Building patient trust: Cultural awareness and competence in healthcare

Trust between patients and providers can present itself in many different ways. When it comes to trusting patients, quality care requires providers to:

• Trust that the patient’s experiences are real and accurately relayed
• Trust that the patient is competent to make their own health decisions
• Trust that the patient is making the decisions they need to make given their circumstances
• Trust that the patient will follow medical order to the best of their ability

Patients, on the other hand, need to:

• Trust that the provider has their best intentions in mind
• Trust that the care the provider is giving (and choices therein) are the best option given all known information
• Trust in the competence of the provider (proper experience, credentials, etc.)
• Trust that medical orders are for the true benefit of their health and medically necessary for desired outcomes
• Trust that the provider is being honest and forthright with information
• Trust that the provider respects them and their agency
• Trust that the provider is motivated by the “right” things, like patient health over the bottom line, efficiency, etc.

It is important to note that distrust is not an inherently unreasonable or harmful attitude and may be a sign of self-preservation in communities that have previously experienced forms of discrimination and bias in the medical setting. Trust in physicians, patient satisfaction, and perceptions of being treated with respect are all lower among racial minority patients than white patients. Other identities and characteristics including gender, sexuality, socioeconomic status, language and ability also affect patients’ experiences when receiving care. “Medicine is not an area where we should assume people trust us—in fact, distrust should be the assumption,” explains Mary Bowman, a clinician at Folx Health, a digital healthcare service provider specifically designed to offer customized care to LGBTQ+ patients. “Historically, medicine has been extremely harmful to many communities including trans people, women, Black people, and indigenous people, to name a few.”

That being said, distrust can have serious harmful consequences for patients when it holds them back from accessing and accepting the care they need. “Individuals that are distrustful of the healthcare system, especially due to poor previous experiences, might only interact with the system if they are facing some sort of emergency or facing some sort of really intense exacerbation of their particular condition. Oftentimes they will also not follow up with care or follow provider recommendations because of this distrust. This is why trust is like the gate through which people can enter and engage with the healthcare system, which is important because the earlier somebody can get into treatment, the better their outcomes will be,” explains Kay Nikiforova, Head of Clinical and Research at Violet, a digital platform dedicated to benchmarking and educating clinicians on delivering culturally competent care.

Cultivating trust in patient-provider relationships is crucial not only for attaining positive health outcomes but also for reducing disparities and barriers within healthcare. Understanding why minority patients may harbor distrust and working to rebuild that trust and create safe environments for patients is a necessary step for achieving health equity.

The nature of trust and distrust in the patient-provider relationship can look different for unique patient populations. LGBTQ+ patients, for example, face numerous health disparities that affect the care they receive and their attitudes toward that care. Countless studies have found that compared to their heterosexual counterparts, LGBTQ+ patients are at greater risk of numerous behavioral and physical health conditions. These risk factors and behaviors include but are not limited to alcohol use, illegal drug use, smoking, obesity, and high prevalence of HIV and STIs, as well as mental health issues like depression, anxiety, eating disorders, and suicide.

LGBTQ+ people also face disparities in access to care, meaning they are less likely to have health insurance, more likely to delay getting care, and more likely to report poor quality of care by healthcare providers. These disparities stem from a number of factors, among them structural barriers to receiving care, a lack of specific training and education among healthcare providers, and patient fears due to stigma, discrimination, and institutional bias in the healthcare system. All of this suggests the need for greater awareness and targeted interventions that can improve trust and quality of care in the LGTBTQ+ patient-provider relationship. This article will look specifically at LGBTQ+ patients in order to bring a more nuanced analysis of the importance of trust in care, with specific examples from LGBTQ+ healthcare companies that are paving the way in offering exceptional and trustworthy care.

In the context of gender-affirming care, sexual and reproductive medicine, and other services oriented toward LGBTQ+ patients, providers are generally offering care in a very intimate realm of the patient’s life. “Verbalizing personal, sometimes traumatizing, experiences and related health concerns can be intimidating, which makes trust all the more necessary to ensure that the patient is not only comfortable but also that they will not be re-traumatized,” says Bowman. For example, some LGBTQ+ patients fear that their provider will misgender them or refer to them using a deadname (a former name or name given at birth, which is no longer used) based on past negative experiences with the healthcare system. This type of experience can be uncomfortable, and retraumatizing, and may prevent patients from getting the healthcare that could save their lives down the line.

