Introduction
Interpersonal trust is an important aspect of the clinical encounter. Trust is defined as one’s expectation that another will behave in a particular way
1 and implies that both parties understand that each others’ interests will not be violated
2. It reflects reliability, understanding and information sharing, all key components of high quality communication
3,
4. In contrast to patients’ trust in clinicians,
3,
5 clinicians’ trust in patients has not been investigated.
While some clinical decisions are based on clear objective measures, others, such as the treatment of chronic non-cancer pain, are based on more subjective assessments. The treatment of chronic pain is further complicated by the fact that while consideration of opioid analgesics is reasonable for moderate to severe pain, their use must be balanced against the risk of opioid misuse
6‐
9.
A number of patient characteristics are associated with an increase risk of opioid analgesic misuse, including history of alcohol abuse or illicit drug use
10‐
12. However, clinicians do not conform their decisions to these well described risk factors. Patients’ race/ethnicity affect treatment decisions
13‐
15. Additionally, the treatment of chronic pain varies by clinicians’ experience and training
8,
16.
In qualitative studies, clinicians have identified mutual trust as an important factor influencing chronic pain management and the prescription of opioid analgesics
7,
17‐
19. Clinicians judge patients’ risk of misuse based on “gut feelings” rather than on specific clinical characteristics associated with risk of misuse
17. Thus, clinicians’ trust in their patients may play a large role in decisions surrounding chronic pain management.
Characteristics such as patients’ race/ethnicity may affect clinicians’ trust. Studies have demonstrated that physicians perceive African American patients more negatively
20. Assessing the relationship between patient race/ethnicity and clinician trust in the patient may be helpful in understanding the effect of race/ethnicity on physician attitudes and behaviors. We analyzed a cohort of socially marginalized patients with HIV and their primary care providers in order to examine the association between race/ethnicity and trust in a uniformly low SES population with high rates of illicit drug use and prescription opioid analgesic misuse.
Results
Of the 296 patients initially enrolled in the Pain Study, 240 were active in the study at one year and provided written consent that allowed us to contact their PCP. We contacted a total of 90 PCPs for these patients of whom 61 PCPs returned completed questionnaires for a total of 169 patients.
Two-thirds of patients were male (65.1%), half were African American (46.8%), and their average age was 50 years. Approximately one quarter (27.8%) reported current use of illicit drugs. Approximately one quarter (22.5%) reported misusing opioid analgesics in the past 90 days. Most had experienced homelessness (82.0%) though few were homeless at the time of the study (5.0%). Most had a high school education or less (73.4%). The median annual income was $11,280. PCPs were mostly white (78.3%). Approximately half (46.0%) were male. The majority were in practice between 10 and 19 years. None were in practice fewer than four years. Most (83.6%) were physicians (Table
1).
Table 1
Patient (n = 169) and Provider (n = 61) Demographic Characteristics, and Unadjusted Association of Predictors with Physicians’ Trust in Patients Scale (PTSP) Scores
Total sample (mean, SD) | -- | 43.2 (10.8) | -- |
Patient age (years, SD) | 49.5 (6.9) | 0.1 (0.1)*
| 0.52 |
Patient sex | | | |
Male | 110 (65) | 44 (1.1) | -- |
Female | 59 (35) | 42 (1.5) | 0.26 |
Annual income (median, IQR) | 11,280 (10,440, 11,904) | -- | -- |
Education | | | |
Less than high school | 49 (29) | -- | -- |
Finished high school | 75 (45) | -- | -- |
Greater than high school | 44 (26) | -- | -- |
Patient race/ethnicity | | | |
White | 60 (36) | 47.3 (1.4) | -- |
African American | 79 (47) | 41.6 (1.2) | <0.001 |
Latino | 12 (7) | 42.8 (2.5) | 0.11 |
Other | 13 (8) | 35.9 (2.9) | <0.001 |
Opioid analgesic misuse†
| | | |
No | 73 (43) | 44.3 (2.0) | -- |
Yes | 96 (57) | 39.7 (1.8) | 0.03 |
