Patient perceptions of trust formation in the surgeon-patient relationship: a thematic analysis

Abstract

Objective

Trust is crucial to the success of any personal or professional relationship. Literature on trust in the surgeon-patient relationship has been largely explored through quantitative methodologies, primarily examining why trust may or may not exist. We aimed to qualitatively elucidate the mechanisms of how trust develops between otolaryngologists and their patients.

Methods

Patients were recruited by surgery scheduling staff following an outpatient visit where a decision had been made to proceed with surgery at a tertiary academic medical center. We used qualitative realist thematic analysis of phone interviews to explore participants’ (n=17) perceptions and conceptualization of trust formation within the surgeon-patient relationship.

Results

Thematic analysis revealed three themes regarding trust formation in the surgeon-patient relationship: 1) Trust Across Various Contexts; 2) Impact of Prior Knowledge; and 3) Interpersonal Connection during the Clinical Encounter.

Conclusion

An interpersonal surgeon-patient connection is crucial to the formation of trust. Trust is also influenced by surgeon and institutional reputation and witnessed surgeon interactions with the healthcare team.

Practice Implications

Patients perceive trust in a surgeon as carrying unique importance. To optimize conditions for trust development in this context, surgical care paradigms should promote meaningful preoperative interpersonal surgeon-patient relationships and positive surgeon and institutional reputations.

1. Introduction

Trust is crucial to the success of any personal or professional relationship. In healthcare, trust is associated with patient-provider communication, seeking and submitting to care, increased adherence to treatment recommendations, and/or remaining with and recommending a physician [1]. The attributes of physicians associated with trust can be grouped into domains of interpersonal communication (both conveying and receiving information), technical competency, and agency (also called fidelity, loyalty or fiduciary duty) [2]. These interrelated attributes are necessary to the practice of medicine, as trust is borne of conditions characterized by risk, uncertainty, and vulnerability, requiring an optimistic acceptance of vulnerability wherein the patient (truster) believes the physician (trustee) will care for his/her interests [3,4].

The attributes of interpersonal communication, technical competency, and agency are particularly salient in the practice of surgery as few patients would elect to proceed with surgery without a high degree of trust in their surgeon [5]. As surgery is distinct in the frequency and intensity of situations characterized by risk, uncertainty, and vulnerability, the development of trust in the surgeon-patient relationship could differ from other clinician-patient relationships [6]. Specifically, in order for surgeons to effect surgical goals, they must engender harm through invasive procedures, positioning patients to be in a situation of extreme vulnerability to and intimacy with their surgeon [5].

Despite the integral nature of trust in surgical practice, empiric evidence of how trust is developed and characterized in the surgeon-patient relationship is limited. Literature on trust in the surgeon-patient relationship explores the impact of surgical complications on trust and is focused on why trust may or may not exist, the majority of which is explored through normative or quantitative methodologies [3,5,7,8]. To better capture this complex relational experience, we used a qualitative approach to elucidate the mechanisms and components of how trust forms between otolaryngologists and their surgical patients. This information can have implications for surgical education, training, and patient care outcomes.

2. Methods

Qualitative realist thematic analysis of phone interviews was used to explore participants’ perceptions and conceptualization of trust formation within the surgeon-patient relationship. As the aim of this study is to explore perceptions of the factors that impact trust in the surgeon-patient relationship for patients that consented to surgery, the methods must facilitate an in-depth exploration of context, meaning, and interpretation of underlying influences while also providing participants the freedom to express ideas and describe complex social interactions, situations, and context in their own words. Thus, a qualitative methodologic approach, which allows for the pursuit of meaning rather than quantification, was chosen as it facilitates rich descriptions through open-ended questions rather than less descriptive information through close-ended questions. Interviews were conducted from February through June 2019. The University of Michigan IRBMED (HUM00156115) deemed the study to be exempt from formal review.

