Earning trust and losing it: Adolescents’ views on trusting physicians

Discussion

Adolescents in our study defined a good doctor as one they can trust and, similar to other studies of adolescent populations, said trustworthiness is a core attribute they seek in a physician.^7-9 The comprehensive model of patient-physician trust developed by Hall et al in adults depicts trust as perceived by the adolescent participants in our study.³ The dimensions of caring, confidentiality, competency, honesty, and holistic trust captured the beliefs expressed by the adolescents, suggesting that adolescent and adult models of physician trust may be similar.

Confidentiality is the one dimension in which the specifics may differ for adolescents and adults. Similar to other research with adolescents,^7,9 adolescents in our study indicated that confidentiality (ie, keeping health and personal information private) is an important characteristic of a good doctor and a trusted doctor. Adults, on the other hand, are less concerned about confidentiality as it relates to trusting their physicians.^2,3,6,17

Adolescents may be uncertain about a physician’s obligation to inform or not inform parents about private information, which, in turn, may increase their sensitivity to confidentiality. Because adolescents, unlike adults, are accountable to an adult who controls access to activities and friends, they may be more likely to conceal sensitive activities for fear of losing privileges. Chronically ill teens may conceal certain symptoms or lack of compliance with treatment for similar reasons.

Developmental differences may help explain the reason younger adolescents in our study expressed more concern and uncertainty about how health information is protected than did older adolescents. The capacity for formal operational thinking that develops during adolescence enables abstraction and leads to an increasing interest in how the outside world views personal attitudes and behaviors.¹⁸ Until adolescents test the responses of the outside world, they may feel center-stage, as though “everyone” is judging them. Keeping personal information private thus becomes extremely important to maturing adolescents.

Adults who have tested the views of others’ responses are better able than adolescents to keep in perspective the interests of the outside world and, therefore, may have fewer concerns about how their personal information is managed. In addition, adults are more likely to have a better understanding of confidentiality policies within a healthcare system and thus realize their private information is safeguarded.

Given that this analysis was part of a larger study and issues surrounding confidentiality were not studied in-depth, future research involving both adolescents and adults focusing on confidentiality and the uncertainty about parental involvement that often accompanies adolescent health care could shed light on this topic.

Although adolescents with and without chronic illnesses discussed the same dimensions of trust, honesty and advocacy were noted more often by the former. This resembles findings reported in studies of adults with serious illnesses.⁶ Adolescents with chronic illnesses tend to consider parents acceptable recipients of bad news. In addition, adolescents with chronic illnesses expect physicians to reveal bad news to either the adolescent or their parent, given the potential dire health consequences of withholding important medical information.

The issue of honesty may have been mentioned less frequently by healthy adolescents since they have not had to contend with major health issues and receiving bad news. Adolescents with chronic illnesses expect good doctors to “go the extra mile,” a task that is increasingly difficult in a health care environment that seeks to limit reimbursement and expenditure.¹⁹

Keeping in mind the qualitative nature of our study and size of our sample, the findings from our focus groups suggest that physicians working with adolescents with a chronic illness be cognizant of their increased need for complete and accurate information, as well as the higher expectation that the doctor will act on their behalf. Additional studies are needed to investigate whether adolescents with a chronic illness have a higher need for honesty and advocacy than healthy adolescents.

Although identified as a predictor, rather than a dimension, of trust,³ duration of the patient-physician relationship was discussed by adolescents with and without chronic illnesses in our study. Comments similar to “he’s been taking care of me for a long time” or “because I’ve known her all my life” were repeated often. Studies in both adolescent^7,20 and adult populations,^2,4,17 have reported similar findings. Adolescents in our study varied in their estimations of sufficient duration, from 4 to 5 visits to knowing the doctor “forever.”

Unlike the many comments pertaining to duration of acquaintance, there was no discussion of the frequency or intensity of visits. Comfort appears to be a prerequisite for trust for adolescents in our study and may perhaps be a moderating factor when examining how the duration of the patient-physician relationship influences trust. The length of time necessary to feel comfortable may vary among individuals and may be influenced by other factors (eg, experience with doctors or the health care system, friendliness of the physician). Thus, it may not be possible to determine a standard time period (eg, 6 months) in which adolescents feel comfortable to trust their doctor. Future studies examining what influences adolescents’ comfort level (eg, length of relationship, intensity of health care experience) with their physician may provide additional insight for improving adolescents’ trust in their physicians.