At the Society for Participatory Medicine, we recognize trust and respect as a two-way relational dynamic essential to our mission to transform the culture of healthcare relationships so people can live their best lives (see our Participatory Medicine manifesto). And on June 16, we are holding a half-day Creative Learning Exchange in Portland, OR, with support and sponsorship from NRC Health and the Oregon Health and Science University’s (OHSU) Departments of Family Medicine and Medical Informatics & Clinical Epidemiology.

This event focuses on trust, as a critical element to advance health equity and participatory medicine. There will be speakers from OHSU, SPM, and Regence, the Oregon Blues plan. But as importantly, virtual and in person participants, including patients and families, will help shape future practices to support trust in the clinical encounter. (Learn more and register at  https://www.eventbrite.com/e/advancing-health-equity-through-participatory-medicine-tickets-594076888967.

The team preparing the event prepared a summary academic literature and highly credible surveys on the topics of health equity and trust to help create a common baseline understanding of these topics among participants. The team looked at both interpersonal and institutional trust. When you take a look at the facts below, you’ll  understand the deep need for fostering patient/clinician trust and collaboration with awareness of structural inequities to help improve outcomes for all patients.

• Women and Black people are more likely to experience administrative errors, diagnostic errors, medication errors, and transition of care errors in primary care.[1]
• Minoritized persons are less likely than white persons to get appropriate cardiac care, kidney dialysis or transplants, and to receive the best treatments for stroke, cancer, or AIDS.[2]
• One in five adults who are Black (21%) or Hispanic (22%) say it is difficult to find a doctor who treats them with dignity and respect, compared to a smaller share of those who are white (14%).[3]
• Forty one percent of female-identifying patients report gender discrimination, compared to 12% of male-identifying patients.[4]
• Higher patient BMI is associated with lower perceived respect by physicians.[5]
• Eight percent of lesbian, gay, or bisexual people, 27% of transgender people, and 19% of people living with HIV report that they were refused needed healthcare.[6]

What are factors that influence interpersonal trust? Consider:

• 77% percent of Hispanic adults and 76% of Black adults say their physician trusts what they say, compared with 88% of Asian adults and 86% of white adults.[7]
• Clinicians with higher levels of implicit bias were rated lower in patient-centered care by Black patients than by white patients.[8]
• Twenty percent of Black adults and 19% of Hispanic adults say they were personally treated unfairly because of their race or ethnicity when getting health care for themselves or a family member in the past 12 months versus 5% of White adults reporting this.[9]

Trust in healthcare institutions-can directly affect health outcomes. Medical mistrust is predictive of underutilization of health services, including failure to take medical advice, failure to keep a follow up appointment, postponing needed care, and failure to fill a prescription.

The infamous and unethical Tuskegee study increased medical mistrust and mortality among older Black men, falling up to 1.5 years in response to the disclosure, which accounted for approximately 35% of the 1980 life expectancy gap between Black and white men and 25% of the gap between Black men and women.[10]

These are factors that influence institutional trust:

• Compared to White adults, Black adults are 19 percentage points less likely to trust doctors (59% vs. 78%), 14 percentage points less likely to trust local hospitals (56% vs. 70%), and 11 percentage points less likely to trust “the health care system” (44% vs. 55%) to do what is right for them and their communities.[11]
• Hispanic adults are significantly more likely to be uninsured than their white and Black non-Hispanic counterparts.[12]
• In organizations with higher patient trust of clinicians and higher clinician trust of the organization, the organizational culture emphasizes quality of care, communication and information sharing, clinical team cohesion, and had aligned values between leaders and clinicians. Those organizations also had greater patient adherence, healthier patient behaviors and lower clinician turnover. (Patients were 60% female and 25% of diverse populations.)[13]

What these facts make clear is that efforts to reduce health disparities and advance participatory medicine need to be sensitive to the historical context that has undermined trust and outcomes for minoritized populations, and must be built explicitly to foster inclusion for all people.

I invite you to come join with the Society for Participatory Medicine and help design actionable ways of improving trust and equity. We welcome your energy and insights!

Liz Boehm is an Executive Strategist and board member of the Society for Participatory Medicine. You can find her on LinkedIn at https://www.linkedin.com/in/liz-boehm/.

For more information about the Creative Learning Exchange on June 16, please visit https://www.eventbrite.com/e/advancing-health-equity-through-participatory-medicine-tickets-594076888967

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[1] Piccardi C, Detollenaere J, Vanden Bussche P, Willems S. Social disparities in patient safety in primary care: a systematic review. Int J Equity Health. 2018;17(114):1–9

[2] Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington (DC): National Academies Press (US); 2003. PMID: 25032386.

[3] KFF/The Undefeated Survey on Race and Health. Liz Hamel, Lunna Lopes , Cailey Muñana , Samantha Artiga, and Mollyann Brodie. Published: Oct 13, 2020. https://www.kff.org/report-section/kff-the-undefeated-survey-on-race-and-health-main-findings/#HealthCareSystem

[4] https://abimfoundation.org/what-we-do/rebuilding-trust-in-health-care

[5] Huizinga MM, Cooper LA, Bleich SN, Clark JM, Beach MC. Physician respect for patients with obesity. J Gen Intern Med. 2009;24(11):1236–9. https://pubmed.ncbi.nlm.nih.gov/19763700/

[6] https://legacy.lambdalegal.org/sites/default/files/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf

[7] https://abimfoundation.org/what-we-do/rebuilding-trust-in-health-care

[8] Blair IV, Steiner JF, Fairclough DL, Hanratty R, Price DW, Hirsh HK, et al. Clinicians’ implicit ethnic/racial bias and perceptions of care among black and Latino patients. Ann Fam Med. 2013;11(1):43–52

[9] KFF/The Undefeated Survey on Race and Health. Liz Hamel, Lunna Lopes , Cailey Muñana , Samantha Artiga, and Mollyann Brodie. Published: Oct 13, 2020. https://www.kff.org/report-section/kff-the-undefeated-survey-on-race-and-health-main-findings/#HealthCareSystem

[10] Marcella Alsan, Marianne Wanamaker, Tuskegee and the Health of Black Men, The Quarterly Journal of Economics, Volume 133, Issue 1, February 2018, Pages 407–455, https://doi.org/10.1093/qje/qjx029

[11] KFF/The Undefeated Survey on Race and Health. Liz Hamel, Lunna Lopes , Cailey Muñana , Samantha Artiga, and Mollyann Brodie. Published: Oct 13, 2020. https://www.kff.org/report-section/kff-the-undefeated-survey-on-race-and-health-main-findings/#HealthCareSystem

[12] https://www.commonwealthfund.org/chart/2019/percentage-uninsured-adults-ages-19-64-race-and-ethnicity

[13] Linzer, M et al, “Where Trust Flourishes: Perceptions of Clinicians Who Trust Their Organizations and Are Trusted by Their Patients” The Annals of Family Medicine November 2021, 19 (6) 521-526; DOI: https://doi.org/10.1370/afm.2732.