Hypothesized predictors of patient–physician trust and distrust in the elderly: implications for health and disease management

Figures & data

Figure 1 The relationship between age, trust (Trust 1 – cooperation, caring, and vulnerability; Trust 2 – quality and hospital reputation; Trust 3 – confidence; Trust 4 – distrust and fear) and patient satisfaction.

Table 1 Sample sociodemographics

Variables	Study 1	Study 2	Study 3	Entire study
Sample size	200 (100.0 %)	141 (100.0 %)	174 (100.0 %)	515 (100.0 %)
Gender
Female	200 (100.0 %)	108 (76.6 %)	78 (44.8 %)	386 (75.0 %)
Male	0 (0.0 %)	33 (23.4 %)	96 (55.2 %)	129 (25.0 %)
Ethnicity
African American	101 (50.5 %)	119 (84.4 %)	140 (80.5 %)	360 (69.9 %)
Caucasian	69 (34.5 %)	15 (10.6 %)	22 (12.6 %)	69 (20.6 %)
Others	30 (15.0 %)	7 (5.0 %)	12 (6.9 %)	49 (9.5 %)
Marital status
Married	105 (52.5 %)	40 (28.4 %)	32 (18.4 %)	177 (34.4 %)
Separated/divorced	27 (13.5 %)	32 (22.7 %)	39 (22.4 %)	98 (19.0 %)
Widowed	50 (25.0 %)	38 (26.9 %)	18 (10.3 %)	106 (20.6 %)
Never married	18 (9.0 %)	31 (22.0 %)	85 (48.9 %)	134 (26.0 %)
Age (years)	58.5 ± 11.7	59.3 ± 18.2	50.5 ± 13.9	56.1 ± 14.9
Education (years)	13.0 ± 2.7	13.0 ± 3.0	11.3 ± 3.2	12.4 ± 3.1
Highest degree
None	28 (30.4 %)	26 (18.4 %)	69 (39.7 %)	128 (23.9 %)
High School	36 (39.1 %)	76 (53.9 %)	96 (55.2 %)	208 (40.4 %)
Associate’s	13 (14.1 %)	13 (9.2 %)	2 (1.1 %)	28 (5.4 %)
Bachelor’s	13 (14.1 %)	18 (12.8 %)	5 (2.9 %)	36 (7.0 %)
Master’s/Doctoral	2 (2.2 %)	8 (5.7 %)	2 (1.1 %)	2 (2.3 %)
Occupation
Employed	131 (65.5 %)	92 (65.2 %)	72 (41.4 %)	295 (57.3 %)
Unemployed	69 (34.5 %)	49 (34.8 %)	102 (58.6 %)	220 (42.7 %)
Income (In $US)
≤ $20 000	36 (40.0 %)	54 (42.5 %)	137 (80.6 %)	227 (44.1 %)
$20 001–60 000	30 (33.3 %)	61 (48.0 %)	27 (15.9 %)	118 (22.9 %)
$60 001–100 000	16 (17.8 %)	8 (6.3 %)	4 (2.3 %)	28 (5.4 %)
≥$100 000	8 (8.9 %)	4 (3.2 %)	2 (1.2 %)	14 (2.7 %)
Health insurance
Insured	199 (99.5 %)	141 (100.0 %)	126 (72.4 %)	466 (90.5 %)
Uninsured	1 (0.5 %)	0 (0.0 %)	48 (27.6 %)	49 (9.5 %)

Note: Values are mean ± standard deviation or n and %. Percentages are derived from column totals and adjusted for missing data.

Table 2 Comparison between trust and satisfaction among elderly (age ≥65 years) and younger (age <65 years) groups

Variables	Younger group (Age <65 years) [n = 364]	Elderly group (Age ≥65 years) [n = 141]	t	p
Trust 1 (cooperation, caring, vulnerability)	4.62 ± 0.54	4.68 ± 0.53	−1.149	0.251
Trust 2 (quality & hospital reputation)	4.70 ± 0.55	4.81 ± 0.43	−1.976	0.049
Trust 3 (confidence)	4.48 ± 0.69	4.47 ± 0.70	0.159	0.874
Trust 4 (distrust & fear)	4.28 ± 0.90	4.03 ± 0.92	2.808	0.005
Total trust	4.52 ± 0.54	4.49 ± 0.47	0.523	0.601
Satisfaction	4.62 ± 0.64	4.69 ± 0.50	−1.199	0.231

Note: Values are mean ± standard deviation.

