Whether distrust stems from discrimination or other negative experiences, “Seek first to understand.”
Fam Pract Manag. 2022;29(2):40
Author disclosure: no relevant financial relationships.
Recognition of health disparities among minority groups has increased over the last two decades, yet many disparities remain.1 As physicians, when we see poorer health outcomes in certain populations, it behooves us to ask why and to act on their behalf.
One potential risk factor for poorer health is distrust of the health care system,2 even after adjusting for factors such as access to care, insurance, economic status, and education. Levels of distrust have been found to be higher among minority groups and may be related to a legacy of discrimination in health care.3 In the case of distrust among Black patients, specifically, the roots are deep. Here are just a few examples:4
The Tuskegee study was a 40-year experiment, 1932 to 1972, by the U.S. Public Health Service that looked at the natural progression of untreated syphilis. Recruited by the false promise of free medical care, 600 Black men, primarily poor sharecroppers, were enrolled in the study. Although 399 had latent syphilis, they were not told. Even when a treatment became available, they were not treated and suffered severe health problems, even death.
Ebb Cade, a Black male, was the first test subject in human radiation exposure experiments that were part of the Manhattan Project. In 1945, while awaiting treatment for fractured bones in his arms and legs caused by a car accident, he received injections of almost 5 mg of plutonium without his consent. Fifteen of his teeth were extracted to see the results of the radiation. Cade died eight years later from heart failure.
During the Civil War, wounded Black soldiers in the Union Army were treated in separate wards from other soldiers. Due to inadequate staffing, supplies, and treatment, Black soldiers often died from wounds that others would recover from. They were also used in medical experiments without their consent.
These may sound like stories of old, but when generations of parents, grandparents, and great-grandparents pass down these accounts and share their own stories of discrimination, distrust can understandably become the default, even though we have made progress as a society.
“Ask, Acknowledge, Ascend” is a tool physicians can use to overcome barriers of distrust, whether due to discrimination or other negative experiences. When we observe signs of mistrust, such as treatment non-adherence, hesitancy, or rebuttal of our medical advice, the first step is to ask the right questions in a respectful tone to try to understand the basis of the distrust. For example, “Is there a reason you prefer not to follow this medical advice?” “Have you had a bad experience in health care that has led to distrust?” “Do you know others who have been discriminated against in the health care setting?” Next, we must listen intently and acknowledge the concerns being expressed. By showing understanding, we can then ascend the distrust, establish rapport, and begin to address the problem.
This article focused on barriers of distrust among Black Americans; however, this approach can be applied to many patient groups. The first step is the same — to understand the basis of the distrust. A helpful adage is “Seek first to understand, then to be understood.” Understanding the other person's point of view takes patience and diligence, and it is counter to our culture, which focuses more on being understood. But before we can effectively deliver a plan to address a problem, we have to understand the root of the problem. We must peer into the unpleasant birthplace of the distrust. The three “A”s provide a framework for doing that.