Repairing Trust

When I was a first-year medical student, classmates and I conducted a health systems improvement project based in the women’s health clinic at our city’s public hospital. The goal of the project was to understand why Black women weren’t returning for their postpartum visits at the same rate as patients of other races/ethnicities, and to close that gap. After reviewing more than 100 patient charts and conducting in-depth interviews with 20 Black patients, the answer was resoundingly clear: our patients just needed to be heard. 

Being seen and heard is at the core of human connection. Dr. Francis Peabody wrote about this intersection and application of our humanity as physicians in his sentinel paper “The Care of the Patient:” “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” Doctors cannot authentically care for patients without caring for them as people. Caring involves showing kindness and concern and requires establishing trust within the patient-physician relationship.  

We are women of Black ancestry who occupy the roles of physician and surgeon. It’s shocking how many patients of all races and ethnicities are still surprised by this. With only five percent of doctors in the United States identifying as Black, the rarity of seeing a Black physician is apparent. In some encounters with patients who identify as Black, the ease with which they interact is palpable. It’s as though a weight has been lifted and the gates opened to being safe, heard, and cared for.  

Most patients respond well to genuine care; however, establishing mutual trust in the patient-clinician relationship is another matter. The AMA Code of Medical Ethics declares that building relationships of trust with patients is fundamental to ethical practice in medicine, and yet physicians don’t often focus on how to establish trust with patients during their encounters. Further, establishing trust within the dependent nature of the patient-physician relationship, along with discordance in self-identifying characteristics, can impose barriers that might be activating and exacerbate the power dynamic for many marginalized patients.  

Physicians must take ownership of building trust with patients, especially patients that don’t look like them and may not share the same beliefs and values. Most importantly, doctors should meet patients where they are and ask them what they need to achieve a patient-clinician relationship built on trust. This proposal is not only rooted in caring, kindness, and concern, but also relies on trustworthiness as an ongoing practice, which goes beyond professional competence. While clinical competence is critical to offering optimal patient care, it’s not enough on its own. Partnering with our patients to build a trusting patient-physician relationship is also vital.  

Here are three things to think about during patient encounters:  

1. Has this patient experienced discriminatory behavior from other physicians?  

2. What trauma and distrust are they bringing to this encounter?  

3. How can I mitigate and possibly repair feelings of mistrust?  

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”-Sir William Osler

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.