What to do when your patient doesn't trust you

By Ashley Perez, MSN, RN, and Joe Hannan
Published January 20, 2022

Key Takeaways

  • Strong communication skills and the free exchange of information build trust within the clinician-patient relationship.

  • Despite a provider’s best efforts, racism, sexism, and other types of discrimination may break this trust.

  • Official ethical guidance from governing healthcare organizations may help clinicians navigate these scenarios when they arise.

The relationship between a clinician and a patient is founded on trust. As providers, you counsel, provide treatments, and make recommendations so patients can make informed healthcare decisions. Unfortunately, when patients doubt your credibility, patient-provider trust fractures.

Disrupted patient-provider trust has several common presentations. With some familiarity, you can begin to recognize the signs and intervene.

Clinician-patient relationship

Vulnerability is inherent to the clinician-patient relationship. Health conditions are often accompanied by stigma, shame, trauma, and are weighted by social determinants of health. Solving these problems collaboratively hinges on trust between provider and patient.

“Previously, the doctors were considered as the receptacle of all medical knowledge and this was used for patient management,” wrote the authors of a 2018 review in the Journal of Healthcare Communications.[] “In today’s era, things are a bit different. The medical knowledge has become a commodity between the doctor and the patient and treatment is customized to individual patients.”

Impersonal to personal

The evolving dynamic of the clinician-patient relationship has made what was sometimes impersonal highly personal. To keep pace, clinicians must strive to understand their patients using trust-focused communication, the researches wrote, highlighting the maxim from the famous Canadian physician, William Osler:

"A good physician treats the disease and a great physician treats the patient who has the disease."

William Osler

“A good physician treats the disease and a great physician treats the patient who has the disease.”

Encountering patient bias

The overwhelming majority of clinicians is committed to building and maintaining patient trust. Unfortunately, not all patients are onboard. Patient bias may manifest in several common ways.

Age

What is ageism?

According to the WHO, “Ageism refers to the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) towards others or oneself based on age.”

Patients may feel that their provider is either too young or too old to adhere to standards of care. They may advertently or inadvertently communicate this bias with phrases, such as, “You look so young! How old are you anyway?,” or “Wow, when did you get your degree?”

Often, these feelings are fear-based and unfounded. All practicing clinicians, if adhering to licensure requirements, are qualified to provide care, regardless of age.

Gender

What is gender bias?

According to Cornell Law School’s Legal Information Institute, “Gender bias refers to a person receiving different treatment based on the person’s real or perceived gender identity.”

Patient gender bias can be implicit or explicit. For example, a patient may use pejorative or condescending terms to a female caregiver, such as “sweety,” “honey,” or “dear.” Or, this bias can be explicit. For example, a patient may refuse care from providers of a specific gender.

While the former is unacceptable, the latter can be substantiated. For example, a male patient may be more comfortable receiving care from a male urologist, or a female patient may feel more comfortable receiving care from a female gynecologist.

Furthermore, a patient’s religious beliefs may preclude them from receiving care from a member of the opposite sex. On the other hand, a patient who refuses care from a provider, solely because of their sex, is unacceptable.

Related: How your patients’ religious beliefs may influence their healthcare decisions

Race

What is racism?

In the clinical context, a 2015 PLoS One meta analysis defines racism thusly: “Racism can manifest through beliefs, stereotypes, prejudices or discrimination. This encompasses everything from open threats and insults to phenomena deeply embedded in social systems and structures.”

Within the clinical context, a patient may refuse care from a provider based on their race or ethnicity. This may be rooted in long-held beliefs. Clinicians may also encounter implicit racism. This sometimes manifests in common refrains, such as, “Where are you from?,” or  “You must have worked hard to become a doctor.”[] All instances are unacceptable.

How to build trust

As delineated by the Journal of Healthcare Communications review, trust-building between patient and provider begins with communication. The key, the authors wrote, is personalizing your communication to each patient.

“Discrepancy can arise as the two individuals (doctor and patient) might decode the same information differently,” the authors wrote.