Current drug use‡
| | | |
No | 122 (72) | 44.8 (1.0) | -- |
Yes | 47 (28) | 39.2 (1.6) | <0.01 |
Lifetime alcohol abuse or dependence§
| | | |
No | 68 (41) | 43.3 (1.4) | -- |
Yes | 96 (59) | 43.2 (1.27) | 0.93 |
Lifetime history of homelessness | 136 (82) | -- | -- |
Homeless at time of interview | 10 (5) | -- | -- |
Incarceration (prison) | 25 (16) | -- | -- |
Provider sex | | | |
Male | 28 (46) | 44.1 (1.27) | -- |
Female | 33 (54) | 42.5 (1.25) | 0.35 |
Provider age (years, s.d.) | 46.7 (8.3) | -- | -- |
Provider race/ethnicity | | | |
White | 47 (71) | 43.2 (1.0) | -- |
Non-white | 13 (29) | 43.3 (1.9) | 0.97 |
Provider type | | | |
PA/NP | 10 (16) | 45.1 (1.8) | -- |
MD | 51 (84) | 42.7 (1.0) | 0.23 |
Years in practice | | | |
4 to 9 | 11 (18) | 45.2 (2.6) | -- |
10 to 19 | 31 (51) | 43.6 (1.1) | 0.57 |
> 20 | 19 (31) | 41.9 (1.4) | 0.28 |
Clinic panel with chronic pain | | | |
Some | 29 (48) | 43.8 (1.4) | -- |
About half | 24 (39) | 41.8 (1.3) | 0.32 |
Most to almost all | 8 (13) | 45.3 (1.9) | 0.52 |
The prevalence of current illicit drug use as well as opioid analgesic misuse did not differ in a manner that was statistically significant between racial or ethnic groups (
p = 0.71 and
p = 0.18 respectively). The mean PTPS score was 43.2 (SD 10.8.) Bivariate models showed an association of both African American and “other” patient race with lower mean PTPS scores, as well as an association between current illicit drug use, as reported by the patient and lower mean PTPS scores (Table
1). Bivariate models showed a trend towards lower PTPS scores among patients who reported opioid analgesic misuse although the effect did not reach statistical significance.
In the adjusted multivariate analysis, non-white patient race/ethnicity was significantly associated with lower PTPS scores (Table
2). Current drug use was also associated with lower PTPS scores (
p < 0.01). Opioid analgesic misuse was not significantly associated with differences in PTPS scores (
p < 0.01). PCPs with more than 20 years in practice rated patients as having significantly lower PTPS scores (
p < 0.05). The test for trend across categories was significant at
p < 0.05. The Wald statistic for the multivariate model was 52.4 with
p < 0.001.
Table 2
Multivariate Model for Physicians’ Trust in Patients Scale (PTPS) Scores
Patient | | |
Female | 3.1 (−1.1, 7.2) | 0.15 |
Age (years) | 0.1 (−0.1, 0.3) | 0.45 |
Non-white | -6.3 (−9.9, -2.7) | <0.01 |
Opioid analgesic misuse*
| -4.7 (−10.1, 0.7) | 0.09 |
Current drug use†
| -5.5 (−8.5, -2.5) | <0.01 |
Lifetime alcohol abuse or dependence‡
| 1.2 (−1.7, 4.1) | 0.42 |
Provider | | |
Female | -1.1 (−5.3, 3.1) | 0.62 |
Non-white | 0.6 (−3.3, 4.4) | 0.76 |
Physician | -2.7 (−7.9, 2.4) | 0.29 |
Years in practice | | |
4 to 9 | 0 | -- |
10 to 19 | -2.6 (−7.7, 2.4) | 0.31 |
> 20 | -6.8 (−12.2, -1.5) | 0.01 |
Clinic panel with chronic pain | | |
Some | 0 | -- |
About half | 0.3 (−3.6, 4.2) | 0.88 |
Most to almost all | 2.3 (−1.9, 6.5) | 0.29 |
Discussion
Our study found that in a cohort of socially marginalized patients with HIV infection receiving primary care, PCPs reported less trust of patients with a history of illicit drug use and patients who were of non-white race/ethnicities. Our findings are consistent with studies that suggest variations in PCPs’ attitudes and prescribing decisions in different racial groups with chronic pain
14,
30. They extend the literature by specifically investigating the construct of trust within a low socioeconomic status cohort. In this sample, where every patient is indigent and many have significant illicit substance use and incarceration histories—and therefore is at higher than average risk for opioid analgesic misuse—one might not expect such variation in trust scores across different racial/ethnic groups. Our finding of attitudes of distrust towards non-white patients is consistent with studies of the general population
31‐
33. In our study sample, rates of illicit substance use and opioid analgesic misuse were similar among racial groups. This finding is consistent with previous reports that showed that African Americans are no more likely to misuse prescription opioid analgesics than are whites
10.
