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Clinically, such experiences can generate cognitive distortions driven by anxiety—and depression—that may impair the patient’s capacity to temper realism with the hope necessary to tolerate uncertainty and to choose wisely from available alternatives. 4,14 Moreover, the prospects for a supportive patient-physician alliance are undermined when the physician is seen by the patient as either untrustworthy or largely powerless to implement his or her own clinical recommendations and protect patient choices due to managed care pressure. The patient’s perception of physician trustworthiness may suffer, for example, when managed care drug formularies restrict the physician from prescribing a medication of choice. Even a trusting relationship, especially when it is founded on blind optimism,  can be destroyed by adversity together with perceived abandonment. As the patient’s distrust increases, responses can include such modes as “fight” (litigate), “flight” (drop out of treatment), or “freeze” (become numb, passive, demoralized, and unable to act effectively in the interest of one’s own health care). The resulting anxiety and depression can lead to a greater likelihood of dissatisfaction with medical care 9 and to an impaired capacity to act on that dissatisfaction by changing health plans. 10

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