THE PARADOX OF TRUST – Where there is smoke, there may be a fire

By: Vanessa Burch, MD, PhD The 2023 Gallup poll of US public opinion showed that while medicine, nursing and pharmacy are still considered honest and ethical professions (Figure 1), ratings of these health care professions have declined in the first quarter of this century (Figure 2).1 Importantly, medicine tops the list of professions with declining honesty and ethics since the COVID-19 pandemic (Figure 3). This opinion poll is supported by the findings of a recent 50-state US survey which also demonstrated declining public trust in physicians and hospitals during the pandemic.2 These US-based observations may not represent a global opinion, and may have many plausible explanations, but the emerging picture mandates a pause for reflection by the health professions education (HPE) community. It seems paradoxical that while we are beavering away at making entrustment the yardstick for decision-making about competence in the workplace with competency-based education (CBE),3 society is whispering that the fruits of our labor are becoming less palatable. On occasion, we as CBE HPE educators, have also expressed our concerns about the trustworthiness of trainees.4 So, the latest opinion poll and survey may not surprise readers of this blog. Indeed, the desire to improve the quality of health care professionals has been a major driver of the interests of the CBE HPE community over an extended period.5 How then are we responding to the idea that public trust in health care professionals continues to decline and needs to be restored? First, it would be helpful to have a better understanding of the meaning of public trust.6 As a HPE community, we have dissected out multiple facets of trustworthiness in a training context.7 What we need to know is how closely this expanded definition of trust is aligned with public opinion. Are there facets of trust, important to society, which we have not captured? While public opinion will always be layered and context-specific,2 this should not deter us from better understanding prevailing public values in as many contexts as possible. Understanding the building blocks of public trust may better align our training endeavors with public needs and close the gap between the trustworthiness of trainees and honest and ethical practitioners, as perceived by the public.8 Second, trainees need to reflect on declining public trust and explore ways in which they can contribute towards reversing the trend. Education initiatives addressing issues of patient-physician trust are growing,9,10 but are we allocating sufficient resources to frank conversations with trainees about public perceptions of trust and the major potential health-related and fiscal consequences of declining public trust in the health care we offer? It seems that “restoring trust may represent a public health imperative”.2 Third, we as the CBE HPE community need to reflect on the many strategies we have developed in our pursuit of producing health care graduates who better serve the needs of society. While trainees may be deemed fit for purpose once educated, this will ultimately have limited impact on population health outcomes if public trust continues to decline. Which of our many educational initiatives are producing graduates who positively impact on public trust? We cannot afford to continue spending public funds on training practitioners in the face of declining trust and consider this to be ‘business as usual’. Public trust is a critical indicator of meeting the needs of society. By current accounts we may not be addressing this mandate as well as we could. Fourth, it is important to consider whether we, as the CBE HPE community, are adequately communicating with the broader public about our training endeavors. We need to reach deeper into spaces where public engagement will keep society more informed about educational developments that focus on improving the trustworthiness of graduates trained to serve society.11 This blog does not intend to gloss over many facets of public trust that do not directly relate to the education of health care professionals. The smorgasbord of factors influencing public trust is vast and not fully explored.8 However, the global CBE HPE community should continue expanding efforts to identify educational factors which speak directly to regaining public trust and focus on strengthening these aspects of HPE training programs. About the Author: Vanessa Burch, MD, PhD, is a rheumatologist and Honorary Professor of Medicine at the University of Cape Town where she was the Clinical Chair of Internal Medicine. Currently she is Executive Director of Education and Assessment at the Colleges of Medicine of South Africa. She is part of a national steering committee responsible for the design and implementation of EPA-based and WBA-driven postgraduate medical education in South Africa. References Brenan M, Jones JM. Ethics ratings of nearly all professions down in U.S. Gallup.com. Published January 22, 2024. Accessed June 18, 2025. Perlis RH, Ognyanova K, Uslu A, Trujillo KL, Santillana M, Druckman JN, Baum MA, Lazer D. Trust in physicians and hospitals during the COVID-19 pandemic in a 50-state survey of US adults. JAMA Network Open. 2024;7(7):e2424984. Ten Cate O, Carraccio C, Damodaran A, Gofton W, Hamstra SJ, Hart DE, Richardson D, Ross S, Schultz K, Warm EJ, Whelan AJ. Entrustment decision making: extending Miller’s pyramid. Academic Medicine. 2021;96(2):199-204. Jonker G, Ochtman A, Marty AP, Kalkman CJ, Ten Cate O, Hoff RG. Would you trust your loved ones to this trainee? Certification decisions in postgraduate anaesthesia training. British Journal of Anaesthesia. 2020;125(5):e408-10. Ten Cate O. Competency-based postgraduate medical education: past, present and future. GMS Journal for Medical Education. 2017;34(5):Doc69. Hall MA, Dugan E, Zheng B, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? The Milbank Quarterly. 2001;79(4):613-39. Ten Cate O, Chen HC. The ingredients of a rich entrustment decision. Medical Teacher. 2020;42(12):1413-20. Taylor LA, Nong PA, Platt JO. Fifty years of trust research in health care: a synthetic review. The Milbank Quarterly. 2023;101(1):126-78. Bauchner H. Trust in health care. Journal of American Medical Association. 2019;321(6):547. Gupta N, Thiele CM, Daum JI, Egbert LK, Chiang JS, Kilgore Jr AE, Johnson CD. Building Patient–Physician Trust: A Medical Student Perspective. Academic Medicine. 2020;95(7):980-3. Wolfson DB, Lynch TJ. Increasing trust in health care. American Journal of Managed Care. 2021;27(12).