Trust is a must

That trust is integral to the therapeutic experience between clinician and patient may be self-evident; nevertheless, as physicians, I believe there’s value in thinking about trust more intentionally: what is it, how are we creating it, and why does it matter?  

Trust is defined by the Oxford English Dictionary as the “Firm belief in the reliability, truth, or ability of someone or something.” It operates in the background of the most ordinary decisions—we could hardly take a bite of food without trust—to the most consequential—imagine boarding a plane without trust in the pilot. Trust is needed to overcome what we cannot know, and it must be exercised in the right amount. Too much trust is foolish and too little paralyzes our ability to act.  

Kenneth Arrow (1921-2017), economist and Nobel Laureate was interested in the effect of uncertainty in economic markets and the value of trust. He wrote, “Trust is an important lubricant of a social system. It is extremely efficient; it saves a lot of trouble to have a fair degree of reliance on other people’s word. Unfortunately, this is not a commodity which can be bought very easily. If you have to buy it, you already have some doubts about what you have bought.” 

In addition to his study of the effect of uncertainty on the market for traditional commodities, Kenneth Arrow studied the effect of uncertainty and trust on medical care. In perhaps the most frequently cited paper in medical economics Kenneth Arrow wrote, “That risk and uncertainty are, in fact, significant elements in medical care hardly needs argument. I will hold that virtually all the special features [that distinguish the provision of medical care from market commodities], in fact, stem from the prevalence of uncertainty.” Furthermore, he noted that “. . . [the patient]—lacking some guarantee [of results]—wants to know at least the physician is using his [or her] knowledge to the best advantage. This leads to the setting up of trust and confidence, one which the physician has a social obligation to live up to.”  

How is this “setting up” done? Carlos Pellegrini, professor emeritus and former director of the department surgery at the University of Washington, reflected on what he’d come to learn about trust between the clinician and patient. Likening “trust’” to the keystone supporting two sides of an arch, he placed “trust” as the keystone to the doctor-patient relationship (and similarly, for a patient’s relationship with other members of the healthcare team and institution). In delivering the John J. Conley Ethics and Philosophy Lecture to the American College of Surgeons in 2016, he said that over his career he’d come to believe that the most powerful influence on trust was communication: verbal communication certainly, but even more so, non-verbal communication such as body language, eye contact, vocal tone, and demonstrations of active listening and empathy. In his address he said, “. . . As the limitations of my ability to heal using only my technical expertise became more obvious to me during my years as a surgeon, I recognized the impact that quality communication between patients and surgeons—the kind that engenders mutual trust—had on the outcomes of my work.” He wondered that more attention wasn’t devoted to the deliberate practice and refinement of these forms of communication.  

As Dr. Pellegrini concluded in his address: “Trust . . . is an indispensable virtue of a good physician.” 

What value does trust bring to the relationship? A scan of the substantial physician and nursing literature on the benefits of trust in healthcare find that patients are more likely to:  

1. Share intimate information.

2. Accept and contribute to self-care. 

3. Return for care. 

4. Recommend the physician and institution to others. 

5. Have higher satisfaction with care. 

6. Experience positive health outcomes. 

Patients in our geriatric medicine clinic report some of these outcomes in post-experience surveys. And not rarely, a patient will remark that a positive experience—typically involving communication with their physician or the staff—led to or increased trust in their care. For example, following a new patient visit, a patient wrote a note to his physician thanking him for “the laying of hands.” At a subsequent visit the patient explained that the “Care taken in performing and explaining the purpose of a detailed physical exam gave him confidence [and that this] “laying of hands” communicated the physician’s competence and caring.” He said, “As a result, I felt comfortable revealing issues that were causing me anxiety.”

Trust in healthcare cannot be bought, but it can be built; in some instances, surprisingly early in the doctor-patient relationship. Verbal or written communication is valuable, but non-verbal forms that transmit presence (like eye contact with the patient rather than computer); competence; the skillful use and explanation for the “laying of hands,” and expressions of empathy, understanding, and willingness to create a therapeutic partnership, may be even more powerful. Indeed, trust is the lubricant of virtually all social interactions and the keystone to the doctor-patient relationship. 
 

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