2.1. Sampling and Recruitment

Eligibility criteria stipulated surgical patients to be 18 years or older in an otolaryngology head and neck surgery department within a tertiary academic medical center. Convenience sampling was used. Patients were asked about interest in participation by surgery scheduling staff immediately following an outpatient clinic visit where a decision had been made to proceed with surgery. LK, who has experience with qualitative interviews and who is not a member of the patients’ care teams, contacted every interested patient by phone. Participants (n=17) provided verbal consent.

2.2. Data collection

All interviews were conducted prior to every participant’s scheduled otolaryngologic surgery. Demographic information was self-identified by patients. Qualitative interviews were conversational in style, following prompts from an interview guide (Supplementary Material) and informed by established qualitative methodology [9]. Interviews were conducted by LK, a senior medical student with experience with qualitative research who was not part of participants’ healthcare teams, digitally recorded and transcribed. De-identified transcripts were discussed by the authors to iteratively optimize the interview guide. Interviews ranged from 7 to 59 minutes (mean of 24 minutes).

2.3. Data analysis

Transcripts were thematically analyzed, using an inductive, open coding strategy as discussed in the six-step guide by Braun and Clarke [10]. Dedoose 8.2.14 software was used to organize and track coded data [11]. Initial codes were developed by LK and JF, a social worker, ethicist, and qualitative researcher who was not part of participants’ healthcare teams. Codes were finalized, and themes were generated in discussion with NDH and AGS, both head and neck surgeons. Thematic analysis necessitates themes to be patterned and relevant to the entire data set, unlike grounded theory which requires theoretical saturation to develop themes [10,12]. Themes were considered robust when they represented coherent and patterned responses across the entire data corpus central to the development of trust in the surgeon-patient relationship. Constant comparative method was used throughout the analysis to explore differences and similarities between different participant groups (i.e. participants who trust physicians implicitly or those who felt trust needs to be earned, and those that researched the surgeon ahead of time or those who did not, etc.) [13]. Seventeen interviews were sufficient to produce rich level of data, thus recruitment ceased [10]. A realist approach acknowledges that a clearer understanding of reality occurs when researchers are explicit about their own perceptions, assumptions, and biases, as separating the researcher from the phenomenon being studied is neither possible nor necessary [14]. Thus, throughout analysis the researchers regularly discussed the ways in which professional vantage points and previous knowledge could impact coding, analysis, and data interpretation and reflexivity was used to limit bias [15]. The Standards for Reporting Qualitative Research (SRQR) framework were used to report the study design, analysis, and results [16].

3. Results

Seventeen participants participated in this study and had a median age of 61 years (range, 21–82) (Table 1). Three participants did not complete all the questions; no participants withdrew. All participant data were used in the analysis. Thematic analysis revealed three major themes regarding trust in the surgeon-patient relationship: 1) Trust Across Various Contexts; 2) Impact of Prior Knowledge; and 3) Interpersonal Connection during the Clinical Encounter. Themes occurred across all participant groups. We illustrate each theme with quotes presented by theme (Tables 2–4).

Table 1.

Participants’ (n=17) demographic information

	Participants No. (%)
Race
White/Caucasian	17/17 (100)
Gender
Female	8/17 (47)
Male	9/17 (53)
Age
20–40	3/17 (18)
41–60	5/17 (29)
61–80	8/17 (47)
80–100	1/17 (6)
Surgical History
Yes	16/17 (94)
No	1/17 (6)
Prior surgery by current otolaryngologist?
Yes	3/17 (18)
No	14/17 (82)
Subspecialty
Head and Neck Surgery	5/17 (29)
Laryngology	9/17 (53)
Skull Base/Rhinology	1/17 (6)
Sleep Medicine	2/17 (12)
Trust in surgeon after meeting him/her?
Yes	16/16a (100)

^aOne participant did not answer the question

Table 2.

