In this issue of The Milbank Quarterly, andrew anderson and Derek Griffith present a conceptual model of trustworthiness and trust in health care organizations that builds on several existing theories. In brief, Anderson and Griffith describe the combination of patients’ assessment of the trustworthiness of clinicians and their propensity to trust clinicians resulting in patients’ intention to trust their clinician and following through with “trusting behaviors” or clinician‐recommended behaviors.
Over the past several years, I have conducted qualitative research to explore what builds patients’ trust in clinicians and in health institutions.1,2 To compare how patients describe the process of gaining trust with the Anderson and Griffith model, I reviewed more than 50 interview transcripts and found that patients’ descriptions of their experiences are largely, though not entirely, consistent with their model.
Propensity to Trust
Anderson and Griffith describe patients varying in their propensity to trust clinicians. Qualitative interviews confirm that patients enter health encounters with a wide range of willingness to trust. A few interviewees described starting off trusting new clinicians (“I give everybody the benefit of the doubt until I see something different”), but more commonly people described that trust needed to be earned (“I think trust comes after I meet the person, it builds up”). Some interviewees described being less open to trusting certain types of clinicians (e.g., older clinicians, male clinicians, those who dismiss natural approaches), and a few interviewees described never being willing to trust a clinician “completely.”
Trustworthiness
Anderson and Griffith explain that the actual trustworthiness of a clinician is unknown to patients, and therefore, patients assess trustworthiness through gathering information and interacting with the clinician. In interviews, we principally heard that interactions with clinicians determined the perception of clinician trustworthiness. Other than word of mouth recommendations, we heard little about outside sources of information informing their perceptions.
Interviewees described three clinician behaviors that determined their perception of trustworthiness: (1) communication (“She takes time to listen” and “He talks straight to me, he doesn't talk over my head”), (2) showing care or compassion (“He seems to be concerned about my health. He is genuinely interested”), and (3) perceived competence (“They fix or heal whatever issue that I may have”). The relationships among these three areas of trustworthiness and trust in one's clinician were confirmed using national survey data, and analyses stratified by race/ethnicity and family income showed consistent findings across groups.2
Additionally, some interviewees described the treatment they received by office staff as impacting their perception of trustworthiness of the medical encounter. Front‐desk staff could make them feel comfortable by greeting them and welcoming them into the office. Or they could do the reverse: “Some doctor places, they don't even acknowledge you, nothing, and that is a tough situation.” Long wait times also negatively impacted trust (“I feel like my health care needs are not important because my time is not important to you”), as did the “give me your money” focus some described in medical settings.
Trust Intentions and Behaviors
Anderson and Griffith describe trust as a latent variable that manifests itself by the degree to which a patient chooses to cooperate with the clinician. This is where people's lived experience begins to differ from their model. Interviewees had no trouble describing the level of trust they had in their clinician or clinicians (“I trust her very much”; “I trust them tremendously”; “Do I trust my primary care doctor? No way”). And they often said that trusted clinicians are “practicing in the best interest of the patient.”
Interviewees described trust, or lack thereof, as impacting their health and health care behaviors. Those who trusted their clinician often described following their clinician's advice: “I absolutely follow her advice and what she suggests to the letter. Whereas if I didn't trust her . . . [I'd] blow off what she says and do what I please.” Another interviewee described a specific example: “There was an instance a couple of years ago where I was having issues and she was firmly telling me it had to do with my sleep and I didn't believe her but I went to the sleep study based on her word and it ended up being sleep apnea, so it affected my life very strongly.”
In addition to not following through with clinician recommendations, interviewees who did not have strong trust in their clinician described postponing care, using the internet to self‐diagnose (“I try to be my own doctor, do research on my own”), and getting second opinions. Those who reported having had a clinician they did not trust most commonly said they found a new clinician. One man explained, “I just changed my primary care because I lost trust in him.”