Table 3 Characteristics of the female breast cancer patients (Study 1: n=170)

Variable	African-American (n=101)	Caucasian (n=69)	p value
Nr of patients	101 (59.4)	69 (40.6)	…….
Age (years)	60.0 ± 10.5	54.3 ± 10.7	0.001
Education (years)	12.1 ± 2.4	14.5 ± 2.6	0.001
Marital status			0.022
Never married	9 (9.7)	4 (8.7)
Married	36 (44.4)	54 (71.7)
Separated/divorced	21 (19.4)	4 (4.3)
Widowed	35 (26.4)	7 (15.2)
No. of children	3.2 ± 1.9	2.1 ± 1.4	0.001
Occupation			0.634
Unemployed	50 (92.0)	10 (100.0)
Employed	4 (8.0)	17 (0.0)
Annual household income (In $US)			0.001
Up to $20 000	33 (29.2)	2 (0.0)
$20 001–40 000	17 (66.7)	3 (66.7)
$40 001–60 000	2 (0.0)	4 (33.3)
$60 001–80 000	0 (4.2)	6 (0.0)
$80 001–100 000	0 (4.2)	5 (4.2)
$100 000+	1 (4.2)	6 (4.2)
Year of breast cancer diagnosis			0.298
1970–1993	18 (17.8)	6 (8.7)
1994–2003	83 (82.2)	63 (91.3)
Type of breast cancer treatment			0.184
None	13 (16.9)	1 (2.2)
Chemotherapy	10 (11.3)	6 (11.1)
Radiation therapy	3 (4.2)	3 (6.7)
Tamoxifen (Nolvadex)	8 (9.9)	5 (11.1)
Combination/other	67 (57.7)	54 (68.9)
Type of breast cancer surgery			0.018
None	4 (5.6)	1 (2.2)
Lumpectomy	43 (50.0)	31 (43.5)
Mastectomy	46 (36.1)	20 (23.9)
Mastectomy & breast reconstruction	5 (4.2)	14 (23.9)
Combination/other	3 (4.2)	3 (6.5)
Measures of trust & satisfaction
Trust1 – cooperation, caring & vulnerability	4.7 ± 0.5	4.6 ± 0.4	0.328
Trust2 – quality & hospital reputation	4.6 ± 0.6	4.6 ± 0.6	0.976
Trust3 – confidence	4.8 ± 0.4	4.9 ± 0.3	0.181
Trust4 – distrust & fear	4.2 ± 1.0	4.5 ± 0.7	0.028
Total trust	4.6 ± 0.5	4.6 ± 0.4	0.400
Satisfaction	4.8 ± 0.5	4.8 ± 0.4	0.452

Table 4 A synthesis of theories and definitions of trust and distrust

Theory (Authors)	Approach	Definition of trust	Definition of distrust	Implications for patient–physician encounters
Table 4A: Trust and distrust as polar opposites
Psychology (Meillinger 1956; Deutsch 1960; Read 1962)	Trust as an individual trait	Trust is one’s confidence in another’s positive intentions and promises.	Distrust is one’s confidence about one’s undesirable behavior.	Foster trusting and avoid distrusting confidence of patients.
Behavioral (Deutsch 1960; Lewis and Weigert 1985)	Trust as a rational predictive choice of a partner. Devoid of real social context, trust is a function of incentives.	Trust is cooperative conduct in a conflicting interpersonal encounter.	Distrust is a non-cooperative conduct in a mixed-motive game situation. Distrust is a psychological disorder.	Normatively, trust is good, distrust is bad. Nurture trust to solve intractable conflict situations and to promote effective collaboration.
Personality disposition (Rotter 1967, 1971; Stack 1978; Tardy 1988)	Trust is a personal pre-dispositional attribute	Trusting pre-dispositions indicate low expectations and cooperate better.	Distrusting predispositions indicate high expectations and cooperate less with the trusted.	Distrust is a psychological disorder that needs to be corrected. Trust–distrust transcends the social context.
Expectation (Rotter 1980; Zucker 1986; Gambetta 1988)	Trust as a generalized expectancy	Trust is a set of expectations that the trusted will behave in a helpful manner as expected by the trustor.	Distrust is a set of expectations that the trusted will not behave helpful as expected by the trustor.	Assure patients that you will act always in their interests, thus converting distrust to trust.
Table 4B: Trust and distrust as complimentary constructs
Organizational psychology (Garfinkel 1963; Baier 1986; Lewis and Weigert 1985; Zucker 1986; Shapiro 1987)	Trust as an organizational phenomenon supported by institutional mechanisms.	Trust as believing in the institutional systems (normal situations and structural assurances) that support trust.	Distrust as believing in the institutional systems (abnormal situations and structural non-assurances) that support distrust.	Complexity, undesirability and vulnerability of modern healthcare outcomes can weaken situation normality and structural assurances that, in turn, could result in high distrust levels.
Sociology (Luhmann 1990; Lewicki et al 1998)	Trust–distrust as a mechanism for reducing social complexity and uncertainty.	Trust and distrust coexist as functional equivalents or substitutes for reducing social complexity.	Trust is a positive expectation of beneficial action; distrust is a positive expectation of injurious action.	Do not over-trust. Total, unconditional trust could be dangerous for managing social relations.
Social psychology (Cacioppo et al 1997; Lewicki et al 1998)	Trust–distrust as a continuum of a psychological state that is unstable and transitory.	Trust as positive-valent and distrust as negative-valent attitudes can coexist.	Trust involves confident positive expectations and distrust involves confident negative expectations regarding trusting partners.	Trust is a necessary ingredient for social order; hence, focus on nurturing trust. Be sensitive to sources of patient distrust and manage them carefully.
Interdependence (Sitkin and Ross 1993; Mayer et al 1995; Williams 2001)	Trust–distrust as interdependent behavioral expectations amidst complexity and vulnerability.	Trust is a function of one’s dependence upon and vulnerability regarding the other party.	Distrust is also a function of one’s dependence upon and vulnerability regarding the other party.	Trust–distrust investment should not be too high, or too low, but geared to meet all situations within the complexities and risks of modern healthcare systems.