The implications of building trusting relationships in LGBTQ+-oriented healthcare are also distinct. Many LGBTQ+ patients may enter the doctor’s office having previously experienced discrimination, bias, or a lack of understanding or specialized knowledge in the medical setting. While 7% of LGBTQ+ people report that they have avoided doctor’s offices out of fear of discrimination, 18% of LGBTQ+ individuals who have already experienced discrimination at the doctor’s report that they have avoided returning. These data are taken from a study by the Center for American Progress (CAP), which reveals a host of other concerning statistics about the discrimination faced by LGBTQ+ patients in their interactions with the healthcare system.

On top of discrimination, mistreatment, and misunderstanding from doctors, some patients may not have family members, friends, or other support systems that listen to and accept them. This means that when these patients are able to build a trusting relationship with a healthcare provider, there is immense potential for open dialogue and effective care to take place. “When you’re talking to a patient about gender-affirming hormone therapy or abortion or their vaginal infection, it becomes about a lot of other things because once you establish that trust, people are going to use it. If patients don’t have other care providers in their life or in their medical team who they can trust with that information, they’re going to trust you and open up to you about a lot that’s going on in their lives,” explains Bowman.

So what builds trust in the patient-provider relationship? There are several factors that influence trust, but a promising answer lies in cultural competence, a level of nuanced understanding and empathy that allows a provider to relate to a patients’ lived experiences—even if different from their own. Cultural competence may be implicit to some degree when patients and providers share identities, otherwise known as patient-provider concordance. This is reflected in the fact that many minority patients naturally trust and seek out doctors who have similar identities and experiences as them. However, concordance has its limitations and even for those without shared identities, training in cultural competence can help develop this skillset in healthcare providers.

Patient-provider concordance, whereby a patient and provider share an important identity or characteristic, can establish a baseline level of trust. This is because a doctor who is concordant with their patient in a meaningful way likely already has some inherent understanding of how that patient’s lived experience, self-perception, personal identity, and other related factors might inform the patient’s healthcare needs and health understandings. A doctor may also have fewer stereotypes and biases about an identity that they hold themselves. For these reasons, having some shared identity and understanding with a patient often leads to a baseline level of cultural competence.

On the patient side, when a patient knows that their doctor has had similar experiences as a result of a shared identity, they may feel more comfortable opening up. This is the case for gay and bisexual young men, who reported being more likely to discuss sexual health topics when they believed their providers are sexual minorities themselves. “Identity concordance is just an immediate closeness as if you’ve already hopped a few extra boundaries,” explains Bowman.

Most studies in this area of research tend to focus on patient-provider race and ethnicity and have found that this type of concordance has real effects that improve trust and other elements of patients’ perceptions of care. A study on Black HIV patients, for example, found that perceived cultural similarity was highly associated with patient trust in the provider. Race-concordant visits have also been characterized by higher patient ratings of satisfaction and more positive judgments of physicians’ participatory decision-making style. The potential negative effects of discordant relationships are notable as well, with ethnic minority patients perceiving less respect and poorer communication in race-discordant relationships with physicians.

As for other types of patient-provider concordance, many studies still remain inconclusive or are currently nonexistent. In order to make broad claims about concordance and its relationship to trust, cultural competence, and healthcare outcomes for minority patients, we need more research focused on concordance with respect to gender, sexuality, socioeconomic status, ability, and other important identities. Nevertheless, there is plenty of empirical evidence suggesting that when a patient sees important parts of their identity reflected in their doctor, they are likely to trust that doctor’s experience and ability to empathetically and thoughtfully treat them. “Individuals from specific communities, say LTBTQ+ folks, for example, will often specifically seek out clinicians with shared lived experience for that element of safety, for that element of trust, for that element of knowing that they won’t have to do that one-on-one training where they’re forced to step in and educate the clinician on their identities and experiences,” says Nikiforova.

However, it is important to acknowledge that while concordance has been tied to benefits, it also has its limitations and isn’t the be-all and end-all of establishing trust. “Identity concordance does not automatically breed trust because trans people are not a monolith, just like Black people are not a monolith, and so on. However, with identity concordance, it’s often just one less thing the patient has to be afraid of. It’s one less power differential that they have to navigate,” asserts Bowman.