Trust Across Various Contexts Supporting Quotes

2.1: I think it [trust in the context of surgery] is quite a bit different [from trust in other contexts]. It’s always scary going in. You’re going to be unconscious; you’re going to be essentially helpless, unable to advocate for yourself, you’re not going to have a family member there to be able to advocate for you. I think it’s [trust] even more important than general practitioner or however setting because you have to completely relinquish control to that person. -P6

2.2: It’s the same [compared to trust in other doctors] ... The trust is same that I have in all of them... because I feel confident with them, comfortable. I feel like I can trust them... I think it’s very important [surgery compared to trust in general] because your life could be in a balance or something could go wrong with your surgeries or whatever, so you need to have real, complete trust. -P4

2.3: It’s [the role of trust] the same role as from a surgeon to a primary care provider. In that, if you don’t feel comfortable with that person, you don’t necessarily feel comfortable with the care that they think that their opinion of what needs to happen is trustworthy... I feel like surgeons [compared to trust in general] have a lot more riding on their shoulders than just on everyday trust in a person. The risks involved in what they do have a higher or more severe outcome, whether positive or negative. -P14

2.4: I would be a little more scared about the surgery... I am nervous about anything going wrong and having to suffer lifelong consequences of nerve pain or anything like that. ... but I feel like there’s potential for things in this particular surgery that could go wrong or whatever. -P17

2.5: It’s more important because, like I said, when you put yourself in a surgeon’s hands and he does surgery, you’re totally in his hands until he’s finished. Like in any other kind of life type situation, if you’re getting signs that “Maybe I should step back or maybe I should pull back some trust,” you can do that, you can’t do that. I meant you give it to him, and you come to whatever conclusion you come to, which is why he said to me, “Well, trust depends on the outcome,” and I said, “No, it doesn’t. [laughs] I meant that – He was saying, “Well, if it turns out good for you, you would think you were right to trust me and not—” No it doesn’t, “I trust you’re going to do your best,” and if you do your best and it comes out x, that doesn’t mean I shouldn’t have trusted you. -P11

2.6: I do feel some of my other surgeries have felt more like almost like an assembly line. All that doctor is concerned about is the one thing they particularly do. In fact, the whole gallbladder thing, I told him I was having some intestinal problems when I went for the pre-surgery meeting. He took it as a flu and said, “We can’t do surgery till we get rid of your fever” or whatever it was. It turned out that I had a necrotizing gallbladder, and I felt like he didn’t think of all the possibilities. He was only thinking about the one surgery he was going to perform, and so it wasn’t like I’m a whole being here. -P17

Abbreviation: ‘P’ indicates participant.

Table 4.

Interpersonal Connection during the Clinical Encounter Supporting Quotes

4.1: I said there wasn’t anything [any information about the surgeon] before I met him. It was just the one on one and the way he handled himself. -P1

4.2: I feel it’s [trust] very important [for deciding to have surgery]. Because I want to know that they’re not just going to do it because that’s their profession, they want to do it and make the money off of it, but that it’s what’s best for me. It’s going to be what’s going to provide me the best healthcare. -P14

4.3: ...but when she came in, she was warm and very nice, looked at me straight in the eye and talked to me. Was not overly rough or anything but talked to me not to the computer, not to the chart but actually talked to me. That made me relax a little bit. -P2

4.4: The fact that he seems to respect me as a person, not just a little specimen that he’s going to do something with. The fact that he’s interacting with me rather than - You know how some doctors are, “If you don’t want to listen to me, find someone you like listening to.” [laughs] Or, “If you don’t want to listen to me, then we’re not doing anything together.” -P11

4.5: Yes, I guess how he treated me. He treated me in a very humane way and not just, it wasn’t just get down and dirty “Let’s get this done.” He checked in on how I was doing when they did the biopsy, he explained a lot of things to me. -P17

4.6: Gosh. I actually do remember he was a very kind-hearted person. He seemed genuinely care about me ... making sure that I had my questions understood and I was able to very effectively communicate ... -P6

4.7: Yes. The fact that he explained everything, gave me options. He diagrams things to show, how things would work, whether it be the surgery for the deviated septum or the implant, how it worked, the pros and the cons of it. He explained everything. He didn’t rush. It wasn’t like, “Hey, I got another patient waiting,” whatever. He took his time. I liked him very much and I trust him very much right now. -P16

4.8: If their reviews were poor, unfair, andyou weren’t comfortable with the interaction going on, I would be fishing. I’d be going out looking for somebody else. -P3

