Trust is one of the central features of patient-physician relationships. Rapid changes in the health care system are feared by many to be threatening patients' trust in their physicians. Yet, despite its acknowledged importance and potential fragility, rigorous efforts to conceptualize and measure patient trust have been relatively few. This article presents a synopsis of theories about patient trust and the evolution of methods to measure it. Clinicians, educators, and researchers interested in this area may find this information useful in practice and teaching. The gaps identified in our knowledge about trust can help target new efforts to strengthen the methodological basis of work to understand this vital element of medical relationships. J GEN INTERN MED 2000;15:509-513.

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In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care. Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation. In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways. Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs. Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled.

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