In addition, it is inevitable that doctors will treat patients who are completely unlike themselves. The underrepresentation of BIPOC and LGBTQ+ providers as well as providers with disabilities, for example, means that many patients with those identities may not be able to find or easily access a doctor who is concordant with them in that way. What’s more, even in situations where the patient and provider are concordant with respect to some identity, there are countless other identities and experiences that the patient brings with them into their doctors visit with which the doctor may not be personally familiar. For instance, a transgender patient may choose to visit a transgender doctor, but the two may still have vastly different experiences when it comes to race, ethnicity, socioeconomic status, ability, or other important identities. Recognizing how intersectionality plays out in healthcare spaces is necessary to achieving culturally competent care, and full concordance just isn’t possible.

Another downside to framing concordance as the sole solution to building trust is that it can create an undue burden for providers of particular lived experiences or identities. Given the relatively small proportion of providers who belong to trans, BIPOC, and other minority communities, there can be extra pressure and stress on those providers to treat the specific communities to which they belong. Logistically, this can be difficult when there are only so many appointment slots available in a day. On top of that, investing time and emotional energy in building trusting relationships with patients, especially those who have previously experienced trauma in the medical setting, can be difficult and tiring for providers who also share a marginalized identity.

The good news is that there are cultural competence programs dedicated to equipping providers with the knowledge and skills necessary to provide trustworthy care. Among those skills is empathy, which is not only essential to building healthy, trustful patient-provider relationships, but which, according to research, can also be learned through education and training. This is important because it means that every provider can and should be taught to more thoughtfully and thoroughly respond to patients’ diverse backgrounds and needs. In other words, the responsibility to build trust in the medical setting and support patients with marginalized identities does not fall solely on minority providers and their ability to be concordant with patients.

In the medical setting, cultural competence refers to the ability of health professionals to understand, respect, and be sensitive to the diversity of patients’ values, beliefs, traditions, cultures, and other identities. Culturally-competent medical providers are able to consider and respond appropriately to differences when treating patients while creating an atmosphere of acceptance, respect, and mutual trust. This means tailoring healthcare delivery to meet patients’ specific social, cultural, and linguistic needs.

“Cultural competence can boil down to the clinician seeing the patient as a person, seeing their identity, and understanding that person through the lens of those identities. With those identities come different healthcare needs, different healthcare outcomes, different treatment types, and different ways that people are able to or not able to communicate with their clinicians,” explains Nikiforova. Such care is crucial for reducing healthcare disparities, increasing engagement, breaking down barriers, and ultimately improving healthcare outcomes.

The Cultural Competence Model (CCM) developed by Dr. Campinha-Bacote is a commonly-cited framework that breaks down the process of how practitioners can become culturally competent. Learning about the basics of the model can be useful to better understand what cultural competence actually means and how it looks in practice. The CCM identifies five constructs, or steps, to achieving and assessing cultural competence, which is briefly described here using Campinha-Bacote’s language:

• Cultural awareness: the self-examination and in-depth exploration of one’s own cultural and professional background, along with recognition of one’s biases, prejudices, and assumptions about individuals who are different.
• Cultural knowledge: the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. This knowledge base should integrate three issues: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy.
• Cultural skill: the ability to collect relevant cultural data regarding the client’s presenting problems as well as accurately performing a culturally based physical assessment.
• Cultural encounters: the process that encourages the healthcare provider to directly engage in cross-cultural interactions with clients from culturally diverse backgrounds. Directly interacting with clients from diverse cultural groups will refine or modify one’s existing beliefs about a cultural group and will prevent possible stereotyping that may have occurred.
• Cultural desire: the motivation of the healthcare provider to want to, rather than have to, engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and familiar with cultural encounters. Cultural desire involves the concept of caring.

The types of behaviors that foster patient trust—communicating clearly, listening thoughtfully, building empathetic connection, and respecting patient autonomy, just to name a few—are also at the heart of culturally competent care. In order to effectively treat patients from diverse backgrounds, an ultimate goal of cultural competence, providers must effectively engage patients and build mutual trust.