Trust in patients represents an important component of the clinical encounter and may serve as a provider-level mediator of disparities in care
34. Even in this study of socially marginalized patients, PCPs’ trust in patients appears to be guided in part by perceptions of racial/ethnic groups, and not solely by individual patients’ illicit drug use or opioid analgesic misuse. Trust is based on a subjective assessment of the patient, and may be influenced by unconscious biases and stereotypes. Clinical situations with high degrees of “cognitive load” (e.g. risk, stress, uncertainty) generally increase providers reliance on biases and stereotypes
35,
36. Chronic pain management, with the possibility of medication diversion and the simultaneous concern of under-treatment of pain, presents just such a situation. Thus, PCPs’ differential trust of non-white patients’ in a cohort of indigent patients might underlie well demonstrated disparities in pain management
13,
37‐
39.
The risk, uncertainty, and lack of objective findings that typify the management of chronic pain are not unique to this condition. Many conditions commonly encountered in primary care lack clear objective findings and are managed very differently between providers. Therefore, it is likely that trust in patients plays a role in many other clinical decisions.
Aside from clinical uncertainty, there are two characteristics of trust in patients that make it particularly relevant to clinical decision-making. First, the construct of trust is future oriented: it involves an expectation of future actions
40,
41. Especially in primary care relationships that involve prevention or management of chronic diseases, differential expectations of patients’ future actions have the potential to modify clinical decisions such as medication intensification. Second, trust is closely related to power. Communication strategies such as patient-centered communication, where the patient’s perspective is elicited and incorporated into decision making, requires sharing power and responsibility
42. Clinicians’ trust of their patient is a necessary step in this process
2. Differences in trust may affect the degree to which patient-centered communication can be achieved.
PCPs who were in practice longer reported lower trust scores of his or her patients. It is possible that an accumulation of negative experiences with patients may lead to decreases in trust. Alternatively, this association may represent broader issues of decreased professional satisfaction, more prevalent among older providers
43. Finally, while our study was underpowered to explore whether the length of time in practice differentially affected trust in patients by race/ethnicity, a third potential explanation is that recent increased emphasis in educational settings about disparities and biases/stereotypes has led to more recently trained providers’ greater trust scores.
Our findings speak to the need to better train clinicians in how to recognize and account for unconscious racial biases and stereotypes. Unconscious attitudes represent an important aspect of disparities education. Training about assumptions and biases may be best integrated into teaching clinical decision-making: increasing clinicians’ awareness of biases and encouraging careful consideration of decisions based on intuition. Alternatively, tests of implicit assumptions may serve an educational role in increasing clinicians’ self-awareness of unconscious biases
44.
Several limitations need to be acknowledged. The social marginalization of patients (marginally housed, HIV infected, with high rates of illicit drug use) limits the generalizability of findings to other populations. Our sample size was relatively small and, in particular, the number of non-white PCPs was small. This limited our ability to analyze patient-clinician racial/ethnic concordance, an important contributor to processes of care
45. Finally, although socioeconomic status (SES) is a common confounder of race and affects PCPs’ perceptions,
20 the uniformly low SES of the patients in this study decreases the chance of SES confounding the relationship.
Findings from this study suggest that patients’ race/ethnicity affects PCPs’ trust in patients in a socially marginalized cohort. PCPs caring for similar populations should be aware of the potential for both their trust in patients and their interpretation of behaviors to be affected by unconscious racial biases. Our findings add support for the implementation of standardized policies regarding chronic pain management as an alternative to management strategies that rely on PCP discretion. Policies such as urine toxiciology and pain treatment agreements have the potential to standardize care. However, recent evidence suggests that their routine use should be reconsidered because of limited evidence of their effectiveness
46. As new approaches to chronic pain management are developed, close attention must be paid to the role of providers’ unconscious biases, and the potential for racial biases to be translated into disparities in care. Future research on PCPs’ trust in patients should target its role as a potential mediator of clinical decision-making, the role of PCP race/ethnicity, as well as whether our findings generalize to other clinical settings and to less marginalized populations.