4.9: With the other [surgeon] that I actually did not go with, walk in, went to the computer, started talking at the computer, didn’t even look at me, went to the chart and then told me right on up, “This is what we’re going to have to do.” Good to find out. I didn’t need that. I never looked back, Ijust felt very uncomfortable. -P2

4.10: ...it’s not a, “Here’s a person telling you what you need to do.” It’s a conversation around patient-center. It’s a collaboration with the patient and a physician. -P14

4.11: Just his knowledge. The fact that he is not just a surgeon but a sleep doctor and understood exactly what was happening with me. He even went so far as to tell me how many of these implants he has done. The implant itself is something relatively new over there and I’m not like the first one. But it’s not like he did thousands of them. He told me how many he’s done. He explained to me the success rates, not successful for everyone. He checked to make sure that it would, in fact, have a chance of improving it. He says there are times when an implant just wouldn’t help someone based on their medical condition. He went through all of that. -P16

4.12: One thing is that I know younger doctors do well, but I’m a retired teacher and I know how much experience means. When I look back on my first few years, you know it took a while. He’s all there and he’s very experienced. -P7

4.13: His success rate. The fact he told me he’s never hit a nerve or a vocal cord calmed my nerves down dramatically. -P9

4.14: ...and then having being medical myself and knowing a little bit about it, that everything that he’s saying that I know about is true to what I know. It lets me know that I do understand that he does know what he’s talking about for a lot of that too. -P4

4.15: I’ve got some bump in my neck and they’re going to take it out. -P1

4.16: I’m going to have an implant put in the left vocal cord of the voice box and the voice box repositioned. This is the outcome of previous surgery in [name of state] to remove a pocket in the esophagus, a diverticulum or whatever it was called. After that surgery, I could no longer talk, and I could no longer swallow. -P15

4.17: ...they’re going to take a polyp off of my throat. I had throat cancer 19 years ago. -P5

4.18: I would say I trust him fully. I know that they’re a great doctor. -P10

4.19: At this point, 100%. -P13

4.20: When it came down to the other members of the team, I figured if the team is strong, then she is strong and that if their team is kind of like ehh. I don’t...if her team is good, she’s good. Do you know what I mean? -P2

4.21: Maybe even subconsciously, a person would get a sense of how they interact with each other, and whether he is distanced from them because basically, you consider that surgeon the top of the hierarchy. If he seems to have good relationships with the other people that work with him rather than being distanced, that would be a good sign to me that they do an overall good job, that they have each other’s backs. -P17

Abbreviation: ‘P’ indicates participant.

3.1. Trust Across Various Contexts (Table 2, Supporting Quotes 2.1–2.6)

Participants discussed whether trust in the context of surgery was different than other clinical or general circumstances. They expressed that trust in the surgeon-patient relationship had exceptional weight and consequences but differed in their stance as to whether the nature of trust was different (2.1, 2.2). Those noting a difference cited uniqueness, gravity, vulnerability, invasiveness and risks associated with surgery (2.3). While several participants recounted that trusting a surgeon required a distinct leap of faith, other participants reported complete trust in doctors in general, or articulated that they believed those who pursue healthcare fields hopefully do so with the right intentions and thus are inherently trustworthy (2.4).

Some participants believed that ability to trust surgeons was dependent upon situation or outcome, while others did not (2.5). Situational dependence if present was influenced by the gravity of planned surgery and potential implications for a patient’s quality of life. Participants also noted from prior experiences that when the patient-surgeon interpersonal relationship is lacking, it may compromise quality of care (2.6).

3.2. Impact of Prior Knowledge (Table 3, Supporting Quotes 3.1–3.12)

Table 3.

