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A Matter of Trust

Hendren, Elizabeth M. MD; Kumagai, Arno K. MD

doi: 10.1097/ACM.0000000000002846
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Trust is a fundamental tenet of the patient–physician relationship and is central to providing person-centered care. Because trust is profoundly relational and social, building trust requires navigation around issues of power, perceptions of competence, and the pervasive influence of unconscious bias—processes that are inherently complex and challenging for learners, even under the best of circumstances. The authors examine several of these challenges related to building trust in the patient–physician relationship. They also explore trust in the student–teacher relationship. In an era of competency-based medical education, a learner has the additional duty to be perceived as “entrustable” to 2 parties: the patient and the preceptor. Dialogue, a relational form of communication, can provide a framework for the development of trust. By engaging people as individuals in understanding each other’s perspectives, values, and goals, dialogue ultimately strengthens the patient–physician relationship. In promoting a sense of agency in the learner, dialogue also strengthens the student–teacher relationship by fostering trust in oneself through development of a voice of one’s own.

E.M. Hendren is chief medical resident, Department of Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada; ORCID: https://orcid.org/0000-0003-0905-4585.

A.K. Kumagai is professor and vice chair for education, Department of Medicine, University of Toronto, researcher, Wilson Centre, University Health Network, and F.M Hill Chair in Humanism Education, Department of Medicine, Women’s College Hospital and University of Toronto, Toronto, Ontario, Canada; ORCID: http://orcid.org/0000-0001-7088-0208.

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s website (https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=65), follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the December 2018 issue for submission instructions and for more information about this feature).

Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on trust in health care and health professions education.

Funding/Support: A.K. Kumagai would also like to acknowledge the FM Hill Foundation for generous support.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s website (https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=65), follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the December 2018 issue for submission instructions and for more information about this feature).

Correspondence should be addressed to Arno K. Kumagai, Department of Medicine, Women’s College Hospital, 76 Grenville Ave., Toronto, ON M5S 1B2, Canada; email: arno.kumagai@utoronto.ca.

Over the course of my medical training, the moments that have affected me the most were when a family expressed confidence in my ability to care for their loved one. It was then that my imposter syndrome faded a little. On the other hand, when there was a breakdown in communication, I felt useless. No matter what strategy I tried, it felt like I couldn’t find the right words to restore a patient’s trust. The most dreaded words a patient could say were, “Can I speak to a real doctor about this?”

—E.M.H. (unpublished personal reflection)

It is almost a truism that trust lies at the heart of the practice of medicine. The nurturing of trust has tangible benefits for both the patient and the physician.1 In contrast, its absence can lead to perceived resistance from patients, strained relationships, animosity, complaints, and ultimately ineffective care.2 However, trust is not just about patient outcomes. Developing trusting relationships with patients, learners, and colleagues is also nurturing to physicians and confers meaning and value to their work.

We do not, however, often stop and think about what constitutes trust. Trust is relational, that is, it involves interactions between individuals. It consists of a decision—either implicit or explicit, fully voluntary or made necessary because of circumstance—by one individual to depend on another for the provision of goods or services. When relationships involve asymmetry in status and power, such as patient–physician or teacher–student relationships, individuals may experience vastly different consequences depending on which position they occupy in the hierarchy. For the more powerful party, broken trust may be an annoyance or inconvenience; for the more vulnerable, broken trust may have major negative effects on one’s career, health, or life.

Similarly, we do not devote much attention in medical education to the teaching of trust, a core aspect of the patient–physician relationship. Through trial and error and under the influence of the hidden curriculum, we expect medical trainees to learn on their own how to build trust with patients. Although some trainees succeed at this, others can become demoralized and vulnerable to burnout when they do not.