It is no wonder, then, that an abundance of studies have linked cultural competence with trust, but also many related measures of effective, high-quality healthcare. For one, cultural competence is closely associated with higher levels of patient satisfaction, which has been shown to build trust and lead to increased compliance and greater continuity of care. Specific aspects of cultural competence like shared decision-making as well as negotiation, mutual exchange of information, and improved communication, have been especially connected to patient satisfaction. This reinforces the idea that the very practices and behaviors that make up culturally competent care naturally foster more satisfaction, trust, and therefore a better patient-provider relationship.

“We don’t really meaningfully talk about patient satisfaction within the healthcare system very often, because sometimes just getting care is difficult enough, let alone getting care that is satisfying. However, patients feeling like they are getting good care is a direct outcome of being seen for their identities, being treated appropriately, and gaining trust. If a patient is satisfied, if they feel like they can trust their clinician, they are much more likely to get care before their condition reaches an emergency threshold. They’re also more likely to adhere to care and schedule follow-ups,” says Nikiforova.

Not only do patients report being more satisfied, but those who receive care from culturally competent providers are more likely to perceive their physician as facilitative. This encourages patients to share and seek information, which helps providers better understand, diagnose, and respond to patients’ needs. Patients who perceive their provider as being culturally competent are also more likely to follow medical advice, a behavior that is essential to achieving optimal medical outcomes and yet surprisingly uncommon. At the root of these positive patient, behaviors are trusted in culturally competent providers. Therefore, culturally competent care both promotes trust-building and communication-positive behaviors on the part of the provider, while also encouraging open communication, compliance, and other healthy behaviors as a result of trust on the patient side.

While much of the research out there tend to focus on patient perceptions of culturally competent care, there is also evidence linking cultural competence to improved health outcomes. “Culturally competent care leads to better care, leads to better outcomes. The idea that cultural competence can directly lead to better clinical outcomes is a newer concept which means we need more studies done around it, and yet there is still plenty of evidence to support this direct link,” explains Nikiforova.

Another key ingredient to culturally competent care is empathy, which helps the provider understand and trust the patient, and vice versa. When discussing what cultural competence looks like in practice, Bowman stressed the importance of empathy. “It’s about recognizing that a person’s a whole person because healing requires an understanding and compassion for someone’s humanity. You can’t turn a person into a list of problems generated by a 15-minute visit that can be addressed exclusively through pharmaceuticals,” they said. Research also backs this up, as empathetic doctors have been shown to have patients with greater adherence to medications and treatment plans, improved trust, and even reduced symptoms. Thus, a major takeaway is that cultural competence has the ability to transform the patient-provider relationship and the patient experience by building trust, but also by fostering empathy and enhancing communication, in turn boosting patient satisfaction, increasing compliance, and improving outcomes.

When it comes to providing culturally competent care to LGBTQ+ patients specifically, some basic skills that providers should implement in their practice include:

• Study and understand the LGBTQ+ population history, including unique health concerns, risks, and barriers to care.
• Develop and exercise communication skills that are inclusive and free of discrimination and bias (for example, using correct pronouns and terminology and avoiding judgment regarding sexual orientation and practices when asking questions and recording histories).
• Practice empathy and active listening to understand the full scope of the patient’s needs and concerns.

For Bowman, another key aspect of providing culturally competent care and building trust with patients is humility: “I enter the exam room or telehealth call with humility, knowing that I am a guest in the intimate space of that person and should act like it. I am entitled to no information or exam, I’m entitled to nothing. Everything is voluntary and consent-based.” For patients who may be traumatized by past experiences within the healthcare system and beyond it–and even for those who are not–entering a medical space knowing that they are listened to, respected and understood by their provider can make a world of difference.

As described earlier in the piece, LGBTQ+ identity concordance can also play a role in establishing cultural competence and therefore trust in the patient-provider relationship. While concordance isn’t necessary to build cultural competence, when an LGBTQ+ patient visits a provider with one or multiple of the same identities, they are likely to receive care that is understanding of and responsive to their specific needs and concerns. In other words, concordant relationships can help set the groundwork for more culturally competent care. This is again evidenced by the fact that many LGBTQ+ patients feel more comfortable opening up to providers who share life experiences with regard to gender, sexual orientation, and other identities like race, and who are therefore knowledgeable about related health issues.