Impact of Prior Knowledge Supporting Quotes

3.1: I was a little nervous because I never met her before. I didn’t know what her personality was really going to be a whole like... I was nervous. And the fact that it [surgery] was very I don’t know anything about. -P2

3.2: ...my [child] has recently been hired in [the] anesthesiology department as a nurse to oversee some of the data [and] has spoken with one of the anesthesiologists who knows my doctor well, and praised him, and told my [child] that he [surgeon] was really a good guy, and he did a good job and stuff, so that kind of added other sources to give me confidence. -P17

3.3: When I was reading up on his Google reviews, they were really good, so it wasn’t like there was even any bad ones. Everybody else had really good experiences with him. I thought I would too. -P9

3.4: I just had really good thoughts. I had heard he was really good. He’s probably one of the top ENTs in the state, and so I was very comfortable with him. -P9

3.5: Well like I said, you actually—If you do the research, you learn a little bit about these people. If you have multiple people, especially people that you trust that have told you, “Yes, this person is very good. They’re going to treat you well. They’re going to, they’ll be able to help you,” then you go in there trusting that person even though you haven’t seen them yet. -P2

3.6: Nothing. -P3

3.7: None [no prior knowledge]. -P1

3.8: I didn’t, really [know anything about the surgeon]...-P5

3.9: I’ve been happy with my treatments. There’s trust there from my personal experience. -P3

3.10: She was just very abrupt and didn’t, wanted me to follow their instructions exactly. You know but I had other issues when I looked up-- It was about osteoporosis; I have osteoporosis in my arm. The medications she was insisting that I take, and she was very insistent, can cause throat problems and I already have a vocal cord problem, you can tell from my voice. I didn’t want to follow those, so I went to another doctor. -P7

3.11: [Institution] has the reputation for being one of the best care centers for [name of state] and I’d rather come to a larger institution instead of a small-town hospital...I think that they are better equipped, and they are more people to consult on your individual cases and more coordination. -P12

3.12: I guess I just had a general have confidence in the university hospital and the doctors there. Although, I have met doctors there that I haven’t really felt comfortable with or liked very much. I expected to trust him before I went because usually [institution] doctors are trustworthy in there. -P7

3.13: It was like most of the doctors that I have from the U, which is why I usually choose [institution]. -P14

Abbreviation: ‘P’ indicates participant.

Participants varied in medical knowledge, medical and surgical histories, pre-visit awareness of their surgeon’s reputation and skills, and expectations for the initial face-to-face clinical encounter. For example, some participants were looking for general recommendations regarding their diagnosis, whereas others were hoping to leave the encounter with specific planned interventions. A few described being nervous and scared prior to meeting their surgeon for the first time, in addition to feeling worried about their prognosis (3.1).

There was diversity regarding level and sources of patients’ prior knowledge of their surgeon. The majority of participants had been referred to their otolaryngologist by other providers, family or friends. Some participants had personal medical connections who provided insights about their surgeon, while others used internet searches and online reviews to obtain information (3.2, 3.3). Participants reported that such information contributed to the formation of trust in their surgeon. The types of information gathered from these sources included the surgeon’s demeanor and level of experience, as well as general background information, such as credentialing (3.4, 3.5). On the other hand, some participants entered the office without any prior knowledge of surgical procedure and/or surgeon (3.6, 3.7, 3.8).

Participants’ past healthcare experiences, both positive and negative, informed their perception of trust in the surgeon-patient relationship (3.9). Participants recalled previous negative experiences both in and outside of surgical disciplines, such as: a distressful clinic experience, not involving the patient in decision-making, or generally poor bedside manner (3.10). Institutional reputation was also a factor in pre-visit feelings of trust. A positive institutional reputation also influenced some participants’ willingness to trust future providers within the same health system and operated as a buffer to mitigate negative prior encounters with specific individuals (3.11, 3.12, 3.13).

3.3. Interpersonal Connection during the Clinical Encounter (Table 4, Supporting Quotes 4.1–4.21)

Personal interaction with their surgeon was a key component of trust development, and many participants recounted memorable aspects of the encounter (4.1). Participants highlighted relational more than informational or transactional aspects of their clinic visit as key facilitators of trust (4.2). Participants reported that traits such as: kindness, thoroughness, respect for the patient, friendliness, honesty, commitment to quality, having the patient’s best interest at heart, and being supportive as important contributing factors to trust (4.3).

