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Article: Differences in trust in physician under 50 years between native and non-native patients: a single Dutch institute experience of 170 patients

Differences in trust in physician under 50 years between native and non-native patients: a single Dutch institute experience of 170 patients

Background Literature suggests that a patient’s ethnicity influences the degree of trust a patient has in his physician. This is of major importance, as trust influences health seeking behavior. No studies on ethnic differences in trust in physicians have been conducted yet in the Netherlands.
Objective To compare trust in physicians between native and non-native patients.
Methods To examine trust, we handed out questionnaires from December 2012 until April 2013, at the outpatient clinic of Internal Medicine at the AMC in Amsterdam. The questionnaires included the 10-item validated Wake Forest trust in physician scale. We examined both global trust and three different aspects: fidelity, competence and honesty.
Results One hundred seventy patients were included in the analysis of which 111 native Dutch and 59 non-native. Natives rated trust in their physicians on average 1.1 points (on a 10 point scale) higher (P=0.002). Especially natives in the age category of 18-50 years had more trust in their physicians than non-natives (P=0.002). However, this difference could not be found in the age category of >50 years. Furthermore, non-natives rated trust in their physician less often as ‘sufficient’ (at least 7 out of 10 points) (OR 0.37, 95% CI [0.16 – 0.88]). This especially accounted for the group 18-50 years (OR 0.19, 95% CI [0.045 – 0.76]). Of the three different aspects of trust, perceived physician competence was the strongest driver of ethnic differences in physician trust (OR 0.27, P<0.001, 95% CI [-0.33 – -0.10]).
Conclusion Native patients of 18-50 years show more trust in their physicians than non-natives. The knowledge obtained in this study should become a basis of a new strategy to improve physician trust in non-native patients.


Cultural differences are known to cause a gap among citizens in general, but also between non-natives and their physicians1. This could affect the quality of healthcare these patients receive.

A premise for any patient-physician relationship is trust. The most important predictors of trust are similar to the predictors of patient satisfaction2. Furthermore, several studies have shown that patients who have more trust in their doctors show better therapy compliance3,4,5­. Also, research has shown that patients are more satisfied with female than male physicians6.

Interestingly, research has shown that patients’ degree of trust in physicians is influenced by the patient’s ethnicity. In the USA, several studies have been conducted investigating this matter. African-American patients seem to have less trust in their physician compared to white patients1,7. Moreover, and as a possible consequence of lower physician trust, these African-American patients seem to be less treatment adherent8.

Several components of trust can be differentiated: fidelity, competence, honesty and global trust9 which are discussed in the Methods section.

In the Netherlands, no studies have been conducted to date investigating ethnic differences in patients’ trust. It is important to know if the personal approach each patient prefers is ethnicity dependent. This could improve treatment adherence. This is of particular importance to the Academic Medical Centre, as it is visited by patients from many different ethnic backgrounds10.

We hypothesize that native patients will have more trust in their physician than non-natives. We compared the components of trust mentioned earlier in patients recruited at the internal medicine outpatient clinic from the Academic Medical Center by questionnaires. Furthermore, we investigated the influence of the physician’s gender on trust.


Study design

A cross-sectional study design using questionnaires was chosen to make participation more effortless for patients to maximize participation. Data were gathered from December 2012 until April 2013.


Patients visiting the outpatient clinic of Internal Medicine at the AMC were included if they were ≥18 years of age, and were willing and able to fill out the questionnaire after their appointment. Excluded were patients who indicated their understanding of Dutch/English was too poor; who indicated that they found the questionnaire too difficult; who did not complete the questionnaire themselves for any other reason; and when the professional they just visited was a nurse. Finally, a patient was considered non-native if at least one parent was born in a foreign country11.

Methods of data collection

The full questionnaire is shown in the Appendix to this article. Part A of the questionnaire included general patient characteristics. Part B was the validated Wake Forest Trust in Physician scale8, also validated in Dutch12. It consisted of four aspects of trust: 1) fidelity: ‘caring for patient’s interests or welfare and avoiding conflicts of interest’, 2) competence: ‘having good practice and interpersonal skills, making correct decisions’, 3) honesty: ‘telling the truth’ and 4) global trust: ‘the absolute core of trust’ and combines the first three components8. Fidelity was covered by question 1 and 2; competence by questions 3, 4, and 8; honesty by question 6, and global trust by all questions. Two questions were added to guarantee the patients’ understanding and own completement of the questionnaire. Moreover, a physician was considered sufficient in ensuring trust if he/she received at least 7 out of 10 points in total.