Trust is not inherent to the interactions between physicians and patients. It is often mistakenly assumed to be conferred on the physician along with degrees and professional credentials. This type of trust—referred to as “presumptive trust”3—is all too often lost through arrogance, negligence, and lack of concern. Trust must be earned and nourished. It is not a lasting contract between 2 parties; rather, it may be specific to an interaction at a single point in time. In this way, trust is dynamic: It is always possible to gain and lose trust as the interaction continues. Many physicians can reflect on distinct moments when an offhand comment or a poorly communicated diagnosis led to strain in their relationship with a patient.

Both nonverbal and verbal communication are key elements of developing trust. Verbal cues can vary, from the choice of words and medical jargon a provider uses to the decision to use a formal interpreter instead of asking a family member to assist in communication.4 Patients want their care providers to offer reassurance, to explicitly state that they are open to questions, and to demonstrate a willingness to learn from the patient.4

Time is another important element in building trust. Patients may have more trust in physicians who spend more time with them and with whom they have an enduring relationship compared with physicians who do not. In a study looking at trust in primary care providers, there was a positive correlation between time spent with the patient and the trust the patient had in the provider.5 However, it was unclear whether it was the time spent that mattered or what was done with that time that built the trust. Some clarification is provided by a more recent study in the inpatient internal medicine setting. In this interview study, patients preferred nonstructured communication where they felt that the provider showed a genuine interest over formal goal setting and structured activities.5

Trust, however, is not always between just 2 individuals, nor is building trust only a matter of improving communication skills, taking more time with the patient, or maintaining eye contact. In the relationship between the patient and the physician, the health care system, history, society, and social status often intervene. Judgments that form the foundation of trust between individuals are often influenced by deeply ingrained, unconscious biases regarding traits such as gender, race/ethnicity, socioeconomic class, sexual orientation, physical abilities, national origin, and age. Physicians often protect themselves against patients’ negative impressions and judgments by donning white coats, which, monogrammed with the physician’s name and credentials, symbolize authority, expertise, and power. A recent study by Petrilli et al showed that such attire is associated with perceptions of professionalism, competence, and trustworthiness.6 Interestingly, the white coat was more strongly associated with perceived capability when the physician was a woman than when the physician was a man, highlighting how unconscious gender bias can affect trust in the patient–physician relationship.6 The frequent assumption of authority as an innately masculine trait speaks volumes to the challenge female health care professionals face in establishing credibility.

In addition to the choice of clothing and inherent physical traits such as gender and ethnicity, there are perceived and objective measures of competence that play into the trust relationship. A physician’s confidence when delivering a medical opinion and the consistency of that opinion with expert consensus can build trust. Sometimes patients seek a second opinion if a physician’s confidence crosses the line into arrogance, and the patients may instead choose to trust a discordant view that aligns with their internal perceptions of their illness. Technical proficiency, particularly among procedural specialists, is a more objective measure of physician competence than confidence; however, although technical competence is a key dimension of physician behavior that builds trust, we would argue that this alone is insufficient. Qualities such as rapport, compassion, and honesty substantially contribute to the development of trust as well.7

A final, yet underemphasized, dimension is the trust the physician has in the patient. While a physician can don a white coat and stethoscope, patients have no such amulets of credibility to inspire confidence and trust. Societal stereotypes, racial profiling, and implicit bias all influence physicians’ trust in patients. From the patient’s perspective, trauma resulting from long histories of structural racism and systemic oppression, negative personal experiences from prior health care encounters, and mistrust of institutions and authorities based on lived experience compromise trust even before the physician steps into the room.8,9 It may therefore be neither fair nor just for physicians to automatically expect trust from patients or to withhold their own trust, labeling patients as “difficult” when history and society dictate alternative explanations for patients’ distrust.