Communication skills were also highlighted, including interpersonal traits such as maintaining eye contact and talking directly to the patient (4.4). Other aspects that stood out to participants from the first meeting with their surgeon included: kindness, demeanor, availability, and feeling like patients were well-informed, not rushed, being listened to, and given full attention (4.5, 4.6). Being thorough yet concise, making time for the patients, and knowing past medical history were also described as contributors to building trust (4.7).

Participants talked about their positive perception of surgeon knowledge, including depth of experience and specialization, and some recounted how their own baseline medical knowledge was helpful in vetting and trusting the surgeon’s recommendations. Several participants hypothesized potential barriers that, if they existed, would prevent them from trusting a surgeon such as: being a poor listener, inflexible, paternalistic, or a lack of bedside manner or integrity (4.8, 4.9). Participants viewed positively shared decision making, being well-informed, and autonomy (4.10, 4.11).

Of participants who expressed emotion after meeting with their surgeon, all were positive. They expressed ease, comfort, and confidence (4.12, 4,13, 4,14). Despite the gravity of many of the planned operations, the majority of the participants described their surgery only briefly when prompted (4.15, 4.16, 4.17). While knowledge of the surgeon and individual openness to trust varied prior to meeting with the surgeon, all participants articulated complete or near complete trust in their surgeon after meeting them (4.18, 4.19).

Additionally, participants discussed that the presence of and the surgeon’s interactions with other members of the clinical team, such as nurses, trainees and general staff, also played a role in facilitating trust of the surgeon (4.20). Participants’ experiences were generally positive, feeling like the team they interacted with was professional, competent, and available, but influence of the team on trust was not purely due to characteristics of team members. Specifically, the witnessed team dynamic was cited by some participants to be an important contributor to development of trust in their surgeon (4.21).

4. Discussion and Conclusion

4.1. Discussion

This novel approach to entrustment focuses on the formation of trust within the surgeon-patient relationship and is singular due to the qualitative methodology employed and insights into mechanisms of trust development in the surgical context. Consistent with quantitative literature on this topic, we found that incorporation of patients’ treatment goals and preferences can increase trust [17] and that interpersonal skills rather than technical ability alone strongly influence positive perceptions of surgeons [7,8]. However, our data go beyond what has been previously reported in the literature. First, we identified that knowledge about a surgeon or their institution acquired prior to an actual clinic appointment may serve as a valuable prologue to the main act for trust development, which is the actual surgeon-patient encounter. Second, our data also suggest that positive collegial working relationships enhance patients’ trust formation. The influence of the surgical team dynamic in trust formation is noteworthy and novel. The opportunity to observe how a surgeon interacts with members of their clinical team was identified as a contributor to development of trust as participants seem to interpret team member interactions as a manifestation of a surgeon’s competence. It is striking that the mere presence of certain surgical/healthcare team members, such as trainees, could influence patients’ overall trust in their surgeon and his/her competency.

Our findings further highlight the relational aspects of the surgeon-patient encounter as integral to the genesis of trust and the importance of the surgeon’s direct role in preoperative evaluation and counseling of a potential surgical patient. Feeling well informed and a surgeon’s own attributes, such as thoughtful listening and thoroughness, were critical to facilitating trust through understanding of relayed information during the patient encounter, underscoring the importance of the interpersonal surgeon-patient connection. The fact that participants stressed relational more than informational or transactional aspects of the encounter with regard to trust suggests that there is not an equivalent alternative to this personal experience. Information conveyed or documentation completed by another provider or team member does not provide relational context with the surgeon. The power of the interpersonal transaction amongst surgeon and patient is at the crux of this reflection.

At a time in healthcare when both financial and patient experience considerations are increasingly influential in designing care models, these data strike a cautionary note about how too much emphasis on the former may compromise the latter. Most surgeons generate more income per given period of time through operating than they do seeing outpatients, and some care models seek to reduce non-surgical clinical time by deferring and delegating preoperative care and counseling. Similarly, some care paradigms seek to optimize scheduling efficiency and resource utilization by not necessarily aligning the evaluating surgeon with the procedural surgeon; outpatient encounters for consultation may be with one surgeon, but the actual operating surgeon is determined by scheduling priorities rather than by continuity.