Table 5 Patient–physician interpersonal relations as a function of low and high, trust and distrust

Patient trust:	Patient distrust
	Low: Low fear Low skepticism Low cynicism Low monitoring Low vigilance	High: High fear High skepticism High cynicism High monitoring High vigilance
High: High hope, High faith, High confidence High assurance High initiatives	Patient–physician: High value congruence; common objectives; frequent interactions; Pooled positive and trust-reinforcing experiences; few defense mechanisms; Conversations are rich, deep, personal and occasionally complex; Hence, reason to be mutually confident; No reason for suspicion; High willed pooled interdependence and cooperation; All opportunities for sharing information pursued; New trust-building initiatives sought.	Patient–physician: Sustained trust and distrust; trust constantly verified; Strong reason to be confident in certain areas and diffident in others; Relationships are multiplex, multifaceted, highly segmented and bounded; like in strategic alliances; Significant amounts of information shared under strict confidentiality; Collaboration opportunities pursued but risks assessed; Vulnerabilities continuously monitored and protected.
Low: Low hope, Low faith, Low confidence Low assurance Few initiatives Low resistance	Patient–physician: Casual acquaintance; Careful, bounded, arms-length discrete transactions; No pooled trust-reinforcing experiences; Conversations simple and casual; No closeness or intimacy; No threats to confidentiality as little information of consequence is shared; No reason to fear or be confident; Limited interdependence and cooperation; Just professional courtesy.	Patient–physician: Undesirable eventualities expected and feared; Conversations are cautious, guarded, and often laced with cynicism Pooled negative distrust-reinforcing experiences; bureaucratic checks; No reason for mutual confidence; Strong reason for watchfulness; Significant resources for monitoring; Harmful or exploitative motives not ruled out; Interdependence difficult over time or at best, carefully managed; Offensive self-defense.

Note: Adapted from Lewicki et al 1998.

Table 6 Patient–physician trust–distrust scale statements

[*Bracketed numbers indicate the most likely quadrant the statement fits under Table 5].

