A Model of Interpersonal Trust, Credibility, and Relationship Maintenance

Trust is essential to the clinician-family relationship in pediatrics, and it is affected by the actions or inactions of clinicians. High levels of trust can support confidence, peace of mind, and a sense of security. Broken trust can lead to anxiety, second-guessing, and frustration. In these opening statements, parents describe lapses in clinicians’ honesty, fidelity, and caring that impaired their trust. Mounting evidence suggests that the US health care system is entering into a crisis of trust, with Americans reporting decreased trust in physicians and the health care system over the last half century.¹ 

In 2014, a report found that only 58% of American patients agreed that doctors could be trusted, ranking 24th among all countries surveyed.¹  Lee et al²  argued that this erosion of trust has resulted from the deprioritization of relationships in modern US health care, and they recommended a framework for increasing trust between patients and health care organizations or health care teams. Although this organizational trust is important, we argue that interpersonal trust in pediatrics between each family and clinician is paramount. Every clinician has an opportunity to reinforce or hinder the family’s trust in the clinician, the hospital, and the greater health care system.

Interpersonal trust is a complex topic that is understudied in the medical literature, and this work is almost absent from the pediatric literature. Understanding trust in the pediatric setting is even more challenging given the triadic nature of communication between child, parent, and clinician. As children and adolescents develop autonomy, supporting their voice becomes even more important to developing a trusting relationship. Although many studies have used “trust in the physician” as an outcome measure, few studies have evaluated the determinants, outcomes, and evolution of interpersonal trust between clinicians and patients. In this limited literature, most studies have been focused on trust during times of crisis rather than times of stability, and none have been focused on pediatrics. However, we argue that trust is more impactful if established and maintained before times of crisis. As such, we propose a model of trust evolution in the clinical relationship, a model that calls for increased attention to relationship maintenance over time (Fig 1). This model was informed by current findings from the trust literature and clinical experiences.

We consider trust to have the following features: (1) making a prediction about future behaviors of others, (2) holding positive expectations that the trustee will perform a valued behavior, (3) being vulnerable to the actions of the trustee.³  In pediatrics, the family develops some level of trust in the clinician, and the clinician demonstrates credibility or trustworthiness over time through actions. The family’s interpretation of the clinician’s actions modulates this level of trust in a continuing cycle.

When a family first encounters a clinician, their level of trust is based largely on preconceived assumptions about the clinician’s competence, so called competence-based trust.⁴  Contributors to this initial competence-based trust can include the family’s need to trust the clinician due to lack of other options and the inherent power differential in the relationship, as well as the family’s cultural background, past experiences within the health care system, perceptions of the particular institution, and personal biases. As such, clinicians have little active role in determining their initial credibility with the family, but their actions will determine the longitudinal trajectory of this trust and credibility.

Families test their clinicians over time against their expectations of what clinicians should do.⁵  As the clinical relationship develops, the family’s trust becomes increasingly contingent on the clinician’s demonstrated actions, which we call relation-based trust. Studies suggest that relation-based trust is supported by demonstrations of caring, fidelity, honesty, and competence.⁴ 

In this model, we hypothesize that relationship maintenance is integral to maintaining and building trust over time. By relationship maintenance, we mean consistently acting in ways that demonstrate caring, fidelity, honesty, and competence, thus demonstrating credibility and further supporting trust. However, the natural history of trust and credibility has not been firmly established in pediatrics nor is there evidence to support specific relationship maintenance practices. Common sense suggests that the following efforts might have sustaining effects on trust. Visiting a family when their child is hospitalized, personally and promptly calling with imaging results, or visiting briefly during follow-up appointments even if they are being seen by a different clinician might signal caring. Following through on promises from the previous clinic visit (eg, “I will type up a treatment summary” or “I will contact your primary pediatrician”) might demonstrate fidelity. Providing truthful prognostic information in a sensitive manner can demonstrate honesty. Demonstrating knowledge and communicating in understandable words and phrases can signal competence. Attention to a respectful and thorough physical examination might demonstrate caring and competence.

These are simple (but not easy) approaches. Although none will be a panacea, together, such approaches might show that the clinician respects the patient and family and will provide safe and effective care. Yet, the success of these interventions hinges on the clinician’s awareness of the patient’s and family’s needs and commitment to addressing them.

Despite good intentions, sometimes trust can break. This break might result from insufficient relationship maintenance, medical or communication errors, adverse events, or (often) some combination of these contributors. When trust is diminished or broken, the clinician should take steps to re-establish credibility and rehabilitate the relationship. Again, these efforts would ideally take place before crises, but breaks in trust might not become apparent until the relationship is strained by clinical circumstances. Clinicians in this situation can borrow concepts from the conflict resolution literature to realign with the family. This literature suggests that communication efforts should be focused on identifying the family’s underlying interests, seeking their truth, and recognizing anger as a reactive emotion.⁶  Although this approach was developed for ethics consultations, we have found these approaches to be effective in the clinical setting when trust has been damaged. This type of communication is often uncomfortable for clinicians and requires preparation and practice. An apology can also help to defuse situations and humanize the clinician but only if sincere. Additionally, clinicians should recognize that trust from the parents does not necessarily indicate trust from the pediatric patient and vice versa. Clinicians interested in bolstering their communication skills might consider online courses or modules, such as VitalTalk, DocCom, or I*CARE, among others.

Without trust, relationships languish, and clinicians cannot provide all the care that patients and families need. Our model of trust evolution proposes that contributors to trust change over time, and necessary interventions to bolster trust must also vary by time and context. However, too much of this critical process relies on common sense rather than evidence, especially in pediatrics. More work is needed to understand how clinicians can affect this process positively and negatively. Future research should aim to characterize the inputs and outcomes of relationship maintenance and relationship rehabilitation. In the meantime, clinicians should reflect on their clinical experiences (and perhaps their own experiences as patients) to identify ways to demonstrate their caring, fidelity, honesty, and competence to patients and families.