These circumstances may be unavoidable in urgent or emergent situations, but for elective surgery, it can deny the patient an opportunity to develop elements of trust rooted in interpersonal interactions with their surgeon until the actual day of surgery. It is incumbent upon all medical professionals to act in ways that serve to engender trust given the recognized importance and implications of trust on various aspects of medical care, such as adherence to treatment recommendations or societal views of the medical profession [1]. If we think of Medicine as an institution with a vast history and future, then we are only temporary stewards of this institution and have an obligation to pass it on in a comparatively superior state to how we found it [18]. For surgical patients specifically, it is reasonable to assume that having a surgeon-patient trust relationship prior to day of surgery is superior to meeting a surgeon in the preoperative holding area, let alone the obvious negative consequences if trust cannot be established that day. While none of the participants specifically cited the informed consent process during their interviews, it has already been noted by Skowron and Angelos [6] that informed consent is more about establishment of trust than information transfer. Furthermore, these care paradigms may contribute to the flawed notion that a surgeon is merely a technician rather than a professional embodying the roles and responsibilities of all physicians, in addition to the unique obligations of surgery.

Our study has limitations. While a rigorous, reflexive coding process and use of constant comparative method allowed for identification of robust and cohesive themes, there may be limitations to broad generalization of our results given sample size, demographic makeup, and convenience sampling approach [19]. All our participants were White/Caucasian; this resulted from the convenience sampling methodology. Our findings may not be transferrable to minority populations where trust in providers may be compounded by existing healthcare disparities [20]; however, while some demographic factors including race or education have been associated with trust in healthcare, such findings in relation to socio-demographic characteristics have not been consistent across the literature [21,22]. Our study also has potential biases. While prior or theoretical negative experiences were recounted by some participants, all participants reported positive experiences with their surgeon. Purposive sampling of patients who had negative experiences and are less trusting would be instructive, as would engagement with care models without surgeon continuity. It is possible that bias was introduced into the study given the authors’ professional experience. However, through reflexivity we attempted to limit this by discussion amongst research team members, acknowledging personal influences on data interpretation and purposefully accepting the opportunity for new and surprising results. Future research directions could include exploring how trust develops in more diverse populations and additional disease states, and how trust in the surgeon-patient relationship is or is not transferable to surgical trainees. The importance to surgeon wellbeing of trusting relationships and meaningful interpersonal interactions with patients is also worthy of inquiry. Finally, investigation of trust as a possible clinical quality measure is of interest [2]. Validated instruments such as the Wake Forest Physician Trust Scale could be utilized to measure trust [23], and degree of correlation with other clinical quality metrics assessed to explore construct validity of trust as a measure of clinical quality.

4.2. Conclusion

The interpersonal connection formed with a surgeon is central to the mechanism of trust development, and care paradigms should acknowledge the importance of direct surgeon participation in preoperative evaluation and counseling. Prior knowledge of a surgeon or an institution can also contribute to trust development as can a surgeon’s witnessed interactions with other members of the healthcare team, including trainees. Trust operates similarly with surgeons as with other health care professionals, however the importance and consequences of trust in a surgeon are perceived uniquely. Rich data regarding how trust develops in the surgeon-patient relationship can be acquired through rigorous qualitative research methodology and is deserving of further scholarship.

4.3. Practice Implications

Trust in surgery has been noted to be distinct in comparison to other doctor-patient relationships due to nature and intensity of surgical encounters and typically shorter duration of relationships [3]. Surgical ethics, which has evolved as a distinct branch of clinical ethics [24,25], has also heralded surgical exceptionalism. While participants in the current study differed in perception as to whether the nature of trust in this context actually differed from trust in other contexts, distinct gravity of consequences, implications, and weight were assigned to trust in a surgeon. Given this circumstance, clinical care design should optimize conditions for trust development by enhancing opportunities for creating meaningful preoperative interpersonal surgeon-patient relationships and by promoting positive surgeon and institutional reputations.