Trust Between Patients and Clinicians: An Overlooked and Affordable Approach to Improving US Health Care

In the past 5 years, social determinants of health have captured the attention of the health care industry as a significant contributor to health outcomes. Tools for clinicians to inquire about unmet health-related social needs—the individual correlate of population-level social determinants of health—are readily available¹ and have been widely incorporated into patient care workflows. Although recognition and management of these contributors to overall patient health and well-being can mitigate barriers to appropriate care, another component of the patient-clinician relationship appears to have been overlooked. Trust is a foundational attribute for many health care issues—equitable health outcomes, enhanced health care value, and improved health care quality—but is seldom explicitly mentioned. Members of racial and ethnic minority groups, the LGBTQ+ community, and people with disabilities often have a history of health care mistrust due to implicit bias and discrimination they may have faced. Mindfully enhancing the significance of trust in patient-clinician relationships has the potential to lead to greater mutual satisfaction, reduce clinician burnout, and improve patient adherence to evidence-based care.² The goal of this commentary is to raise the visibility of the importance of trust in the patient-clinician relationship to ensure it is acknowledged and incorporated into policy and tactical considerations to enhance Quadruple Aim goals.³

Importance of Trust

Trust is a catalyst for achieving equitable health outcomes, and its significance in the patient-clinician relationship has been well described.^4,5 Unfortunately, clinician focus has shifted increasingly to the treatment of diseases, rather than evaluating the whole patient, including how nonclinical concerns (health-related social needs and medical mistrust) influence clinical outcomes. The confluence of health care complexity, health care systems consolidation, and a workflow-driven, guideline-based, clinician-centric approach to care delivery has reduced provider autonomy for how patient care is delivered. Greater attention has been directed toward clinically driven treatment objectives that align with health system performance and quality measures, which are often associated with revenue implications. As a result, there has been a diminishing focus on the importance and value of trust in health care among patients, with their perceptions of health care’s trustworthiness declining in recent years.⁶ Not surprisingly, patient trust in health systems is significantly lower than that in physicians.⁷

From the patients’ perspective, earned mistrust exists and is an understandable—and protective—response by racial and ethnic minority individuals to years of systemic racism.⁸ Declining trust in clinicians has created additional challenges during patient encounters. Implicit bias resulting from racism or classism exhibited by clinicians during care delivery can exacerbate medical mistrust among patients, and this can effectively create a mutually reinforcing—and potentially disruptive—cycle that leads to collective frustration. Although clinicians may be aware of the importance of trustworthiness, evidence suggests they may not always perform trust-building behaviors.⁹ As a consequence of mistrust of their clinicians, patients may exhibit suboptimal adherence to treatment recommendations.⁶

In the absence of a trusting relationship, clinician efforts to determine unmet social needs and their referrals for support may yield limited value. Patients may be unwilling to expose their vulnerabilities to clinicians they don’t trust—and even if they do, they may not be receptive to offers of assistance.¹⁰ Even the care team approach to inquiring about unmet social needs may perpetuate mistrust by using a checklist approach instead of asking patients what matters to them and what barriers exist to better health.¹¹

What is needed is a shift in stakeholder perspective to elevate the importance of patient-clinician trust in health care outcomes. Mutual trust is earned as a result of direct, unbiased, and understandable communication between patients and clinicians, ideally in a longitudinal setting—and complemented by an effort to understand and incorporate the context of each patient’s lived experience. As attributed to President Theodore Roosevelt, “Nobody cares what you know until they know how much you care.”

Developing Trustworthiness

How can health systems and large health entities support clinicians in developing trustworthiness? From our vantage point, this objective is foundational to improving health outcomes—and in the setting of value-based care, business success. Accordingly, health care business leaders are best suited to lead their organizations in this process, with recognition that patient-clinician relationships have a substantial influence on health care outcomes. Nowhere may this approach be more important than in addressing longstanding health inequities, where medical mistrust and implicit bias are often deeply embedded in day-to-day health care delivery. Clinician-specific reporting of patient experience and variation in health outcomes measures by race or ethnicity can provide a focus for organizational quality improvement efforts, with ongoing reporting to evaluate progress toward more equitable outcomes.

In 2023, Toll and Sinsky described the “deep work” of relationships in health care and the potential to rebalance relationships to improve overall outcomes.¹² “Creating primary and secondary care environments that promote the elements of the deep work of doctoring and leverage technology to support relationships can bring us closer to Quadruple Aim outcomes of better care, better health, lower cost, and fulfilling work. The bedrock of this vision is strong relationships with patients, families, and colleagues,” they wrote.¹²

Incorporation Into Business Operations

Value-based payment models for health systems have the potential to elevate the visibility and importance of patient-clinician trust within an organizational business model. When the success of payment models is predicated on clinical outcomes, and those outcomes are in large part a function of patient-clinician collaboration, then a trusting relationship becomes a requisite for success. Trusting relationships can also be expected to reduce variability in health outcomes. In parallel, some health systems have begun to incorporate patient safety measures as a component of value-based contracting.¹³ Measures of variability in health outcomes may serve as a proxy for perceived trust between patients and clinicians, with patient experience measures or Net Promoter Score providing a more direct assessment of patient perspectives.

Patient-Clinician Trust and Health Equity

In efforts to mitigate health inequities, evaluation of patient-clinician trust by sociodemographic subpopulations is insightful. Using national survey data, Greene and Long⁷ published results in 2021 showing that individual race and ethnicity were not associated with significant differences in trust of personal physicians, most doctors, or health care systems. However, individuals in lower household income categories had significantly less trust in personal physicians, most doctors, and health care systems. Notably, individuals in the lowest 2 income groups (< 139% and 139%-249% of the federal poverty level) were half as likely to have a personal doctor as the highest income group (> 400% federal poverty level). The authors did not report data regarding the intersectionality of race/ethnicity and income in their analysis.