I have very strong positive hopes about modern medicine and what doctors can do for me. [1]* I have tremendous faith in physicians, doctors, nurses and other healthcare providers. [1] I have every reason to suspect the profitability motives of the health insurance companies (eg, HMO, HAP). [4] My unfamiliarity with our complex healthcare delivery system makes me very distrustful of what my doctors can do for me. [2] The cost-controlling devices of managed healthcare (eg, HMOs) make me very skeptical about the treatment-efficiency of my doctors. [2] At times, I am very cynical about the morality of our healthcare delivery system. [2] The government should very carefully monitor our entire healthcare system. [2] The current complex healthcare system makes me doubt the competence of my doctors, nurses and other caregivers. [2] I deeply distrust managed care (eg, BCBS, HMOs, HAP) that controls my doctor’s care for me. [4] I am losing faith in our health delivery system that is controlled by health insurance companies. [3] Our information privacy laws make me feel very uneasy when disclosing vital information about myself to my doctors. [4] I am very scared that when I get sick I will be totally dependent upon doctors, nurses and hospitals. [4] I am afraid my interests and health objectives do not meet those of my primary physician. [3] I am very afraid that my interests and health objectives do not meet those of my specialty doctors. [4] Given our profit-oriented managed healthcare systems (eg, HMOs), I have every reason for suspecting the quality of care my doctors can deliver to me. [2] My conversations with my doctors are rich, deep, personal and very straightforward. [1] Because of my fears and anxiety about my disease, I am not fully ready to cooperate with my doctor. [2] I have tremendous confidence in my doctor’s technical and professional skills in handling my case. [1] I have full faith in my doctor, in his/her abilities, skills and decisions. [1] I am very confident about my doctor’s sincerity in treating my sickness. [1] I do not give my best cooperation in listening and following my doctor’s advice. [3] I am very obedient to whatever my doctor will ask me to do regarding my health problem. [1] I am afraid my doctor will exploit my vulnerability concerning my ill-health and not really care. [4] I am very hesitant about disclosing negative information about myself to my doctor. [4] I am distrustful of my doctor’s interests and intentions regarding my treatment. [3] At times, I am scared about my doctor as to what he/she will say, decide and do about my disease. [3] I deeply distrust doctors, nurses, and hospitals, in general. [4] The hospital administration is very careful in its choice of nurses and other support staff. [1] I feel very comfortable in the hospital because of the very cooperative and understanding staff. [1] My hospital has the best reputation for medical excellence. [1] Because modern medicine is so sophisticated, I totally depend upon my doctor’s knowledge and skills. [2] Thanks to regular government quality control, I am very trustful of my doctor and his/her treatment. [2] Despite my unfamiliarity with doctors, nurses and hospitals, I feel very confident about my treatment. [1] I trust my doctor to put my medical needs above all other considerations when treating my medical problem. [3] . I love my doctors and nurses so much for the sensitivity with which they communicate with my family. [1] My doctor is a very caring person and I feel very happy about it. [1] I feel that my conversations with my doctors are very careful, bounded, guarded and discrete. [3] I have no reason to hope for high levels of mutual confidence as far my doctors are concerned. [4] I am very watchful and vigilant as to what doctor will say, diagnose, and treat about case. [4] I feel no closeness to my doctors and feel forced to deal with them with just professional courtesy. [3] I pursue all opportunities for sharing all my health information with my doctors with utmost openness. [1] I feel my doctor cannot do much for me because of the severity of my illness. [4] I feel the hospital can do only so much for me owing to my health insurance carriers. [4] I feel I cannot rule out harmful motives of my doctors as far as my health is concerned. [4] It is too risky for me to totally collaborate with my doctor during my office visits. [3] It is part of my personality that I deeply distrust doctors, nurses and hospitals in general. [4] I naturally distrust my doctors once I know that they do not care. [2] I am a very trusting person when it comes to healthcare, doctors and nurses. [1] Given the complexity of modern healthcare, I cannot but trust doctors and nurses. [2] I am afraid to trust my doctors, nurses and hospitals when I encounter a serious disease. [3] There is great sense of bonding with my doctor because of his/her gentleness and compassion. [1] I am very satisfied with my treatment because of the excellent teamwork skills of my doctors. [1] I am very happy and content with my doctor. [1] I would not change my doctor for anybody in the world. [1] I would gladly recommend my doctor to anybody. [1] I am very satisfied with my doctor. [1] I love my doctors and nurses because they treat me as a person with dignity, feelings and beliefs. [1] I am very satisfied with the entire staff of doctors, nurses, and support people. [1] I am very satisfied with my nurse. [1]

Abbreviations: BCBS, Blue Cross, Blue Shield; HAP, Health Alliance Plan; HMO, Health Maintenance Organization.

