Trust is a key foundational element in any relationship, including the physician-patient relationship. Studies show that 70 to 80 percent of patients have not been truthful with their providers at some point during their annual visit. Aside from the occasional white lie, 23 percent of patients report habitually lying about, minimizing, or avoiding certain details of their health history.

Studies show that patients mostly lie when asked basic health questions, such as those about exercise, smoking habits, and drinking. Patients who are suffering from chronic illnesses are the least likely to lie about their health.

The physician-patient relationship is critical to a patient’s health. Patient dishonesty has been linked to negative health effects. Patients who do not trust their physicians are less likely to get annual exams, maintain compliance with their health plans, or talk about their symptoms. Additionally, it can be difficult for providers to build rapport with their patients if the patients are not forthcoming with their medical history. 

Types of Patient Trust

Scholars associate two types of trust with physician-patient relationships: interpersonal and social.

Interpersonal Trust — Interpersonal trust is built on several interactions (i.e., visits) with the patient. The key is that the patient has several opportunities to witness the physician exemplify the traits that make them appear trustworthy. 

Social Trust  — Social trust operates on an entirely different level compared to interpersonal trust. Patients may equate their trust in their provider to their trust in the healthcare system as a whole. If the patient does not like the healthcare system or aspects of it for any reason, they may unconsciously associate that negative thought with their physician. This may be especially evident when it comes to insurance coverage, diversity, and accessibility.

Understanding the Psychology of Trust

These differing perceptions of trust weigh heavily on the physician, especially those who participate in value-based programs, or those that measure a physician’s success by their patients’ health outcomes. A physician cannot improve a patient’s health if the patient is not forthcoming with their symptoms. But why do patients lie in the first place? Don’t they want to feel better? Psychologists attribute the reasons why patients are not forthcoming with their physicians to: 

• Social pressures. Most patients who do not fully engage during visits with their providers minimize or avoid disclosing details to avoid embarrassment, discrimination, to maintain self-esteem, or to avoid lectures from their doctors. For example, male patients are more likely to minimize information about their alcohol use to avoid social stigma related to alcohol addiction. Depending on the culture, some female patients may be unwilling to see a physician without a male present, which may inadvertently create another barrier to care.
• The Ostrich Effect. It sounds counterintuitive, but patients may not be truthful about their health because they don’t want to hear from their provider that they are sick. One study found that women were six percent less likely to get preventive mammograms once they heard a coworker of theirs was diagnosed with breast cancer. Oftentimes, patients are scared of the painful procedures and large medical bills that may come with treating serious illnesses.
• Attachment theory. For some patients, it takes time to get comfortable with the level of intimacy required in the physician-patient relationship. The idea is that a patient’s attachment style may dictate how they will interact with their physicians.
• The ego ideal. This theory ties directly to Freud’s concept of the id, ego, and superego. According to the ego ideal theory, patients are not forthcoming because they want to present a particular image of themselves to their physician. For example, some patients may lie about sticking with a particular diet in order to avoid seeming like a “bad” person.
• Fear of being a burden. Sometimes, patients will say they are fine or avoid bringing up health-related conversations in order to end a visit because they are afraid their health problems will burden their physician. Some patients may also do this if they feel rushed during a visit or if they spent a long time in the waiting room.

Additional Factors to Build Trust

Beyond social theory and patient preferences, the latter of which a physician has little control over, there are external factors physicians can mitigate in their practices to build patient trust:

• Understanding the social determinants of health. Social determinants of health are a driver for patients’ trust in their physicians. Getting to know a patient and what may be their barriers to medical care can help physicians build trust. Before starting an exam, it can be helpful to talk to patients about their stress and help them address those factors if the patient expresses that their stress is high. Writing down particular details to bring up in a future visit can also show patients that their physicians were listening and are keeping track of their health.
• Knowing cultural differences. Taking a few minutes to look at some studies regarding cultural differences can mean all the difference to a physician’s relationship with their patients. Culture determines what certain groups of people eat, what they wear, what they say, and their interactions with their physicians. Understanding these differences can help physicians communicate with their patients in a more effective manner.
• Giving explicit instructions. Studies show that explicit instructions can help patients understand why they should be forthcoming with their physicians. Studies have shown that patients are more likely to comply when physicians tell them explicitly what they need to know and why. This is important not only to build rapport, but to motivate a patient to give their provider accurate details concerning their medical history. Additionally, discussing specifics with patients of different cultures can help alleviate anxiety. For example, in religions that prioritize modesty, female clinicians may be inclined to discuss why they need their female patient to remove a certain garment for their exam.
• Assessing office processes. Long wait times and rushed visits in the office reduce the amount of time a patient has with their physician, decreasing patient trust. Adjusting office workflows to accommodate packed schedules, or simply asking your office staff to say, “Your wait time may be a bit longer than usual because our office is particularly busy today,” can help build trust and confidence before the patient even sees the physician.

It may take time for patients to develop trust in their physicians, but that doesn’t mean physicians must reorganize their whole practice to build it. Instead, turning visits into a conversation with a patient, rather than an interview, may be the best way to get a better sense of the patient’s condition and how they are doing. Ultimately, understanding the reasons behind a patients’ unwillingness to share their health concerns can help physicians obtain better health outcomes for their patients.

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