Data linking patient-clinician trust and health outcomes provide some intriguing insights. In their 2017 meta-analysis, Birkhäuer et al¹⁴ found that small to moderate correlations existed between patient trust and self-reported subjective health outcomes but not objective or observer-rated outcomes. There was a large correlation between patient trust and satisfaction with care delivery. Analysis of the data by racial/ethnic or income subpopulations was not included.

These findings provide support for the significance of patient trust in their clinicians as well as the important role of trust in engaging with clinicians and the health care system. Because individuals who are Black or Hispanic are often in lower-income wage groups, further research evaluating the intersectionality of race/ethnicity and wage and the role of patient trust in health care delivery is urgently needed.

Policy Implications and Considerations

The importance of trust is undervalued in health policy discussions and should be acknowledged and incorporated into potential policy solutions to enhance care delivery. Research activities regarding trust in health care have been limited, but it is likely that issues related to trust are often a component of research activities, although without direct measurement.¹⁵ In their detailed review of trust research in health care, Taylor et al characterize the centrality of trust—and the associated research challenges—into 5 subdomains: (1) patient trust in clinician, (2) clinician trust in patients, (3) clinician trust in clinician, (4) patient and clinician trust in health care organizations, and (5) general trust in the health care system.⁵

To build trust in health care organizations from a policy-making perspective, Taylor et al provide 3 recommendations, as follows⁵:

• Create and enforce health policies that penalize exploitative behavior.
• Enhance health system trustworthiness by ensuring that concerns regarding conflicts of interest and regulatory capture are mitigated via regulatory controls.
• Build public trust by incorporating transparency in their role in health care delivery.

We feel that the broad array of recommendations put forward by Sinsky et al regarding relationship building^2,12 and Taylor et al regarding trust5 can be complemented by additional, focused considerations that specifically target inequitable health outcomes, as follows:

1. Health systems bear responsibility for mitigating ongoing issues of systemic racism, including implicit bias and medical mistrust. Offering cultural competency training for clinical staff, in addition to inclusion during medical school and residency, may provide benefit but, in the absence of a systematic approach to training evaluation and patient outcomes, may not fully address observed health disparities. Instead, a more involved approach is necessary to understand and address root causes of variation in observed health outcomes, incorporating patient feedback and clinician-level data analysis. Health systems must prioritize sustainable and practical training for cultural humility.

2. As a construct outside the realm of clinical diagnosis and treatment guidelines, a measure of trust in patient-clinician relationships may not need to be evaluated as an additional performance measure. Instead, trust can be integrated into ongoing health system efforts to improve health equity by assessing outcomes variability across racial, ethnic, and socioeconomic subpopulations. If accountable care organizations are going to commit to narrowing inequity gaps, they have to look at more than addressing unmet social needs. The opportunity exists for health systems to incorporate performance measures in their contracting to drive more equitable outcomes. With growing employer interest in value-based care and direct contracting, interested stakeholders may welcome this proactive approach.

3. Health systems can independently or collaboratively support community initiatives to address health inequities by describing their health equity initiatives and providing ongoing outcomes reporting by sociodemographic subpopulations. Proactive, voluntary disclosure of subpopulation health outcomes by demographic and/or socioeconomic status can help to build trust with community members by increasing transparency. Similarly, internal, physician-level analyses of subpopulation-related health outcomes can help to identify opportunities related to trustworthiness and trust-building.

4. Ambulatory care workflow processes can be structured to ensure that clinician practices provide follow-up to patients for social service referrals for unmet social needs. By integrating those referrals as part of whole-person care, clinicians can help to build trustworthiness by ensuring that patient priorities are being addressed.

5. Further research may provide additional evidence-based insights into how strengthening the patient-clinician relationship can lead to more equitable health outcomes.

Conclusions

Increasing trust in health care delivery has the potential to benefit all stakeholders. Individuals with chronic conditions may be in the best position to directly benefit from improved patient-clinician relationships by being more likely to reach treatment goals. Importantly, because they offer health insurance for a substantial portion of the US population, employers can also derive benefit in several ways. Improved care outcomes can reduce—if not eliminate—the need for myriad point solution vendors, reducing existing fragmentation in health care and lowering health care costs. Improved workforce health and well-being can boost employee engagement, performance, and business outcomes.

Aligning health system efforts to move beyond a transactional approach to health care and provide more holistic, relationship-based, whole-person health has great potential to enhance trust in the health care system and drive more equitable outcomes. The Veterans Administration transition to whole-person health¹⁶ embodies this approach by shifting away from the transactional “What’s the matter with you?” to a trust-building “What matters to you?” As a result, patients are empowered and heard, and they and clinicians can develop more authentic and trusting relationships. The importance of trust in patient-clinician interactions is foundational to a mutually rewarding, relationship-based care delivery model, and it should no longer be overlooked. The individuals and communities we serve should expect nothing less.

Acknowledgment

The authors would like to express their appreciation to Daniel B. Wolfson, MHSA, for his thoughtful and constructive suggestions to enhance this commentary.

Author Information

Dr Sherman is the medical director of the North Carolina Business Coalition on Health, adjunct professor in the Department of Public Health Education at University of North Carolina-Greensboro, and a member of the editorial board of Population Health, Equity & Outcomes. Dr Tobb is a cardiologist at Cone Health in Greensboro, where she is also the clinical integration officer for the Center for Health Equity.

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