In this biracial population of patients with hypertension, positive physician affect was significantly associated with higher patient trust in the entire sample and among black patients. This study also confirmed previous findings of lower trust among black compared to white patients3,4,23,24,34,35
and less patient-centered communication behaviors among black compared to white patients14,16
. Physician informational behaviors and communication process variables were not significantly associated with patient trust, in models adjusted for patient factors, race concordance, and intervention group status.
Although previous work has not examined the associations between objective measures of physician affective behaviors and patient trust, one study assessed the association between patient perceptions of physician’s supportiveness and trust23
. Also, within the Primary Care Assessment Survey, patient reports of interpersonal treatment and of trust were found to be positively correlated36
. Neither of these studies examined their findings by patient race, but their overall associations were consistent with our overall model for positive physician affect and patient trust.
An intriguing and somewhat parallel result was found within the context of depression medication management visits conducted by psychiatrists37
. Psychiatrists’ positive affect was associated with appointment keeping adherence for both black and white patients; however, analysis stratified by patient race showed that the appointment keeping rate for blacks at low levels of positive affect was substantially lower (32%) than the rate found at moderate (58%) and high (64%) levels of physician positive affect. For white patients, this difference was far less marked (80% (low) vs. 96% (moderate) and 98% (high)). These findings suggest that positive physician affect may moderate trust and that the consequences for continuance in treatment are stronger for black than for white patients37
The effect of race concordance in patient-provider dyads on the association between patient perceptions of provider behavior and trust was also previously examined23
. This sample did not include black concordant interactions, but patients in discordant visits perceived that their physicians were less supportive compared with patients in white concordant visits, and post-visit trust ratings were lower in black (patient) discordant visits compared with white (patient) discordant and white concordant visits23
. In our secondary analyses, we observed that positive physician affect was significantly associated with patient trust in race-discordant relationships. Positive physician affect was not significantly associated with patient trust in race-concordant relationships, but the magnitude of the association was similar to that observed in race-discordant relationships.
Our lack of observed associations between physician communication process variables and patient trust is somewhat consistent with prior work. Similar to the analysis of patient trust and patient-centered behaviors of primary care physicians22
, we failed to show a statistically significant association between patient-centeredness with trust; the previous work also failed to show associations between two components of patient-centeredness and trust22
. Despite this similarity, our findings expand on the prior work where each physician’s communication style was measured using a standardized patient and related to trust ratings from patients within his or her practice, whereas we measured communication behaviors in actual patient visits. In addition, our sample of black and white patients enabled us to assess race-specific differences in the association between physician communication behaviors and trust.
Our findings regarding informational and partnership behaviors differ from those of previous work23,24
, in which patient ratings of physician informational behaviors23,24
were related to trust, and in one study, a stronger association was observed among black patients24
. These findings might differ for several reasons, including differences in study sample composition or in the measurement and analysis of communication data. In sensitivity analyses, we found no association between physician biomedical or psychosocial information giving behaviors and trust.
Perceived discrimination and its relationship to racial/ethnic health disparities have been well documented38
, although the mechanism by which they are related is poorly understood39
. As expected, prior discrimination was strongly associated with trust40
, and unrelated to most physician verbal communication behaviors41
. Our observation that physician positive affect was related to trust among black patients even after adjustment for prior discrimination is consistent with prior work that suggests that blacks are particularly sensitive to non-verbal cues and may use them in making judgments about the quality of interpersonal treatment42
. Moreover, social psychology studies suggest that implicit racial bias among physicians and stereotype threat among minority patients may be underlying factors. These may lead to poor communication behaviors, reinforcing physicians’ racial stereotypes and patients’ negative expectations, thus leading to impaired patient-physician relationships42,43
This analysis has several limitations. First, the cross-sectional nature makes it impossible to establish a causal relationship between physician communication behaviors and trust. It is possible that prior interactions with the physician or experiences in the health system in general influenced the patient’s report of trust. Alternately, physicians may display more positive communication behaviors in the presence of higher trust. Second, knowledge of the study’s objectives may have biased physician performance; however, we adjusted for physician intervention assignment and previous work suggests audiotaping has little systematic effects on communication44,45
. Third, our ability to detect small associations between certain communication behaviors and patient trust was limited by the small sample, which was underpowered to examine variations in this secondary analysis, particularly in race- and concordance-stratified analyses. Fourth, unmeasured variables, such as the length of the relationship between the patient and the physician, may have affected the results. This study did assess how well the physician knew the patient, which was not associated with patient trust. Finally, we did not measure the interactive nature or the responsiveness of physicians to patients’ specific concerns. More in-depth and nuanced qualitative analyses of the visit-specific context might provide further insights into the relationships between communication behaviors and trust.
A major strength of this study is that it is one of few studies to examine the influence of communication on trust using objective measures of physician behavior and assessments of trust from actual patients. In addition, it is one of few studies to examine whether this relationship is modified by the race of the patient or race-concordance in the relationship.
In conclusion, physicians’ positive emotional tone is associated with higher trust, particularly in the visits of African-American primary care patients. Because affective behaviors have also been shown to differ by patient race and race-concordance with physicians, communication skills training programs targeting emotion-handling and rapport-building behaviors are promising strategies to reduce disparities in healthcare and to enhance trust among ethnic minority patients46–48
. These findings have several implications for medical education, future research and clinical practice. Medical training institutions should focus on identifying effective ways of teaching and reinforcing these skills among all physicians, particularly those who care for patients from vulnerable populations. Directions for future research include improving measurement of patient-centered communication and testing the effect of training programs on patient outcomes in diverse populations. Finally, medical practices’ efforts to increase their organizational focus on patient-centeredness, for example, by measuring patient experiences and linking performance within this dimension of quality to reimbursement or other incentives, may improve patient trust and patient-physician relationships.