Nurses handed out the questionnaires and detailed instructions throughout the day. To avoid inclusion or performance bias, neither the nurses nor the patients were told that the aim of the study was to investigate ethnicity-dependent differences in trust.

Statistical methods

Analysis was conducted using IBM SPSS Statistics 19.0. For categorical data, the chi-square test was used, and for non-parametric unpaired group comparisons the Mann Whitney U test. Age groups were based on the median age. In addition, lineair regression and binary logistic regression were used. Odds Ratio’s in logistic regression analyses were adjusted for educational level, patient’s age and gender, gender of physician and self-reported severity of disease. For all analyses, a two-sided P-value < 0.05 was considered statistically significant.



Patient characteristics

Approximately 75% of patients approached agreed to fill in the questionnaire (185 patients). Of these, 170 were included, of whom 65% were native and 35% non-native patients (table 1a). Not all ethnicities could be analyzed seperately due to a lack of power. Thus, these were combined into a single group ‘non-natives’ (table 1b).

Total grade of trust

The mean total trust grade was 8.13 on a scale of 1 to 10. Native patients rated their physician on average 1.1 points higher than non-natives. In the age category of 18-50 years, natives showed more trust their physicians more than non-natives (p=0.002). However, no significant difference was found in the age category of >50 years (table 2).

In addition, patients in general reported a higher total grade of trust in female than male physicians (p=0.02). Also, overall, patients with a lower self-reported severity of disease showed more trust (p=0.004).

‘Sufficiency trust’

The binary logistic regression analysis showed that non-native patients of 18-50 years were less likely to rate their physician trust as ‘sufficient’ (a trust score of at least 7) (OR 0.37; p=0.02) (table 3a). Trust in female physicians was, overall, more often rated as ‘sufficient’ (p=0.03). In general, patients with a lower self-reported severity of disease ranked their physician trust more often as ‘sufficient’ (p=0.02).

Of the three components of trust – fidelity, honesty and competence – only perceived competence scored significantly lower in non-native patients (p<0.001).


This study showed that within the outpatient clinic of Internal Medicine at the AMC, native patients of 18-50 years scored their physician significantly higher on global trust and perceived competence. Moreover, we found that patients in general have more trust in female than in male physicians. Important to mention is the high appraisal both native and non-native patients gave their physicians.

With this study we provide the first insight in trust in physicians in the Netherlands. We accounted for the confounding effect of the language barrier by handing out both Dutch and English questionnaires. Furthermore, we included questions to detect patients with poor understanding of the questionnaire. This makes our results more reliable as an indicator of trust.

Our largest limitation was that we only recruited patients from the internal medicine outpatient clinic of the AMC. Patients with less trust might not even visit the outpatient clinic, and are therefore not included, inducing a selection bias. Moreover, our group of non-natives was too small to analyze different ethnicities separately. Thus, we had to group all non-natives. This could have reduced the strength of our results. The small sample could also explain why no ethnic difference in trust was found in the age category of >50 years. Finally, we did not take the physician’s ethnicity into account in our analysis to guarantee the physician’s anonymity. Race discordance between patients and physicians could have influenced our results.

The findings of our study correspond with previous research1,7,8. The lower trust found in non-natives could be explained by cultural differences that may underlie the patient’s expectations of the physician. Physicians could also have an unconscious racial bias against patients from minority groups, which in that case is of influence on their interaction13.

Moreover, our results showed that female physicians were more likely to be trusted than males. This corresponds with research done earlier, which could be explained by the more caring role females still have in our society6.

Considering our results, several approaches developed in the USA to improve trust are extremely relevant and should be used in the Netherlands as well. Future physicians should undergo training in a social psychologic approach14 in non-native patients, especially in order to improve trust and with trust therapy compliance3,4,5­. Physicians to be should also pay more attention to caring and comfort, technical competency and encouraging and answering questions, as these behaviors are strongly associated with patient trust2. Further research is needed investigating ethnic differences in patients’ trust in the rest of the Netherlands, also including the physician’s ethnicity in the analysis.

In conclusion, our study proves that physicians should intensify their recognition of ethnical differences in patients’ perceptions of healthcare. Large-scale interventions should be put into use, targeting the members of minority groups. Finally, we need to keep monitoring patients’ attitudes towards their physicians, to be able to detect potential difficulties due to ethnical differences.

J.V. Veld & H.M. Garcia Garrido

Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands


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