Dissertation Title:  "Trust and Agency: The Patient-Physician Relationship in the Era of Managed Care"

Trust is essential in social life. Interpersonal relationships are complex and often unpredictable, and as such, trust minimizes the cognitive and emotional hesitancy of individuals, groups, and communities to engage in mutually beneficial exchanges. Without some degree of trust, joint action and cooperation are limited by explicit contracts, while potentially beneficial social relationships fail to develop altogether, due to prohibitively high transaction and monitoring costs. Therefore, trust serves as an "efficient" catalyst that increases the likelihood of joint action and broadens the possibilities of social cooperation. Due to the central importance of trust as a social catalyst, it has been the focus of considerable scholarly interest among sociologists, psychologists, and economists. Despite this academic interest in the social value of trust, few attempts have been made to investigate, either conceptually or empirically, the "epidemiology" of this social good. Conceptual clarity and empirical research is especially lacking in social relationships where trust is seen as a fundamental component of a good dyad. One such social dyad is that between patients and their physicians, and the lack of academic inquiry into trust is that it has been taken for granted.

In Paper One of my thesis, the goal is to shed light on the complexities and nuances of interpersonal trust, with particular emphasis on the therapeutic relationship between patients and their physicians. Moving beyond the precepts offered by perspectives that characterize persons as self-interested agents or embedded moral beings, a dynamic model of interpersonal trust that does not characterize trust as an all or none phenomenon based on either a "market-based" or a "virtue-based" ethic is developed. In this model, patients and physicians are participants in an interdependent, but inherently asymmetric social dyad, where patients' trust in physicians is dependent on a "role-based" ethic of the medical professional.

In Paper Two, and following my explication of a more complete model of interpersonal trust, the development of a reliable and valid measure that is designed to assess patients' trust in their physicians is presented. Patient trust directly stems from the physician's role-based obligations to his or her patient. As a physician-confidant, I feel obligated to keep patient information confidential. As a physician-informant, I feel impelled to reliably inform patients of all relevant medical information. As a physician-craftsman, I feel accountable to provide patients with competent advice and care. As a physician-advocate, I feel bound to act in the patient's best interest, even at the risk of forgoing personal interests. Therefore, a scale of patient trust should capture these role-based aspects of a physician-professional.

In Paper Three, the goal here is to use the Patient Trust Scale in order to evaluate the impact of significant organizational changes in the health care system on trust in the patient-physician relationship. In this era of managed care, the influence of third parties, and more specifically the direct financial incentives imposed by health plans and insurers, on clinical decision making has raised concerns about physicians serving as double agents who have conflicting obligations to patients and health care organization. Therefore, the relationship between methods of physician reimbursement and patient trust is examined.