Cultural competence can best be achieved through specialized training programs. While concordance often gives providers some baseline understanding of their patients that can help them reach cultural competence more quickly, all providers—those who hold marginalized identities in common with patients and those who do not—can and should gain cultural competence skills and practices through intentional training. Providers can learn how to adapt their interaction style to match their patients’ preferred styles, engage with patients in a way that is culturally sensitive, and promote open dialogue in order to reach a place of shared understanding and trust.

Cultural competence training programs aim to improve cultural knowledge, understanding, and skills, ultimately leading to behavior change in patient-provider encounters. These types of training programs are important for all providers to learn how to foster trusting relationships and ultimately offer exceptional care to all patients, keeping in mind their cultural backgrounds. Generally, the goals of cultural competence training are the following:

• Increase physician awareness of healthcare disparities and their attitudes contributing to disparities
• Increase knowledge of healthcare issues unique to minority populations
• Increase behaviors that will enhance the physicians’ ability to build rapport, communicate effectively with patients who culturally differ, and develop a plan of care acceptable to the patient

While there is no national mandate for cultural competence training in healthcare, many states, organizations, and programs have implemented their own cultural competence requirements and training programs. For example, New Jersey has led the way in creating cultural competence in healthcare since it passed Senate Bill 144 in 2005, requiring doctors to have training in cultural competence as part of their curriculum before they can be licensed. The Office of Minority Health created the National Standards for Culturally and Linguistically Appropriate Services (CLAS), which are designed to provide a template of action steps for delivering culturally competent healthcare. These standards are not technically laws but are in sync with legislative requirements and are meant to be adopted by organizations in each state.

There is currently an emerging ecosystem of provider organizations and care navigation organizations that are making it easier than ever for patients to find healthcare that they trust. A new cohort of “culturally sensitive” or “culturally specific” companies recognize that building trust with patients is key to increasing healthcare utilization and outcomes, especially for populations who have previously lacked access to safe, equitable, and quality care. In these health spaces, cultural competence is not an ideal, but the norm. These companies employ diverse care teams who have been trained in cultural competence and who often also share identities and lived experiences with their patients. The result is exceptional healthcare rooted in trusting patient-provider relationships.

Many culturally sensitive care organizations tailor their services to a specific target population. Given the health disparities and barriers to accessing quality care that many LGBTQ+ patients face, several community-specific organizations have stepped up to focus exclusively on offering exceptional and accessible culturally competent care to LGBTQ+ patients.

For example, Included Health, a care navigation platform acquired by Doctor on Demand + Grand Rounds,  “makes finding quality, queer-friendly care easy” by helping members connect with trusted physical and mental health providers, access gender-affirming care, navigate insurance coverage and benefits, and find community support for LGBTQ+ issues.  As a care navigation organization, or “dedicated care concierge,” Included Health focuses on making the existing healthcare system work better for LGBTQ+ patients, rather than offering their own healthcare services by company providers.

Other companies like Folx and Plume offer direct-to-consumer health solutions to LGBTQ+ patients. Plume focuses exclusively on gender-affirming care, while Folx provides a range of services including hormone therapy, STI kits, PrEP, and other treatments. On their website, Folx specifies that their clinical team is made up of “Queer and Trans folks that are highly trained and sensitive to the unique challenges LGBTQIA+ folks have faced when accessing healthcare.” Evidently, both patient-provider concordance and cultural competence training are cornerstones of Folx’s approach to healthcare.

Violet is another company paving a new way to promote high-quality, trustworthy healthcare, specifically by creating and enforcing cultural competence standards. Violet has created their own cultural competence framework, which the company uses to benchmark the cultural competence of providers and care delivery teams. This process entails collecting and analyzing data about each providers’ identities, professional experiences, and education. Violet then assigns specific badges to providers, such as “BIPOC Proficiency Certified,” “Transgender and Gender Nonconforming (TGNC) Excellence Certified,” and “LGBQ Awareness Certified.” With these badges, patients can then find the right providers for them. Lastly, Violet connects clinicians with quality cultural competence training and education programs.

These are just some of the many companies and care organizations that are prioritizing patient-provider concordance and cultural competence in order to provide exceptional, trustworthy healthcare. These programs and approaches to care will only become more important and prevalent as the healthcare system as whole shifts toward a more patient-centric, value-based care model. While there is still much more work to be done, we are experiencing a shift that is making it easier than ever before to get care that we can trust.