Table 7 Distribution of trust–distrust scale statement by theories of trust–distrust

Theory (Authors)	Approach	Definition of trust	Definition of distrust	Trust–distrust scale items
Table 7A Trust and distrust as polar opposites
Psychology (Meillinger 1956; Deutsch 1960; Read 1962)	Trust as an individual trait	Trust is one’s confidence in another’s positive intentions and promises.	Distrust is one’s confidence about one’s undesirable behavior.	1, 18, 19, 20, 34, 49
Behavioral (Deutsch 1960; Lewis and Weigert 1985)	Trust as a rational predictive choice of a partner. Devoid of real social context, trust is a function of incentives.	Trust is cooperative conduct in a conflicting interpersonal encounter.	Distrust is a non-cooperative conduct in a mixed-motive game situation. Distrust is psychological disorder.	5, 16, 17, 21, 24, 29, 35, 36, 41
Personality Disposition (Rotter 1967, 1971; Stack 1978; Tardy 1988)	Trust is a personal pre-dispositional attribute	Trusting pre-dispositions indicate low expectations and cooperate better.	Distrusting predispositions indicate high expectations and cooperate less with the trusted.	2, 6, 22, 25, 27, 46, 47, 48, 50
Expectation (Rotter 1980; Zucker 1986; Gambetta 1988)	Trust as a generalized expectancy.	Trust is a set of expectations that the trusted will behave helpful as expected by the trustor.	Distrust is a set of expectations that the trusted will not behave helpful as expected by the trustor.	3, 4, 14, 15, 23, 44,
Table 7B: Trust and distrust as complimentary constructs
Organizational psychology (Garfinkel 1963; Lewis and Weigert 1985; Baier 1986; Zucker 1986; Shapiro 1987)	Trust as an organizational phenomenon supported by institutional mechanisms.	Trust as believing in the institutional systems that support trust.	Distrust as believing in the institutional systems that support distrust.	3, 5, 9, 11, 15, 28, 30, 43
Sociology (Luhmann 1990; Lewicki et al 1998)	Trust–distrust as a mechanism for reducing social complexity and uncertainty.	Trust and distrust coexist as functional equivalents or substitutes for reducing social complexity.	Trust is a positive expectation of beneficial action; distrust is a positive expectation of injurious action.	7, 11, 26, 38, 42, 43
Social psychology (Cacioppo et al 1997; Lewicki et al 1998)	Trust–distrust as a continuum of psychological state that is unstable and transitory.	Trust as positive-valent and distrust as negative-valent attitudes can coexist.	Trust involves confident positive expectations and distrust involves confident negative expectations regarding trusting partners.	8, 16, 37, 39, 40, 44, 45,
Interdependence (Mayer et al 1995; Sitkin and Ross 1993; Williams 2001)	Trust–distrust as interdependent behavioral expectations amidst complexity and vulnerability.	Trust is a function of one’s dependence upon and vulnerability regarding the other party.	Distrust is also a function of one’s dependence upon and vulnerability regarding the other party.	9, 10, 12, 31, 32, 49

Table 8 Distribution of scale statement in the trust–distrust quadrants

Patient distrust
	Low	High
High	Quadrant 1	Quadrant 2
	1,2, 16, 18, 19, 20, 22, 28, 29, 30, 33, 35, 36, 41, 48 [15 items]	4, 5, 6, 7, 8, 15, 17, 31, 32, 47, 49 [11 items]	26
Low	Quadrant 3	Quadrant 4
	10, 13, 21, 25, 26, 34, 37, 40, 45, 50 [10 items]	3, 9, 11, 12, 14, 23, 24, 27, 38, 39, 42, 43, 44, 46 [14 items]	24
Total number of items	25	25	50

Table 9 Profile of patient–physician trust levels: costs versus benefits

Physician’s trust level		Patient’s trust level
		Low	High
Low	Costs	Both patient and physician: low mutual cooperation, low mutual honesty, low mutual benevolence	High agency costs for the patient: high trust investment costs; high affect and emotion costs; high health-loss probability; very few options; low monitoring ability. For the doctor: no significant costs
	Benefits	Both patient and physician: low involvement; low interdependence; low investments, and low benefits.	Almost none to patients; Significant benefits to doctors.
	Risks	Physician-opportunism Low physician commitment	Patient abuse; Patient exploitation, Patient dissatisfaction; Patient may switch & not return.
High	Costs	High agency costs for the doctor: high trust investment costs; high affect and emotion costs; high loss probability; very few options; low monitoring ability. For the patient: no significant costs	Both for patient and physician low agency costs such as: bonding costs monitoring costs warranty-guarantee costs; search costs
	Benefits	Almost none to doctors; Significant benefits to patients.	Both for patient and physician: high commitment; high mutual cooperation, healthy interdependence; high mutual honesty, high mutual benevolence high satisfaction.
	Risks	Doctor abuse; Doctor exploitation, Doctor dissatisfaction; Doctor may refuse treatment. Patient’s opportunism. Patient’s betrayal.	Sustaining high mutual trust; High dependence; Stifled creativity due to over-trust; Few other options due to over-trust.

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