al., 2004). A possible explanation of this effect could be that more education may leave patients
challenging physician authority more (Haug & Lavin, 1978). In support of this explanation Helmes,
Bowen and Bengel (2002) found that women with lower education and less knowledge preferred
leaving the decision of genetic testing for breast cancer risk up to their health care providers. Those
with higher education and more knowledge preferred to make up their own minds.
Gender did not significantly predict trust in any of the tested models. Also, it did not predict trust in the
patients’ own physician. This is in line with earlier research (Thom et al., 1999; Mikulincer & Nachshon,
1991; Fiscella et al., 2004).
The second hypothesis, which stated that attachment style would predict trust in the physician, was
not supported. Anxious attachment did not significantly predict trust in any of the models. Higher
attachment avoidance did significantly predict weaker trust, although this effect disappeared when the
interaction effects between avoidant attachment style and enhanced honest communication and the
interaction between avoidant attachment and enhanced caring communication were added. In
19
previous research attachment avoidance is a stronger predictor on several measures, such as distrust
(Carnelley et al. 1994) and dishonesty (Cole, 2001), than attachment anxiety. This could possibly be
explained by the working models that are implied in attachment theory. As suggested by Bartholomew
and Horowitz (1991), attachment can be categorized by a different combination of a negative image of
themselves and/or of other people. Those with more anxious attachment styles tend to have a
more negative image of themselves. Those with avoidant strategies in attachment are characterized
more by their more negative working model of other people. They could thus be inherently more
inclined to a negative sense of trust in other people. In anxiously attached individuals, in the case they
are threatened or their attachment system is activated, they strive to create intimate bonds and to
merge with the other (when it concerns relationships). This could be why trust is higher in these
individuals and does not differ significantly from those with less attachment anxiety.
It could be that attachment style was not a strong predictor of trust because the study design does not
involve a development of a relationship over time. Trust builds iteratively through experience and this
explains greater trust in long-term rather than short-term medical relationships (Kao, Green,
Zaslarslay, Koplan & Cleary, 1998b). Also, it is not their own treatment, but another patients’ consult
respondents are seeing. There is no face-to-face contact and thus no opportunity for personal (nonverbal) interaction (asking questions, reflecting, eye-contact).
Furthermore, the inherently impersonal nature of the videos means there is no need to trust as
there is with their own physician: patients do not need to have the same intention and determination to
trust this oncologist and may therefore respond differently than if they were the vulnerable patient in
need themselves. If they were the vulnerable patient themselves, the attachment system could
possibly also be activated more – as Bowlby (1982) has argued that attachment should be most
strongly triggered under conditions of distress.
In line with these arguments, we found that higher attachment avoidance strongly predicted
patients’ trust in their own oncologist, with whom they have presumably had repeated interactions and
possibly a more intimate relationship. Patients with anxious attachment styles also reported less trust
in their own physician than those with less anxious attachment, although this effect was smaller in
size. Unfortunately it is not possible to check for possible interaction effects concerning communication
by patients’ own physicians. Future research might focus on attachment styles and communication in
these real life relationships. Such research might give more information on the patient and physician
characteristics that influence patient trust over a longer time-span and with repeated interactions.
Even though attachment style on its own was not a predictor of trust in the final model, the interactions
were significant. This could possibly be explained by the fact that although the attachment need was
only moderately triggered under low-distress conditions and under the impossibility of interacting with
the other, their evaluation of the encounter was still influenced by their attachment style. Mechanic and
Meyer (2000) found that patients typically test their doctor’s responses against their expectations and
feelings about what would be most appropriate, to decide if they trust their doctor. These expectations
and evaluations about what would be most appropriate are likely to be influenced by attachment style.
20
The positive effect of enhanced care on trust was less strong for those with a more avoidant
attachment style. This is according to expectations. This means that patients with more avoidant
attachment patterns do not have a strong preference for physicians reacting on a cue of the patient
regarding a concern, exploring a concern, and stating that they are always available for further
questions. Refraining from or limiting these additions could fit the need of these patients.
The interaction between attachment avoidance and honesty and attachment avoidance and
caring communication completely explained the effect of attachment avoidance on trust. The positive
effect of enhanced honesty was less strong for those with higher attachment avoidance. This was
against expectations. It is possible that those with more avoidant attachment styles, have less trust in
a physician that utters more honest communication, because honesty of the physician – in this case,
introducing possible side effects with the wish to fully inform the patient of all possible outcomes and
stressing his inability to rule out metastasis with complete certainty – makes for a less controllable
situation. Their uncertainty about the situation and the threatening possible side-effects of a treatment
could activate stress and thereby, their avoidant patterns. Especially because avoidantly attached
individuals strive for more control in personal relationships (Mikulincer, 1998), they might be less
inclined to trust someone who admits they are only human (thus creating uncertainty). Where a more
securely attached individual could prefer open and honest, constructive communication, avoidant
persons have been found to rely on distancing strategies in relationships (e.g. ignoring the problem,
taking distance from partner), thus decreasing trust (Mikulincer, 1998).
Further research is necessary to investigate which kinds of communication patients with an
avoidant attachment style might prefer. It can be hypothesized that these patients cope better with less
uncertainty. A physician might thus try to create a secure situation, while communicating in a not too
intimate fashion, where the patient is respected in his or her independence and some feeling of
control. It could be difficult to decide up front which patient has which attachment style. If possible,
physicians could issue a short questionnaire or could ask one or two questions in that direction.
Physicians could also be aware of behaviour typical for avoidant attachment, such as distant, aloof
behaviour, the need for control and a strong focus on independence. It seems enhanced care,
honesty and competence is a suitable implementation for every consultation, but that those who are
more avoidantly attached, it might have less positive influence upon trust. It is thus recommended for
physicians to stay alert to those who are insecurely attached.
A limitation of this research is also one of the strengths of this research – the experimental
design. While it enhances the internal validity and thus the conclusions of this research, it decreases
the ecological validity. These results will still have to prove themselves valid in clinical practice. The
manipulation of communication style, not often performed in such a manner (videos) was successful in
that it measured what it intended to measure and lead to significant variance in reported trust.
This creates possibilities for use of this type of measure in the future.
Bensing and Verhaak (2004) published a review stressing the importance of research that can move
the field of clinical communication from a ‘one size fits all’ model to one in which communication is
tailored to the illness, the patient and the moment. The present study, including attachment style of the
patient, is only one step in this direction. Future research can focus increasingly on communications
21
skills of the physician; not only at the level of ‘skills’, but also at levels of cognition, emotion, and value
(Salmon & Young, 2005). Continued education of health care professionals and hospitals in
communication with their patients can have many health related benefits and these are often mediated
by patient trust. There are still many ways to improve the quality of communication in such a way that
patient trust can grow. More research in this area is necessary in order to further the progress and
development of the education and training of health care professionals.
22
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