Interviewees described health and health care behaviors as the result of trust, which is consistent with the models used in empirical research on trust.3‐7 Anderson and Griffith, though, define trust synonymously with health‐related behaviors: “Trust as a behavior is the degree to which a patient chooses to cooperate or collaborate with a provider . . .” This difference may have important implications in terms of what is considered patient trust and how it is measured. For example, one interviewee who strongly trusted her doctor described changing her exercise regimen in response to her doctor's recommendation, but not being able to successfully alter her eating habits: “It is tough . . . not eating foods that you are so used to eating.” Her inability to follow through with her doctor's recommendation was not due to lack of trust; rather, it was because of how challenging behavior change can be.
Measuring Trustworthiness in Health Organizations
Anderson and Griffith propose measuring health care organizations’ trustworthiness using medical error rates and publicly reporting them stratified by race and ethnicity. By doing so, they argue, there would be greater transparency, which could disproportionately help patients from historically marginalized groups, and it would identify ways for clinicians to improve care processes and reduce disparities.
Interviewees have highlighted to me the importance of health care organizations having a culture in which all clinicians and staff show they care about their patients and communicate effectively to be perceived as trustworthy. Based on this, I would recommend focusing public reporting on measures of clinician and receptionist communication and caring, which are included in the widely used CAHPS Clinician & Group Survey. Stratifying these measures by race/ethnicity could help organizations track how well and how equally they meet all their patients’ needs. And while I am not optimistic that many patients will view the data (none of the interviewees mentioned using public reports of quality data, which is consistent with prior research8,9), I share Anderson and Griffith's optimism that public reporting has the potential to encourage clinicians to identify problems and seek to reduce racial and ethnic inequities.
References
- 1. Greene J, Samuel‐Jakubos H. Building patient trust in hospitals: a combination of hospital‐related factors and health care clinician behaviors. Jt Comm J Qual Patient Saf. 2021;47(12):768‐774. [DOI] [PubMed] [Google Scholar]
- 2. Greene J, Ramos C. A mixed methods examination of health care provider behaviors that build patients’ trust. Patient Educ Couns. 2021;104(5):1222‐1228. https://www.sciencedirect.com/science/article/pii/S073839912030478X. [DOI] [PubMed] [Google Scholar]
- 3. Fu LY, Zimet GD, Latkin CA, Joseph JG. Associations of trust and healthcare provider advice with HPV vaccine acceptance among African American parents. Vaccine. 2017;35(5):802‐807. 10.1016/j.vaccine.2016.12.045. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Braksmajer A, Fedor TM, Chen S‐R, et al. Willingness to take PrEP for HIV prevention: the combined effects of race/ethnicity and provider trust. AIDS Educ Prev. 2018;30(1):1‐12. 10.1521/aeap.2018.30.1.1. [DOI] [PubMed] [Google Scholar]
- 5. Birkhäuer J, Gaab J, Kossowsky J, et al. Trust in the health care professional and health outcome: a meta‐analysis. Nater UM, ed. PLoS One. 2017;12(2):e0170988. 10.1371/journal.pone.0170988. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Medendorp NM, Visser LNC, Hillen MA, de Haes JCJM, Smets EMA. How oncologists’ communication improves (analogue) patients’ recall of information: a randomized video‐vignettes study. Patient Educ Couns. 2017;100(7):1338‐1344. 10.1016/J.PEC.2017.02.012. [DOI] [PubMed] [Google Scholar]
- 7. Gupta S, Brenner AT, Ratanawongsa N, Inadomi JM. Patient trust in physician influences colorectal cancer screening in low‐income patients. Am J Prev Med. 2014;47(4):417‐423. 10.1016/J.AMEPRE.2014.04.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Bhandari N, Scanlon D, Shi Y, Smith R. Why do so few consumers use health care quality report cards? A framework for understanding the limited consumer impact of comparative quality information. Med Care Res Rev. 2019;76(5):515‐537. [DOI] [PubMed] [Google Scholar]
- 9. Greene J, Fuentes‐Caceres V, Verevkina N, Shi Y. Who's aware of and using public reports of provider quality? J Health Care Poor Underserved. 2015;26(3). [DOI] [PubMed] [Google Scholar]