By Clair Baleshta

The importance of medical knowledge is highly emphasized in our current healthcare system. Due to a focus on evidence-based medicine, we direct a considerable amount of attention to topics like research and empirical knowledge when it comes to treatment recommendations or other clinical practices. Unfortunately, the significance of this knowledge tends to overshadow the role that trust also plays in healthcare. Trusting relationships between care providers and patients can serve many important functions, but one aspect of trust that is not often discussed is the impact it has on our ability to produce and communicate the knowledge that we depend on in medical settings.

Before discussing this specific function of trust, note once again that the concept is often altogether overlooked in healthcare. Our focus on the importance of things like evidence, facts, and the provision of accurate information to patients can direct attention away from trust in clinical encounters. For example, if a patient refuses to consent to a highly recommended treatment, their clinician may assume that the patient is misinformed, does not comprehend the information being provided to them, or is simply acting irrationally (Hall et al. 2012, Goldenberg 2019). In many circumstances, however, a lack of trust may be just as relevant to the refusal as any other factor.

To consider a more thorough example, suppose a patient was recommended insulin therapy for their diabetes. In response, the patient expressed a concern about becoming addicted to the medication. As this is a common myth about insulin use (American Diabetes Association 2007), the clinician quickly dismissed the patient’s worry and instead asked them to sign a consent form for the treatment. The patient refused to consent, which the clinician viewed as entirely irrational.

From the patient’s perspective, however, the clinician’s dismissal of their concern made them less trusting of the treatment recommendation. The patient’s fear of addiction, although seemingly ungrounded, was connected to genuine concerns about the disruption to their life that a dependency on insulin might cause. By disregarding their worry, it appeared to the patient that their clinician did not care about these underlying concerns related to their wellbeing. Ultimately, without being able to trust that the clinician had their best interest at heart, it was difficult for the patient to accept any recommendations.

To contrast this example, high levels of trust in healthcare settings have been associated with greater acceptance of recommended treatments as well as adherence to those treatments (Allinson 2016) . This notion of trust, generally speaking, refers to an assured reliance on the character, ability, strength or truth of someone or something (Merriam-Webster 2020). Trust also necessarily involves an element of risk; if we were already certain of someone’s truthfulness (for example), then it would not be needed in the first place. So, with trust comes a level of vulnerability (McLeod 2015). This requirement brings forth clear applications to healthcare, since the dependency of patients on care providers often necessitates trust (McLeod 2015).

Although understanding this need for trust might not be difficult in contexts where dependency is obvious, we all rely on trust far more in our daily lives than most of us recognize. Since no one person has the resources, time, or expertise to independently learn most facts about the world, much of our knowledge comes from trusting information provided to us by others (Hardwig 1991). If we did not trust in this way, we would not be able to know, for instance, that the earth is round or that certain countries exist (McLeod 2015). In fact, even much of our formal education system relies on trusting what our educators tell us.

Similarly, trust is central to the production of knowledge in the medical sciences. This may seem counterintuitive, given that science is commonly viewed to be a highly skeptical and questioning field of study (Crease 2004). Yet, with dramatic increases to the specialization of experts in the discipline, along with the time-consuming nature of data collection and analysis, very rarely can one researcher carry out all aspects of a study on their own (Hardwig 1991). This is evident from the increasing commonality of large research teams and multi-author papers (Hardwig 1991). Trust in the knowledge and work of fellow experts is required for research collaboration to be effective, and it is also needed anytime new research builds on the previous work of others (Hardwig 1991). In this way, trust is necessary for the collection of empirical data and evidence that our healthcare system relies on.

Recognizing that medical experts depend on trust may make it easier to see the relevance of the concept when applied to patient care as well. Trust is needed not just for the production of knowledge, but also for the communication and acceptance of it. Because of this, trust is often required for evidence-based medicine and practices like informed consent to be effective. When a patient does not adequately trust their care provider, recommendations carry far less weight. No amount of data or evidence can improve this since the patient does not have faith in their source. A lack of trust may also pose challenges for the informed consent process, as it becomes far more difficult for patients to disclose information or ask questions if they do not trust their provider (Allinson 2016). Therefore, to ensure that scientific evidence is being effectively communicated, and that patients are genuinely informed about their options, attention must be paid to establishing trust.

There are many ways that care providers, regardless of specialization, can increase their trustworthiness with patients. One way is for providers to take the time to recognize and address all patient concerns respectfully. The example of a patient refusing insulin therapy is meant to show that a loss of trust can occur when even seemingly ungrounded concerns are not recognized. Demonstrating reliability is another fundamental way to avoid diminishing trustworthiness as a care provider. Whether or not a provider follows through on commitments and behaves consistently in their relationships with patients greatly impacts their ability to retain trust. Also, taking extra steps to advocate for patients by facilitating processes or helping to connect them to resources is a very effective way to establish trustworthiness when possible.

One thing that all of these points make clear is how building trusting relationships takes time (Fritz & Holton 2019). While this is a resource that care providers are often short on, doing the extra work upfront to establish trust with patients can actually save both time and resources in the long run (Goold 2002). But also note that, more than any of the specific trust-building strategies mentioned above, the most important part of establishing trust is simply paying attention to it. Just being cognizant of the role trust plays in healthcare will help providers notice opportunities for creating or maintaining it, as well as recognizing the times when it must be improved.

Clair Baleshta is a Knowledge Integration graduate from the University of Waterloo and will be commencing her Masters in Philosophy at the University of Guelph in September 2020.