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Trust in Medical Education

Just as trust occurs in the bond between patient and physician, trust also forms between learner and teacher as they interact in the workplace. Many institutions and specialties have embraced competency-based medical education (CBME), built on the principle of entrustable professional activities (EPAs) for assessing competence.3 A learner is considered entrustable for a particular task when a supervisor indicates that the learner can independently do that task based on direct observation. Entrustment is situational and is impacted by factors similar to those that affect the patient–physician relationship, such as the duration of the relationship between the teacher and the learner.10 Entrustment is coupled with the notion of formative feedback, which also involves credibility and trust. The learner must trust the teacher to give feedback free of bias, and the teacher must trust the learner to accept the teacher’s authority and credibility to assess and critique clinical performance. These interactions—direct observation, formative feedback, and entrustment—are extremely complex processes and are permeated with the challenges affecting any trust relationship as described above. In this context, the recent crucially important observation that, compared with feedback from male clinician teachers, feedback from female clinician teachers following an objective structured clinical examination is viewed as less credible by internal medicine residents11 makes the characterization of this approach as “objective” deeply problematic.

Learners may also possess characteristics such as appearance, gender, and race that may be perceived by some patients as more or less trustworthy. For example, on a medicine clinical teaching service, an older male medical student may be assumed to be the team leader, as the student fits a preconceived stereotype of what a doctor should look like. In contrast, a female trainee or attending physician often is mistaken for a nurse. This can introduce conflict and tension into a team-based work environment and leave trainees feeling demoralized and undervalued. Alternatively, many trainees and physicians from diverse ethnic backgrounds are mistreated by patients, who refuse to see them as equal to their peers because of stereotyping and prejudice.12

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Dialogue: A Tool for Building and Teaching Trust

Trust is not naturally bestowed by privilege but, rather, earned through hard work. Because trust is both dynamic and relational, it may be fostered by a form of communication that is neither declarative nor overbearing but, instead, is one that calls on individuals to engage themselves as human beings with one another. This form of communication is dialogue. Dialogue requires thoughtful, exploratory exchanges with the goal of enhanced understanding through the shared appreciation for the identities, backgrounds, values, and perspectives that each participant brings. Unlike discussions, which are goal or answer driven, dialogues open up new lines of questioning and new ways of seeing and knowing.13,14 When done well, dialogue shifts power dynamics from the vertical hierarchy of a discussion between a teacher and learner or between a physician and a patient to a more collaborative relationship in which the student or patient is seen as an expert in their own self and life, with an equal role in the conversation.13

From a practical sense, dialogue may be the most useful when disagreement arises in the patient–physician relationship. Teachers can guide learners to use a lack of perceived buy-in from a patient as an opportunity to reflect. The learner can be prompted to think about how they can more fully explore the patient’s values, priorities, and perspectives. Teachers may normalize these challenges to building trust by sharing their own experiences—both successes and failures—in nurturing and sustaining trust.

In the hard work of building trust, learners must be supported. It should be recognized, however, that even dialogue and other approaches, such as trauma-informed care,15 may not be sufficient to overcome the long histories of systemic racism and discrimination that a patient has experienced. Nonetheless, even in challenging situations, close listening, humility, and dialogue may create a small opportunity for greater understanding and concern.

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Bridging the Trust Gap

Although trust is essential to effective patient–physician relationships, it is largely left up to students to learn lessons about communication in an environment that is often ripe for misunderstanding and mistrust. Additionally, in an era of CBME and EPAs, learners have to adjust their actions to earn the trust of 2 parties: the patient and the preceptor. Furthermore, with the priority given to assessments these days, it appears as though the emphasis in education is to satisfy the requirements of the latter. Dialogue between physicians and patients and between teachers and students may offer a way forward toward mutual recognition and respect. It is from this soil that trust may grow.

On a final note, we would argue that the ultimate goal of entrustment in medical education is not the professional entrustment of a learner by a teacher but, rather, the development of a sense of trust in oneself and one’s own abilities and judgment. The trust that arises from within, from authentic engagement in learning, dialogue, and serving others, has a corollary: self-confidence, agency, and an overcoming of the impostor syndrome in embracing the challenges and joys of practicing truly person-centered care.

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Acknowledgments:

The authors would like to thank the Department of Medicine Group on Dialogical Teaching and Person-Centered Care for inspiring discussions.

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