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 pain14,30
. 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 population31–33
. 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 whites10
Trust in patients represents an important component of the clinical encounter and may serve as a provider-level mediator of disparities in care34
. 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 stereotypes35,36
. 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 management13,37–39
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 actions40,41
. 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 responsibility42
. Clinicians’ trust of their patient is a necessary step in this process2
. 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 providers43
. 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 biases44
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 care45
. 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 effectiveness46
. 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.