How can trust be strengthened in physician-patient relationships? Why does trust matter so much?

"We know that trust can be an important component for a successful patient-physician dialogue. How can trust be strengthened? Does it vary according to patient demographics? Could there be generational differences in how we approach fostering trust between physicians and patients?”

In numerous projects we’ve seen the essential role that trust plays in an amazing range of interactions and industries; trust demonstrates again and again why it has a reputation as a universal social lubricant.  When trust is present, people are more likely to cooperate and comply (even when compliance is inconvenient), show less tendency to question or argue with information, perceive less risk and hassle, are more willing to purchase goods, show greater loyalty, and are more willing to express positive word-of-mouth.  It’s no surprise that trust is also absolutely essential between doctors and patients, especially when the doctor must recommend treatment that is novel, expensive, inconvenient or comes with risks.  

In medicine, anecdotal evidence suggests that older patients tend to question treatment suggestions less often, and are more compliant with treatment recommendations, consistent with “Physician as authority” norms that are thought to be more prevalent in past generations.  Empirical evidence mirrors this to some degree.  For example, a study of adherence to COVID measures showed older people were much more compliant with social distancing, mask, and testing recommendations.  However, it’s important to look “underneath” demographic factors to consider is whether this “compliance” is due to age itself, or due to situational factors that may tend, themselves, to be correlated with age.  Are older people more worried about their health? Does greater stability afford older people the ability to comply more easily with inconvenient measures?  Do they tend to have greater risk perception?  It’s often the case that attitudinal variables, or situational ones, have greater power to shape behavior than demographic ones, and again and again, data suggests it’s often more useful to look at the situational or behavioral factors.   

It’s not the case that demographic factors are useless in predicting or shaping behavior, just that other factors are often more powerful.  In fact, there are clear indicators that age and some other demographic factors (female gender and caucasian ethnicity often come up) tend to be consistently (though mildly) linked with greater treatment compliance.  A study reviewing papers from 1970 through 2005 reflects this, showing a trend towards greater treatment compliance among older patients, (although not universally).  However, it’s important to note that the same review demonstrated that the reviewed studies consistently showed that the quality of the physician patient relationship was a stronger predictive factor…and predicted adherence across every age segment! (Jin, Sklar, Oh and Li, 2008).  This is another indication that while there might be some incremental use in considering a patient’s age when thinking about their likelihood of working effectively with a physician, there’s much more potential in considering the relationship itself.    

Another study that makes the same point in a different way asked patients, directly, about their level of trust in their physician, and investigated the relationship between this trust, demographic variables related to the patient, and situational variables associated with their latest consultation.  Once again, the surveys revealed a clear indication that age is increased with greater trust in physicians, with trust increasing after age 35 and another incremental increase associated with patients older than 65; other demographic factors (i.e., Caucasian ethnicity, rural vs urban, perceived health status) played a role too, although less strongly than age.    

Crucially however, these effects were dwarfed by the effects of situational variables describing how patients’ experiences in the consultation room translated to increased (or decreased) trust.  For example, ratings of how seriously the physician took the patients’ problem were much more important than age (or any other demographic factor) in predicting trust.  Physician behaviors like “Treating you with care and concern” and “explaining tests and treatments” were just as important in predicting trust as age was and, taken together, variables related to the physicians’ behavior were much more powerful in predicting trust than all demographic variables combined.  Moreover, these factors had an even greater impact on trust as patients aged.    

For those wishing to increase trust as a means of improving health, adherence or compliance, focusing on patient experience, and especially on physician behavior, is much more valuable than looking at patient demographics.  While demographic factors often play a role in many important social realms, in almost every case, attitudinal and situational variables outstrip demographic ones in terms of importance.  Efforts to build trust between physician and patient, so essential in every aspect of the medical relationship, are better focused on key physician behaviors that we know, even intuitively, build trust:  demonstrating respect, listening to concerns, fully explaining options, allowing patients a voice in their treatment.  Not only are these the most substantive and effective ways to improve trust, but they appear to work across age groups and are perhaps even more important for older patients who may have the experience and wherewithal to recognize important situational cues that signal trustworthiness.    

References:

Carlucci, D’Ambrosio, and Balsamo (2020) Demographic and Attitudinal Factors of Adherence to Quarantine Guidelines During COVID-19: The Italian Model. Frontiers of psychology, 21.  

https://doi.org/10.3389/fpsyg.2020.559288  

Croker, J. E., Swancutt, D. R., Roberts, M. J., Abel, G. A., Roland, M., & Campbell, J. L. (2013). Factors affecting patients' trust and confidence in GPs: evidence from the English national GP patient survey. BMJ open, 3(5), e002762.  https://doi.org/10.1136/bmjopen-2013-002762  

Jin, Sklar, Oh, and Li (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutic Clinical Risk Management, 4, 269-286.