Personalized communication requires exploring this information gap. Concretely, that involves gathering a “proper history” from the patient, which informs exams and then management. The exchange of information assists patient decision-making, building trust.

Making a good first impression

Like in most other interpersonal settings, first impressions are significant in clinical encounters. A 2017 BMC Medical Education study elucidates this.[] Researchers interviewed 21 new patients at an HIV clinic to draw insights about their feelings about working with a new healthcare provider. Researchers conducted three interviews: Before their first visit, 2 weeks after the first visit, and 6 to 12 months after the first visit.

"Face it, you go to the doctor (when) you’re in a complete state of vulnerability. There’s something wrong with you and you need someone to tell you you’re okay or you’re going to be okay."

Patient account from BMC Medical Education

Researchers found that anxiety was a predominant emotion prior to the first patient encounter. One patient, Joe, said the following:

“Face it, you go to the doctor (when) you’re in a complete state of vulnerability. There’s something wrong with you and you need someone to tell you you’re okay or you’re going to be okay.”

Another patient, George, offered this:

“I hope I’ll get a sense of, some kind of sense of security … that, you know, I’m gonna be taken care of.”

Communication tips

How can a clinician use communication to ease anxiety, convey security, and build trust? The American Association for Physician Leadership recommends the following:[]

  • Eye contact: Eye contact shows you’re paying attention. When possible, place yourself on the same level as the patient, and look at them when speaking or listening—not at your EHR or devices.

  • Listening: Ask open-ended questions. Then, repeat what you heard to show understanding.

  • Light touch: A hand placed on a shoulder can show you care. But it can also be problematic if misinterpreted. Contact should be appropriate, and in the presence of another provider.

Responding to patient breaches of trust

Unfortunately, even if an HCP goes out of their way to build trust with a patient, that trust can be broken by racism, sexism, ageism, and other modes of discrimination. According to a 2021 study published in the Journal of General Internal Medicine, clinicians have commonly experienced the following:[]

  • Assumption that a legitimate doctor is White, male, and able-bodied

  • Legacy of the Black experience

  • Working through the struggle of discrimination

  • Ethical dilemma of providing care to discriminatory patients

What should an HCP do if they encounter these scenarios? The AMA Code of Medical Ethics offers some guidance:[]

  • Exploration: “Insofar as possible,” physicians should attempt to address experiences or conditions underlying the offensive behavior. If a provider’s safety is in jeopardy, this takes precedence, and the threat should be de-escalated or removed.

  • Judgment: Clinicians must weigh a patient’s requests against care goals.

  • Communication: If a patient persists with discrimination, inform them that they can seek care from other sources.

  • Termination: If a patient continues to be derogatory, prejudiced, or disrespectful, terminate the relationship.

A 2019 AMA Journal of Ethics article also provides an overview of guidance from the Mayo Clinic, specifically the SAFER Model.[7][]

What is the SAFER Model?

The SAFER Model is a five-step methodology to guide clinician responses to misconduct from patients or visitors. For clinicians in leadership roles, it may serve as a useful staff training tool, the AMA wrote.

When faced with a discriminatory patient, the SAFER Model offers the following guidance. Keep in mind that your employer likely has its own values and reporting methods:

  • Step in when you see behavior that doesn’t fit in with Mayo Clinic values.

  • Address the inappropriate behavior directly with the patient or visitor.

  • Focus on Mayo Clinic key values, such as respect and healing.

  • Explain Mayo’s expectations and set boundaries with patients and visitors.

  • Report the incident to your supervisor and document the event using the Patient Misconduct form.

What this means for you

Clinicians strive to build trust with their patients. Unfortunately, they may encounter racism, sexism, ageism, or other forms of discrimination from patients in their practice, all of which erode that trust. Official guidance recommends that HCPs do what is reasonable to understand or mitigate this discrimination. While they must factor in a patient’s clinical needs, clinicians are not required to suffer abuse.

Related: Are Americans losing trust in doctors?

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